^M Digitized by tine Internet Arcinive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/manualofinjuries1902mars A MANUAL OF THE INJURIES AND SURGICAL DISEASES FACE, MOUTH, AND JAWS. BY JOHN SAYRE MARSHALL, M.D.(sv»a.un,v.), Former Professor of Dental Pathology and Oral Surgery, and Emeritus Professor of Oral Surgery of the Dental Department of Northwestern University. Former Professor of Oral Surgery of the American College of Dental Surgery. Attending Oral Surgeon to St. Luke's Hospital, Mercy Hospital, and Baptist Hospital of Chicago. Fellow of the American Academy of Dental Science. Member of the American Dental Association, and of the State Dental Society of Illinois. Member of the American Medical Association, and of the Cook County Medical Society. President of the Examining Board for Dental Surgeons, United States Army. SECOND EDITION, REVISED AND ENLARGED. PHILADELPHIA: THE S. S. WHITE DENTAL MFG. COMPANY. 1902. -Copyright, 1897, by John Sayre Marshall. •Copyright, 1902, by John Sayre Marshall. TO MY FRIENDS AND CONFRERES, JONATHAN TAFT, M.D., D.D.S., AND S. B. PALMER, M.D.S., IN REMEMBRANCE OF THE KINDLY SYMPATHY AND ENCOtJRAGE- MENT SO OFTEN EXTENDED IN THE EARLIER YEARS OF MY PROFESSIONAL LIFE, THIS BOOK IS AFFECTIONATELY DEDICATED BY THE AUTHOR. PREFACE TO THE SECOND EDITION. The kindly spirit in which the first edition of this work was received by the profession and its quite general adoption by the American Dental Colleges as a text-book upon the subjects of which it treats, has inspired the author to present this second edition, with the hope that it will receive the same generous treatment at the hands of the critics, and that it will maintain its position as a recognized text-book and a reliable book of reference. The work has been thoroughly revised and brought up to date, and much new material has been added to the text, also many valu- able and interesting illustrations introduced. On account of the in- crease in the subject matter, the review questions have been omitted from this edition. John Sayre Marshall. August, igo2. PREFACE TO THE FIRST EDITION. The plan of this volume is the outgrowth of several years' ex- perience as a teacher of Oral Surgery, in Medical and Dental Colleges. During these years the author has been more and more impressed with the disadvantages under which teachers and students have labored in the old system of teaching by didactic lectures. The same feeling has been growing, year by year, among many of the teachers in the Ameri- can Medical and Dental Colleges, and many of them have expressed themselves as anxious to adopt a recitation system of teaching in their special departments. The greatest objection which has been raised to the inauguration of such a system of teaching has been the lack of text- books arranged upon a suitable plan for teaching by this method. The author has endeavored to fill this requirement in the depart- ment of Oral Surgery by the preparation of this volume. In the selec- tion and presentation of the various subjects comprising the work, he has constantly kept in mind the particular needs of the medical and dental student. In Part First will be found those subjects which be- long to the General Principles of Surgery, while Part Second is devoted to the more common Injuries and Surgical Diseases which are asso- ciated with the Face, the Mouth, and the Jaws. These subjects have been divided into short chapters, suitable to class recitation work, and each chapter is followed by a series of review questions covering the most important facts presented upon each topic. These questions can be used by the teacher as a basis for class quizzes; they will also enable the student to quiz himself upon every subject presented. How well the author has succeeded in the undertaking he must leave to the criticism of his colleagues; but he trusts that the general plan will meet with the approval of all interested in a better system of teaching. vii VIU PREFACE. The very excellent illustrations upon Bacteriologic and Pathologic subjects have been made from photo-micrographs especially prepared for this volume by the author's friend and confrere, Dr. Vida A. Latham, of the Bacteriologic Laboratory of the Woman's Medical Department of the Northwestern University, and he takes very great pleasure in making this acknowledgment. To Dr. William H. Knapp, of Chicago, he is also indebted for valuable services rendered in photographing some of these slides and for the photo-micrographs of the karyokinetic figures; and to T. Charters White, of London, England, for several interesting photo-micrographs. Especial thanks are due to the various authors quoted in the work, for much valuable information gathered from their labors, and also to Dr. N. Senn, Mr. Christopher Heath, Mr. J. Bland Sutton, Dr. W. D. Miller, and to their publishers, W. B. Saunders, Churchill & Co., Cassell Publishing Company, The S. S. White Dental Manufacturing Company, and F. A. Davis, for courtesies extended in permission to use many valuable illustrations. John Sayre Marshall. CONTENTS. PART I. CHAPTER I. Surgical Bacteriology. Parasites. The Microscopic Study of Bacteria. Functions of Bacteria. The Pyogenic or Pus Microbes. Infection i CHAPTER II. Surgical Bacteriology (Continued). Action of Bacteria. The General Principles of Antiseptic Treatment 21 CHAPTER III. Inflammation. Inflammation. Irritation. Hyperemia. Exudation. Temperature. Pulse. Symptoms of Acute Local Inflammation. Description of the Inflam- matory Process in the Vascular Tissues 3^ CHAPTER IV. Inflammation (Continued). Suppuration. Pus. Constitutional Symptoms of Acute Inflammation. Sthenic Fever. Asthenic Fever. Predisposing Causes. Symptoms and Diagnosis. Prognosis 54 CHAPTER V. Treatment of Inflammation. Curative Treatment. Local Treatment — Depletion— Rest — Cold — Heat. Constitutional Treatment — Diet 61 CHAPTER VL Chronic Inflammation. Causes. Induration. Hypertrophy. Tumefaction. Fatty Degeneration. Caseation. Treatment— Local — Constitutional 68 CHAPTER VIL Abscess. Definition. Causes. Classification. Acute Abscesses— Symptoms— Treat- ment— Antiseptic Solutions. Methods of Opening Abscesses. Chronic Abscess — Causes — Symptoms — Treatment 72 ix X CONTENTS. CHAPTER VIII. Ulceration. page Definition. Causes — Age — Sex — Occupation — Traumatism. Classification. Healing. Prognosis. Treatment — Operative — Constitutional 80 CHAPTER IX. Necrosis, Caries, and Gangrene. Necrosis — Definition — Causes. Caries — Definition — Causes. Gangrene — Definition — Causes. Dry Gangrene or Mummification. Moist Gan- grene. Symptoms. Prognosis. Treatment 90 CHAPTER X. Traumatic Inflammatory Fever. Definition. Causes. Treatment 102 CHAPTER XL Septicemia. Definition. Causes. Avenues of Infection. Sapremia — Symptoms. Symp- toms of Septicemia — Diagnosis — Prognosis — Treatment 106 CHAPTER XII. Pyemia. Definition. Predisposing Causes — Climate — Age and Sex. Active Causes. Symptoms. Diagnosis. Prognosis. Treatment 113 CHAPTER XIII. Erysipelas. Definition. Causes. Symptoms. Diagnosis. Prognosis. Varieties. Ery- sipelas of the Mucous Membrane. Treatment 120 CHAPTER XIV. Tetanus. Definition. Causes. Period of Incubation. Forms of the Disease. Acute Tetanus — Symptoms — Diagnosis. Chronic Tetanus — Prognosis — Treat- ment 130 CHAPTER XV. Shock and Collapse. Shock — Definition. Collapse. Pathology — Symptoms — Prognosis — Treat- ment. Shock from Dental Operations 138 CONTENTS. Xi CHAPTER XVI. Ligatures, Sutures, and Suturing. PAGE Ligatures — Catgut — Kangaroo — Silkworm-gut — Silver Wire. Ligation of Vessels. Sutures — Continuous — Interrupted — Pin — Quilled — Clamp — Button — Buried — -Cobbler's — Shotted 148 PART II. CHAPTER XVII. Wounds. Definition. Classification. Healing of. Methods of Healing — First Inten- tion — Second Intention — Third Intention. Surgical Cleanliness 157 CHAPTER XVIII. Treatment of Wounds. Asepsis. Arrestation of Hemorrhage. Coaptation. Drainage. Physiolo- gical Rest. Dressings 168 CHAPTER XIX. Gunshot Wounds. Diagnosis. Effects of Dififerent Missiles. Explosive Efifect. Hydraulic Pressure. Compressed Air, or Projectile Air. Rotation of the Bullet. Deformation. Heating. Primary Fatal Hemorrhage 173 CHAPTER XX. Gunshot Wounds of the Face. Classification— Of the Nose— Of the Malar— Of the Upper Jaw— Of the Mandible. Symptoms. Treatment 184 CHAPTER XXL Fractures of the Inferior Maxilla. Definition. Fractures of the Alveolar Process. Of the Body of the Lower Jaw. Displacements. Lines of Fracture. Symptoms. Diagnosis. Prognosis 198 CHAPTER XXII. Fractures of the Inferior Maxilla (Continued). Treatment. Abscess of the Jaws 208 CHAPTER XXIIL Fractures of the Superior Maxilla and Upper Bones of the Face 224 CHAPTER XXIV. Delayed Union and Ununited Fractures. Causes. Treatment of Delayed Union— Of Ununited Fractures 239 Xii CONTENTS. CHAPTER XXV. Dislocation of the Inferior Maxilla. Definition. Dislocations of the Lower Jaw — Causes — Symptoms — Treat- ment. Subluxation of the Jaw — Causes — Treatment 248 CHAPTER XXVI. Ankylosis of the Jaws. Definition. Temporary Ankj'losis — Causes — Treatment. Permanent An- kylosis — Causes — Diagnosis — Treatment — Mechanical Treatment — Surgi- cal Treatment 255 CHAPTER XXVII. Periostitis of the Jaws. Definition. Causes. Symptoms. Acute Diffuse Periostitis — Causes — Treat- ment. Mercurial Periostitis — Symptoms — Treatment. Chronic Perios- titis of the Jaws 264 CHAPTER XXVIII. Necrosis of the Jaws. Definition. Causes. Symptoms. Treatment 268 CHAPTER XXIX. Necrosis of the Jaws (Continued). Exanthematous Necrosis — Symptoms — Treatment. Mercurial Necrosis — Treatment. Arsenical Necrosis — Treatment. Phosphorus Necrosis — Symptoms — Treatment. Syphilitic Necrosis — Symptoms — Treatment. Reproduction of Bone 273 CHAPTER XXX. Stomatitis. Definition. Stomatitis Simplex — Symptoms — Treatment. Stomatitis Ca- tarrhalis — Causes — Symptoms — Treatment. Stomatitis Aphthosa — Treatment. Stomatitis Ulcerosa — Causes — Symptoms — Treatment 282 CHAPTER XXXI. Leucoplakia. Definition. Varieties. Etiology. Symptoms. Diagnosis. Pathology. Prog- nosis. Treatment 294 CHAPTER XXXII. Surgical Tuberculosis. Tuberculosis — Avenues of Infection — Pathology 308 CHAPTER XXXIII. Surgical Tuberculosis (Continued). Tuberculosis of Bone — Symptoms and Diagnosis — Dififerential Diagnosis — Prognosis — Treatment 318 CONTENTS. xiii CHAPTER XXXIV. Surgical Tuberculosis (Continued). ' PAGE Tuberculosis of the Skin — Pathology. Tuberculosis of the Skin of the Face — Of the Mucous Membrane of the Mouth — Of the Tongue and Pharyn.x. Dififerential Diagnosis. Prognosis. Treatment 331 CHAPTER XXXV. Actinomycosis Hominis. Definition. Etiology. Pathology. Symptoms and Diagnosis. Prognosis. Treatment 344 CHAPTER XXXVI. Diseases of the Maxillary Sinus. Suppurative Inflammation of the Maxillary Sinus — Etiology. Devitalized Pulps. Alveolar Abscesses. Malposed Teeth. Foreign Bodies. Trau- matic Injuries. Catarrhal Affections. Mucous Engorgements 358 CHAPTER XXXVIL Diseases of the ]\Iaxillary Sinus (Continued). Suppuration of the Antrum of Highmore — Symptoms — Diagnosis — Diflfer- ential Diagnosis — Prognosis — Treatment 374 CHAPTER XXXVIII. Diseases of the IMaxillary Sinus (Continued). Syphilitic Ulceration of the Antrum of Highmore — Diagnosis — Differential ■ Diagnosis — Treatment. Necrosis of the Walls of the Maxillary Sinus — Symptoms — Treatment 382 CHAPTER XXXIX. Cystic Tumors of the Maxillary Sinus. Mucous Cysts of the Antrum — Sj-niptoms and Diagnosis — Prognosis — Treatment. Polypus of the Antrum — Symptoms and Diagnosis — Prog- nosis — Treatment 389 CHAPTER XL. Diseases of the S.\liv.\ry Glands. Inflammation of the Parotid Gland — Symptoms and Diagnosis — Prognosis — Treatment. Salivary Calculi — Causes — Symptoms — Diagnosis — - Treatment. Salivary Fistulje— Causes — Diagnosis — Treatment 394 CHAPTER XLI. Neuralgia. Definition. Causes. Predisposing Causes. Exciting Causes. Trifacial Neuralgia — Symptoms — Causes — Diagnosis 401 XIV CONTENTS. CHAPTER XLII. Treatment of Trifacial Neuralgia. page Therapeutic Treatment — Surgical Treatment 412 CHAPTER XLIII. Congenital Fissures of the Lip and the Vault of the Mouth. Origin — Non-Union of Superior and Lateral Processes — Arrested Develop- ment — Faulty Nutrition — Heredity — Maternal Impressions. Prognosis 420 CHAPTER XLIV. Congenital Fissures of the Lip and the Vault of the Mouth. (Continued.) Surgical Treatment — Operations. Hare-Lip — Uranorrhaphy — Staphylor- rhaphy — Mechanical Treatment 431 CHAPTER XLV. Tumors. Definition. Origin. Germinal Layers. Structure. Classification 449 CHAPTER XLVL Tumors of the Face, Mouth, and Jaws. Epithelial Tumors. Papillomata — Definition. Cornu Cutaneum — Treat- ment 460 CHAPTER XLVn. Epithelial Tumors (Continued). Adenomata — Definition — Causes. Adenoma of the Skin — Diagnosis and Symptoms. Adenoma of the Palate — Diagnosis and Symptoms — Prog- nosis — Treatment. Adenoma of the Tongue — Diagnosis and Symptoms — Prognosis — Treatment. Adenoma of the Salivary Glands — Diagnosis and Symptoms — Prognosis — Treatment 470 CHAPTER XLVIIL Cystomata. Definition. Cysts of the Jaws and Teeth — Diagnosis — Prognosis — Treat- ment 485 CHAPTER XLIX. Cystomata (Continued). Multilocular Cysts of the Jaws — Definition — Causes — Diagnosis and Symp- toms — Prognosis — Treatment 493 CHAPTER L. Cystomata (Continued). Dentigerous Cysts — Causes. Dermoid Cysts. Diagnosis and Symptoms. Differential Diagnosis. Prognosis. Treatment 500 CONTENTS. XV CHAPTER LI. Carcinomata. PAGE Definition. Origin. Varieties and Structure. Squamous-Celled — Cylin- drical-Celled — Glandular. Infection and Dissemination. Prevalence. Sex. Age 514 CHAPTER LII. Carcinomata (Continued). Causes — Heredity — Bacteria. Exciting Causes. Diagnosis and Symptoms. Prognosis. Treatment 529 CHAPTER LIII. Carcinomata (Continued). Carcinoma of the Skin. Of the Face — Diagnosis — Prognosis — Treatment. 539 CHAPTER LIV. Carcinomata (Continued). Carcinoma of the Lip — Diagnosis — Prognosis — Treatment 553 CHAPTER LV. Carcinomata (Continued). Carcinoma of the Buccal Mucous Membrane and Jaws. Of the Antrum — Treatment 564 CHAPTER LVI. Carcinomata (Continued). Carcinoma of the Pharynx. Of the Palate and Uvula — Symptoms — Treat- ment. Carcinoma of the Tongue — Causes — Symptoms and Diagnosis — Prognosis — Treatment. Carcinoma of the Tonsils — Symptoms — Prognosis — Treatment. Carcinoma of the Salivary Glands — Treat- ment 571 CHAPTER LVII. Mesoblastic Tumors. Fibromata — Definition — Origin — Varieties — Causes. Fibroma of the Gums — Diagnosis — Prognosis — Treatment. Fibroma of the Skin 586 CHAPTER LVIII. Chondromata. Definition. Diagnosis. Prognosis. Chondroma of the Salivary Glands.. 596 CHAPTER LIX. Osteom.\ta. Definition. Compact Osteomata. Cancellous Osteomata. Treatment 603 XVI CONTENTS, CHAPTER LX. Angiomata. I'AC.K Definition. Origin. Diagnosis. Treatment 6i6 CHAPTER LXI. Sarcomata. Definition. Origin. Varieties and Structure. Round-Celled Sarcoma. Spindle-Celled Sarcoma. Myeloid Sarcoma. Alveolar Sarcoma. Melano-Sarcoma. Mixed-Cell Sarcoma. Retrogressive Changes. In- fection and Dissemination. Causes. Diagnosis and Symptoms. Prog- nosis. Treatment 625 CHAPTER LXII. Sarcomata (Continued). Sarcoma of the Jaws — Periosteal — ^luco-Periosteal — Endosteal — Odonto- Sarcoma. Sarcoma of the Salivary Glands 646 CHAPTER LXIII. Treatment of Sarcoma of the Jaws 659 CHAPTER LXIV. Odontomata. Definition. Fibrous Odontomes. Cementomes. Compound Follicular Odontomes. Radicular Odontomes. Composite Odontomes. Diag- nosis. Prognosis. Treatment 667 CHAPTER LXV. Odontomata (Continued). Causes. Aberrations in Development and Position. Diagnosis and Symp- toms. Prognosis. Treatment 687 CHAPTER LXVI. • Retention Cysts. Cysts of the Skin. Comedo — Causes — Treatment. Milium — Causes — Treatment. Sebaceous Cysts or Wens — Causes — Prognosis — Treat- ment. Sudoriparous Cysts — Treatment. Cysts of the Mucous Mem- brane. Muciparous Cysts — Causes — Diagnosis and Symptoms — Treat- ment. Mucous Cysts of the Antrum of Highmore — Treatment. Cysts of the Salivary Glands. . Ranula — Causes — Diagnosis and Symptoms — Prognosis — Treatment 694 Index 7^5 Injuries and Surgical Diseases of the Face, Mouth, and Jaws. PART I. CHAPTER I. SURGICAL BACTERIOLOGY. The promulgation of the Germ Theory of disease was the begin- ning of a great revohition in the practice of both medicine and surgery; a revolution which at the present time is still going on with increasing success, recording victory after victory, and constantly invading new territory heretofore occupied by dread pestilence and epidemic disease, and tearing from their grasp trophies in the form of the discovery of the causation of these dreaded maladies, and of the means wherewith to successfully combat them. The application of the principle of the germ theory of disease has had its greatest successes in the department of surgery; in fact, it has placed modern surgerv^ upon the exalted pin- nacle which it occupies to-day. Without the discovery of the pyogenic bacteria and of the other pathogenic forms now known to science, and without a knowledge of the principles of modern antiseptics, much of the success which has been achieved in surgery during the last two decades would still be an impossibility. "In the light of the germ theon.^ disease may be considered to be a battle between the organism and an invading army of parasites, while the treatment of diseases resolves itself into the question of how best to assist the organism in overcoming the enemy which has entered its territory." (Gradle.) Parasites. — Definition. Parasites are plants or animals which live upon other plants or animals. Parasites may belong to either the animal or the vegetable king- dom. In the early history of bacteriology there was great diffi- culty in classing them. In most instances the parasites which enter 2 SURGERY OF THE FACE, MOUTH, AND JAWS. the animal organism are microscopic in size ; hence they are re- ferred to as micro-organisms, microbes, or bacteria. Bacteria are now generally considered as belonging to the vegetable kingdom. The bacteria belong to the fission plants known as the Schizophyta or Schizophytes, a division of the Thallophyta including those varieties which multiply by fission or division. These are divided into two sub- classes, those which possess chlorophyll, namely, the Cyanophyce<2 (usually referred to as Algce), and those having no chlorophyll, or the Schizomycetes (usually referred to as Fungi). "Many of these are so small as to approach the limits of visibility, even when the highest powers of the microscope are used." When located in the animal tissues they are demonstrated with great difficulty, and only by the aid of special staining agents can they be differentiated from the cel- lular elements of the tissues ; even then doubt sometimes shadows the certainty of the demonstration, and it becomes necessary to make experimental cultivations of the products of tissue disintegration in the case before a positive diagnosis can be reached. The sphcBrohacteria, or micrococci, are the smallest of all the bacterial forms. Fig. i represents some of the common forms of bacteria. These organisms, the bacteria, are classed by Pasteur under two general heads, namely : Aerobes and Anaerobes. The aerobic microbes require the oxygen of the atmosphere in order to maintain life, and therefore live upon the surfaces of sub- stances. The yeast fungi are examples of aerobic microbes (Fig. 2). The anaerobic microbes do not require oxygen to maintain life, and therefore live beneath the surfaces of liquids and inside of living bodies. The Bacterium tetani is an example of the anaerobic microbes. The greater portion of the bacteria are aerobic. Some of them are so dependent upon oxygen that the slightest diminution in the supply is sufficient to arrest or completely prevent their development. These have been called obligate aerobic bacteria. Others grow in media rich in oxygen, and also where there is no oxygen. These have been termed facultative aerobic bacteria. Nearly all the pathogenic forms of bacteria belong to the facultative variety. The tissues of the body con- tain a certain amount of oxygen, but this is soon consumed by the micro-organisms in their growth; consequently they would die if they did not have the faculty of living without oxygen under certain condi- tions. The anaerobic bacteria are exceedingly rare among the patho- genic forms. The presence of oxygen retards their growth or com- pletely arrests their development. The spores, however, maintain their vitality in oxygen for a considerable period of time. Pasteur discovered that when artificial cultures of certain patho- genic bacteria were exposed for a considerable time to oxygen, gener- SURGICAL BACTERIOLOGY. Fig. I. A .'}• ittite •V OQggQOOO Various Forms of Bacteria. a, Cocci, d, Diplococci c, Cluster-cocci (Staphylococci), d, Coccus chains (Streptococci, Toru- la). ^, Surface-shaped colonies (Merismopedia). /", Pocket-shaped colonies (Sarcina). ^, a double coccus chain produced by a single fissation of each member in a direction at right angles to the long axis of the chain, h, Vibriones. t, k, Spirilla. /, Spirochsetes. m, Spiromonades. n, Spirulina. o, Cladothrix. fi, Rods (bacilli). ^, Clostridium, r, Leptothrix (threads), r', Articulated threads. J, Rhabdomonas. t, u, v, Zoogloea. (In part after Fliigge & Zopf.) Fig. 2. Various Forms of Yeast Fungi. a, Colonies of round cells (Saccharomyces conglomeratus?). d, Single cells of dilTerent forms partly forming daughter-cells, c, Cylindrical cells of pellicle-fungus (Saccharomyces mycoderma). 4 SURGERY OF THE FACE, MOUTH, AND JAWS. ally from three to eight months, the virus became very much attenu- ated. His first experiments were with the microbe of chicken cholera and the bacillus of anthrax. He found that a chicken inoculated with the weak cultures of the chicken cholera bacillus was rendered immune to the action of the virulent virus, and that the attenuated culture of the anthrax bacillus, prepared in the same manner, rendered sheep immune to anthrax, or if they contracted the disease after inoculation, it appeared in only a very mild form. Paul Bert has shown that oxygen, under a pressure of from 20 to 40 centimeters, destroys the vitality of the anthrax bacillus. The Microscopic Study of Bacteria. — In order to successfully study bacteria, a good quahty of microscope, with oil immersion lenses and Abbe condenser, is an absolute necessity. Anilin dyes are gen- erally used to stain the micro-organisms, which are often very tena- cious in their hold upon the staining fluids, thus making it possible to discover the minute forms which would otherwise be invisible. Portions of tissue which it is desired to examine for the presence of bacteria are first cut into small fragments, about a quarter-inch square, and placed in absolute alcohol. It is best to do this imme- diately, that the tissue may be preserved in the condition which it pre- sented when removed from the body. The alcohol should be changed as often as twice, and at the end of forty-eight hours the specimen will be ready to be cut into sections. These must be cut very thin, and at once placed in a dilute solution of fuchsin or gentian violet, and allowed to remain from one to six hours. They are afterward decolorized in water which has been acidulated with acetic acid, washed in water, then dehydrated with alcohol, clarified, and mounted in Canada balsam. Double staining, or contrast staining, is sometimes used for the purpose of better definition. By this means the micro-organisms are stained one color, and the tissues a decidedly different one, but always of a paler hue. The examination of blood, pus, urine, and sputa is accomplished by first evaporating a film of the material upon a cover-glass, fixing, and treating the cover-glass as a section. Ziehl's method of exam- ining urine for the tubercle bacillus is to place the cover-glass, which has been prepared by evaporating one or two drops of urine upon it, in the following solution, previously warmed, allowing it to remain from five to ten minutes : Fuchsin, i gram; Carbolic acid solution (5 per cent.), 80 c.c; Alcohol (95 per cent.), 20 c.c. It is afterward decolorized with a 5 per cent, solution of sulfuric acid, which effectually removes the coloring matter from everything SURGICAL BACTERIOLOGY. 5 but the micro-organisms. After washing with distilled water, it is placed in a watery solution of methyl blue for five minutes, again washed in distilled water, dried, and mounted in Canada balsam. By this method the bacilli take a red stain, while the deposit in which they are held is colored blue. The same general methods are applicable in the examination of sputa from phthisical patients. Grain's Method. — (a) Place a cover-film in absolute alcohol for one or two minutes. (b) Stain in anilin gentian violet for one or two minutes. (c) Remove superfluous stain by draining. (d) Now place in Gram's solution of iodin for one-half to one minute, — until the specimen turns black. (e) Soak up the superfluous iodin solution. (f) Wash in alcohol until the film is almost colorless, — until no more stain comes away. Dry and mount in xylol balsam. (g) If to double stain, pass quickly through a dilute alcoholic solution of eosin. The leucocytes and ground substance will be col- ored pink, the gonococcus and also the chromilin violet. (Ji) Wash in water; examine if deep enough. T)ry thoroughly and mount in xylol balsam. Examine with oil immersion. Formula. — Gentian Anilin Wafer, i. Mix 4 c.c. anilin oil with 100 c.c. distilled water. Shake for one or two minutes. 2. Filter resulting emulsion through filter-paper moistened with distilled water. 3. To 100 c.c. of anilin water add 11 c.c. of a concentrated alco- holic solution of gentian violet. Shake. Mix thoroughly. Always filter before using. This does not keep well, consequently only small quantities should be prepared at a time. Gram's Iodin Solution. Iodin crystals, i gram; lodid potassium, 2 grams; Distilled water, 300 c.c. Functions of Bacteria. — Certain species of bacteria are disease- producing, or pathogenic; others are color-producing, or chromogenic. Another species is ferment-producing, or zymogenic; another is aero- genic or gas-producing; other forms are saprogenic — ^these are en- dowed wdth intense putrefactive properties ; while still others have as yet no discovered function. ^^^hen arranging bacteria according to their relation to disease, it is customary to class them under two general heads : First. N on- pathogenic, or those which do not as a direct cause pro- duce disease. Second. Pathogenic, or those which are the direct cause of disease. 6 SURGERY OF THE FACE, MOUTH, AND JAWS. Fermentation and putrefaction are the results of the g^rowth of micro-organisms in the substances which ferment or putrefy. Among the non-pathogenic micro-organisms are included the saprophytic germs. These organisms, which may become indirect causes of disease, can live and grow only in dead and dying tissues. Organisms of this character entering a wound in which there are pent- up discharges and dying tissues, increase with great rapidity, and pro- duce certain substances of a poisonous and irritating character, called ptomaines, the absorption of which by the system gives rise to symp- toms which are denominated as septic intoxication, ptomaine -fever, or septicemia. Pathogenic micro-organisms grow and flourish in dead and dying matter, and invade the living tissues and destroy them. They also enter the circulation by direct inoculation through wounds and abra- sions, and are carried to all parts of the body, and wherever deposited increase in numbers with amazing rapidity, forming fresh foci for the production of poisonous and irritating substances. The chief differ- ence therefore between the saprophytes and pathogenic germs is that the former act as indirect causes of disease by the production of poison- ous substances which are absorbed by the system, but they have no power to penetrate the tissues or enter the circulation ; while the latter possess this power, and act as direct disease-producing agents. The pathogenic micro-organisms may be divided again into two general classes: First. Micrococci. Second. Bacilli. Each of these classes has been divided and subdivided by the bac- teriologist into an almost endless variety. This classification is the result of a thorough and careful study as to their size, form, and length, their growth, groupings, and action in the various culture-media, their chemical reaction, the color imparted to the culture-media, their sus- ceptibility to the various staining agents, and their action upon fer- mentable substances and living organisms. New forms of bacteria are constantly being discovered, and further research into the life and habits of old forms develops new features and modes of action which a little while before had not been dreamed of, while the etiology of certain diseases which were before considered as obscure are one by one being cleared up by the discovery of a specific microbe, which, when introduced into the system in sufficient quanti- ties, will produce the disease. It has been recently announced that Kitasato has discovered the plague bacillus, and that it resembles the micro-organism of chicken cholera. The Micrococcus is an individual bacterium, the smallest of all the bacterial forms, having spheric elements — tiny, globe-like masses of SURGICAL BACTERIOLOGY. 7 matter in some instances isolated, in others united in twos or in larger numbers, or disposed in chains or chaplets, or deposited in masses of zoosilea, — a gelatinous matrix secreted by the bacteria themselves. {a, Fig. I.) ^^'hen united in twos they are called Diplococci (b, Fig. i). Fig. 3. DiPLOCOCCUS Pneumoni.b from Lung. X Fig. 4. Tetanus Bacillus. Sometimes they are united in such a way as to resemble a bunch of grapes. They are then termed Staphylococci (c, Fig. i). If arranged in chains or chaplets they are denominated Streptococci {d, Fig. i). The pneumococcus or diplococcus of pneumonia (Fig. 3) is a good representation of the diplococci. surgery of the face, mouth, and jaws. Fig. 5- i-^ ' S Bacillus of Asiatic Cholera. X 1200. Fig. 6. Various Micro-OrgaxNISms of the Mouth. Leptothri-x buccalis, Micrococci and Bacilli, etc. X 1200. SURGICAL BACTERIOLOGY. n The bacillus of tetanus (Fig. 4) would seem from its form, which is like a drum-stick, to be a combination of a micrococcus and a bacillus, but in reality it is a bacillus with a spore at one end. The bacillus of cholera (Fig. 5) seems to be a combination of the same character, but having a curved stem resembling a comma; hence it has been named the comma bacillus, or Koch bacillus, after the name of its discoverer. Fig. 6 represents various micro-organisms of the mouth. Fig. 7. Old or Matured. OiDiuM LACTis. (Milk Mold. The Bacterium lactis, which is an active agent in the production of dental caries, is a short, straight, rod-like bacillus. Its function is that of forming lactic acid, and it is the organism that causes the souring of milk. The Oidium lactis (Fig. 7) is common in the mouth. The Leptothrix buccalis (Fig. 8), another bacterium frequently found in the mouth, and associated with dental caries, is a long, slen- der, thread-like bacillus, usually found grouped in masses. Fig. 9 shows the Leptothrix gigantige. lO SURGERY OF THE FACE, MOUTH, AND JAWS. One of the difficulties which the bacteriologist and the pathologist have to meet is the seeming identity of certain forms of bacteria found Fig. 8. LKPTOTHRIX EUCCALIS. X 1200. Fig. 9. LEPTOTHRI.K GIGANTI.^. / 1200. in diseases presenting dissimilar characteristics ; for instance, the Streptococcus pyogenes (Fig. loj seems to be identical with the SURGICAL BACTERIOLOGY. I I Streptococcus of erysipelas, the only discernible difference being one of size, the coccus of erysipelas being the larger. The cocci multiply only by fission or division, a process similar to karyokinesis (Fig. ii). The cell elongates prior to its segmentation, when a constriction appears in the center, which becomes deeper and deeper until complete division of the cell into two equal parts takes place. These new cells soon attain the size of the parent cell. Fig. 10. •-?? Streptococcus pyogenes. X 1200. ^00 CO 00^ Fig. II. O @ Fission of Bacteria (Cocci). a and d, Fissation in one direction ; b, in two ; c, in three directions. The staphylococci, diplococci. and streptococci are generally found in the broken-down tissue and discharges w^hich result from in- flammatory action, particularly in pus formations. The Bacillus is an individual bacterium of rod-like form, and in- cludes all the elongated forms of bacteria, except such as are spiral and have a gyratory motion, which are classed with the genus Spirillum. A Spirillum is an individual bacterium whose elements are curved, often forming a spiral of several turns. The comma bacillus of Koch, 12 SURGERY OF THE FACE, MOUTH, AND JAWS. found in the discharges of cholera patients, is a spirihum, and repre- sents the simple curved variety; while the spirillum of Miller, found in carious teeth, represents the spiral form. Some of the spirilla have cilia attached (Fig. 12). Fig. 12. Bacilli. Spirilla Cilia. X 1250. Bacilli are rigid or flexible, motile or non-motile, and reproduce their kind either by direct fission or by endogenous spore-formation, — the formation of a cell within the body of the parent cell (Fig. 13). This process is a very rapid one. Fliigge observed the process of seg- FlG. Spore Formations in Bacilli. mentation in a coccus to occur in twenty minutes. Cohn has made the calculation that if it should take one hour to complete the process of segmentation, and for the new cell to attain the size of the parent cell, one coccus, multiplying by this process, would in one day produce 16,000,000 cocci; at the end of two days 281,000,000,000, while at the SURGICAL BACTERIOLOGY. I3 end of the third day it would have reached the enormous number of 46,000,000,000,000. The spore possesses an exceedingly dense enveloping membrane, which protects it from deleterious external influences until such time as it finds a soil favorable to its growth and development. The parent cell is usually enlarged in the center or at one end by the presence of the spore, and when the latter reaches its full development, gelatinous softening of the cell-membrane takes place, the cell breaks up, and the spore is set free. During the process of development of the spore into a bacillus it loses its tough enveloping membrane and is therefore more readily destroyed. The majority of bacteria grow at a temperature of 37° C.=:98° F. Spores resist the action of germicidal agents to a much greater degree than the bacilli which produce them. Mature bacteria cannot resist a temperature of 'j'j° C, 170° F. Most of them are destroyed when exposed to 55° C, 131° F., while spores have been known to resist a temperature of 100° to 120° C, 212° to 236° F. A temperature of 100° C, 212° F., if maintained for ten to fifteen minutes, will effectually destroy the most persistent of spores. Spores which have gained an entrance to the body may remain dormant for years, and give rise to no untoward symptoms until aroused to activity by conditions which favor their growth and devel- opment. Two conditions are necessary for the germination of bac- teria, viz: a certain amount of heat and moisture. Both must be pres- ent. The requisite amount of heat minus the moisture, or the moisture without the heat, is in neither case favorable to their development. This is eminently true in the treatment of dental caries and devitalized teeth; with thorough desiccation of the cavity of decay or of the root- canal, and the prevention of the ingress of moisture, caries will be ar- rested in the one case, and suppuration prevented in the other. In no department of surgery is thorough antisepsis more important than in operations upon the teeth. The Pyogenic or Pus Microbes. — The micro-organisms with which the surgeon has most frequently to contend are those which cause suppuration. Their effect upon the inflammatory exudates, leucocytes, and cellular elements of the tissues, is one of specific action by which they convert them into pus-corpuscles. They are therefore called pyogenic or pus-microbes. Of these there are several varieties, most of them of the globular or coccus form. The number of bacterial forms which have been found in connection with surgical diseases, and fully identified as their exciting cause, is not large; yet the statement may be safely made upon the basis of our present knowledge, that all traumatic infective diseases can be traced to the action of micro-organ- isms which have gained an entrance to the tissues. Koch lays down certain rules as a crucial test, before the positive 14 SURGERY OF THE FACE, MOUTH, AND JAWS. assertion can be made that a particular organism is the specific cause of a disease: ist, it must be found in all cases of that disease; 2d, it must be found in no other disease; 3d, it must appear in such quantity and be so distributed that all symptoms can be accounted for by its presence; 4th, the organism must be capable of being isolated from the diseased tissues, and be grown upon some of the artificial culture- media; 5th, when injected into an animal it must be capable of repro- ducing the disease. All of these conditions can rarely be fulfilled in many cases, yet when a certain form or variety of bacteria is constantly present in a particular disease, it is pretty good evidence that it is the cause of that disease. Infection. — The eft'ect of infection with the pyogenic cocci will always vary with the number of the microbes entering the tissues, the favorable or unfavorable conditions of the tissues for their growth, and the general susceptibility of the organism. These facts have been abundantly proved by repeated inoculation experiments upon animals. Watson Cheyne found that the number of the bacteria in- jected makes a very great difference in the intensity of the symptoms and the character of the disease. He arrived at a general idea of the number of bacteria in a given quantity of fluid by means of the plate culture, the fluid having been diluted for the purpose; a definite quan- tity of this fluid was injected into an animal, and at the same time plates were made from an equal quantity. The number of organisms in the fluid injected was thus quite accurately determined. In the case of the Proteus vulgaris of Hauser, Fig. 14 (a bac- terium commonly associated with putrefaction), he found that a dose of i-io c.c. of an undiluted culture contained about 250,000,000 bac- teria, and when injected into the muscular tissue of a rabbit quickly proved fatal; while a dose of 1-40 c.c, containing about 56,000,000, caused very extensive abscess and resulted in the death of the animal in from six to eight weeks. Doses which contained less than 18,000,000 very rarely produced any effect. He also demonstrated that with cultures of the Staphylococcus pyogenes aureus it was necessary to inject a dose sufficient to include at least 1,000,000,000 cocci into the muscle of the rabbit to procure a speedy fatal effect; while a dose of 250,000,000 caused the formation only of a small circumscribed abscess. The Staphylococcus pyogenes albiis was found to produce the same results, but with somewhat larger doses. Another interesting fact discovered by the same investigator was, that concentration of the bacterial material in a certain locality was necessary to produce the most marked results. Dividing the dose and injecting it at different times or in different locations at the same time, did not produce the same results as when it was all injected into a smgle locality. SURGICAL BACTERIOLOGY. 15 The susceptibility of the human organism to the action of the pyogenic cocci is not very great, and the results produced by them will vary according to the numbers introduced and the conditions of the tissues at the time. The introduction of small numbers of these microbes, if accompanied with the toxic substances which are present in the virulent cultures, is more liable to cause suppuration than when not so accompanied, and the extent of the inflammatory process will bear a close relation to the quantity and quality of these substances. (Warren.) Fig. 14 Bacillus proteus vulgaris of Hauser. X 1000. The entrance of a few pus-microbes into a wound may be entirely harmless unless the conditions are favorable for their growth and mul- tiplication. Such conditions would be represented by retained exuda- tions, a blood-clot, or irritation of the wound from sutures or dressings. Pathogenic micro-organisms are frequently found in the blood of healthy living persons, but it remains a disputed question as to whether they can exist in the body without causing disease. Experiment has proved that pathogenic micro-organisms are harmless so long as they remain in the circulating blood, but if they become localized then their specific pathogenic action becomes manifest. Pathogenic spores may remain in the healthy body for an indefinite period, in a quiescent state, or until some pathologic change takes place in the tissues, furnishing the soil and conditions for their germination. Fodor injected pathogenic bacteria into the circulation of rabbits, i6 SURGERY OF THE FACE, MOUTH, AND JAWS. for the purpose of studying their effect upon the tissues and the mode of elimination. In a majority of instances he found that they had en- tirely disappeared from the blood at the end of twenty-four hours, and he is of the opinion that they were destroyed by the blood-corpuscles. Metchnikoff advanced the theory that the leucocytes, which are always present in large numbers in acute inflammatory processes, and which he denominated phagocytes, have the power of appropriating and destroying the invading bacteria. The relative frequency of the presence of pyogenic cocci in cases of suppuration in the human species is shown by Steinhaus to be as follows: Out of 330 cases reported by different observers, the sta^ny- lococci were present in 66.5 per cent.; the streptococci in 20.4 per cent.. 5i I4 ^^}.f^u y Staphylococcus pyogenes aureus. X 1200. and a mixture of these two forms in 9.5 per cent., while the tenuis was present in only i per cent., and the other forms even more rarely. In other words, pus micro-organisms were present in 97.4 per cent, of cases. The Staphylococcus pyogenes aureus (Fig. 15), yellow cocci, — so called from the fact that it is arranged in clusters, and gives a yellow color when cultivated in beef-gelatin, — is the most common of all the pus-microbes. It is globular in shape, and its diameter ranges from 0.7 to 0.87 micro- millimeter. The size depends upon the age of the coccus and the soil in which it grows. It multiplies by fission, but the line of division is difBcult to make out. It grows readily upon beef gelatin at the house temperature, but is more active when grown in a temperature like that of the body, and does not require a large amount of oxygen to maintain a vigorous growth. It has the power of lique- fying gelatin by virtue of its peptonizing action, and it receives the color of nearly all the staining agents very readily, and is well adapted SURGICAL BACTERIOLOGY. I7 to the Gram method. It is also very tenacious of life, and requires to be subjected to the boiling temperature for several minutes in order to destroy its vitality. Cultures of this coccus have a peculiar and dis- agreeable odor like that of sour paste. It is found abundantly outside of the body. Its most common seat is the superficial layers of the skin, particularly in those parts of the body which are kept moist, like the. axill?e, between the buttocks, etc.; also under the free ends of the finger-nails; in the mucus of the nasal passages, pharynx, mouth, and; digestive tract. It has likewise been found in the air, especially of lnoc-«iital wards which were in an unsanitary condition; in garden soil>. in the dirt of the streets, in dirty dish-water, and in fact almost every- where. The SfapJiylococais pyogenes alhus — white coccus — cannot be dis- tinguished from the aureus, except that it does not develop the yellow or golden-colored pigment. It would seem to be a variety of the aureus but for the fact that it cannot be so cultivated as to give the color of the yellow coccus. It always maintains its white color in any culture-medium upon which it will grow. It has the power of lique- fying gelatin. It is found less often than the aureus, is not so virulent, and the disturbances in the tissues caused by its presence are less pro- nounced. The Staphylococcus viridis Uavescens ,—gxetmsh.-ye\\o^ coccus, — found in the vesicles of varicella, is an exceedingly rare variety. According to Babes it occupies an intermediate position between the aureus and albus. The cocci are irregular in shape, and larger than the aureus. When cultivated upon agar-agar, it forms a delicate film. Its characteristic color is a greenish-yellow pigment. The Staphylococcus pyogenes citreus — lemon-colored coccus. This variety seems to be in all respects like the aureus and albus in its behavior, with the exception that it develops a pale-yellow or lemon- yellow pigment when cultivated in beef gelatin. It liquefies gelatin more slowly than the aureus or albus. The Staphylococais cereus albus et Havus — white and yellow cocci. These are two rare and unimportant forms. The albus is found in the pus of acute abscesses, and Tils discovered it in hydrant water. The Havus was also found in acute abscess. Passet, the discoverer, has only found them in two cases of abscess; other investigators have been unable to find them. Under the microscope they cannot be distin- guished from the other varieties. When cultivated in artificial media, they each develop their characteristic pigment, and produce a dull, waxy growth when cultivated upon the surface of gelatin plates. The Micrococcus pyogenes tenuis. This coccus obtained its name from the great delicacy of it? growth. It was discovered by Rosen- bach in the pus of an abscess, and is another rare form of pyogenic 3 l8 SURGERY OF THE FACE, MOUTH, AND TAWS. COCCUS. It is more than probable that like the cereus it may have had only an accidental presence in an abscess, and not be in any sense a pus-microbe. Under the microscope it presents a somewhat irregular shape, and is larger than the aureus. It produces a thin, transparent, varnish-like film upon the agar culture. The Streptococcus pyogenes (Fig. i6) is a very important variety of the pyogenic cocci. It is usually found alone, but occasionally it is associated with the staphylococci. The arrangement of the organism is in chains or rows, usually from six to ten being attached together. They measure in diameter about one micro-millimeter. Micro- scopically they are identical with the streptococcus of erysipelas, the only discoverable dift'erence being one of size, the erysipelas organism being the larger. The streptococcus grows at house temperature, but is more active at a temperature of from 30^ to 37° C. On culture- media the coccus reaches its full development in from four to five days. It is not particularly sensitive to the absence of oxygen, but nevertheless grows best upon the surface of the gelatin. At first it has a transparent whitish appearance, but later this color changes to a faint brown. It grows most readily in bouillon, multiplying with great rapidity. The organism is found under normal conditions in the saliva and mucous secretions of the mouth and nasal passages, in vaginal mucus, and in the urethra; it is also found as a "mixed infection" associated with the pathogenic organisms of typhoid fever, pneumonia, tuberculosis, scarlet fever, and diphtheria, and may therefore be an important agent in causing the various complications of these affec- tions. The BacUhis pyocyaneus is a widely distributed form, but not neces- sarily a pus-producing microbe. It is the organism of blue or green pus, and is found in wounds with purulent or serous discharges, in the perspiration, and in the viscera of human cadavers. It is a small, slen- der rod with distinctively rounded ends, and may occur in chains or rows, usually arranged five or six in a row. It has active motility, and produces upon gelatin a beautiful green fluorescent pigment. The pigment is formed when the organism is in contact with the oxygen, and this may be seen upon the edges of dressings and bandages. It grows readily at house temperature, and belongs to that class which will grow and multiply with a scant amount of oxygen. Spores have not been seen to form. The coloring matter produced by this organ- ism has been termed "pyocyanine." It was discovered by Bouchard that cultures of the Bacillus pyocyaneus will prevent the development of anthrax or splenic fever, if injected into the tissues of animals al- ready infected with virulent cultures of the anthrax bacillus; and that the disease could be cured by the same means even after it had devel- oped. SURGICAL BACTERIOLOGY. 19 The Bacillus pyogenes fcetidus is a rare and unimportant organism found in ischio-rectal abscesses. Upon gelatin cultures it forms upon the surface a white or grayish film of delicate growth. When grown upon agar or potato, it produces a light brown color and has an offen- sive odor. The Micrococcus tetragemis is also a somewhat rare form, and was first found by Gaffky in a tuberculous cavity of a lung; it is also occa- FlG. 16. ^ «^ » '■% 1 m ) . •^ ^'^ ! A • V 1 ' ^4 5 "^ ^' > . % ^ ^. ^ Streptococcus pyogenes. ■sionally seen in both morbid and healthy expectorations. Steinhaus found it in an acute abscess near the angle of the jaw. lakowski also found it in two cases of acute abscess, one of the finger, the other in the palm of the hand. This organism is characterized by being grouped in fours and involved in a capsule, hence its name, tetragenus. In cul- ture-media the coccus does not grow in any regular order, .but when found in the tissues it is always in groups of four imbedded in a gela- tinous envelope. It takes the stain of all anilin dyes, and also of the 20 SURGERY OF THE FACE, MOUTH, AND JAWS. Gram method. It is an aerobic organism, and when grown upon gelatin appears as thick, globular, whitish masses with a somewhat glistening surface, but does not cause liquefaction of the gelatin. Steinhaus and others have proved by experimental research that pus may be produced without the aid of the pus-producing micro- organisms, by the introduction into the tissues of certain irritating chemical substances, but that the pus so produced was aseptic, anming (Ziegler), take place in the following order: The first stage in the process of division of the nucleus is the disappearance of the nuclei, while the substance of the i6o SURGERY OF THE FACE, MOUTH, AND JAWS. nucleus assumes the form of a mass of sinuous filaments or a raveled coil, which is termed the coil-form of the mother nucleus. From this stage in the process the nuclear substance alone is susceptible to the action of staining reagents, and for this reason the nuclear substance has been termed chromatin (Fig. 55). The filaments now become thicker and the coil looser; breaks occur in its continuity, and it gradually passes into a wreath-like form. The arrangement of the filaments is in a series of loose central and Fig. 55- K Cells from the Epidermis of Very Young Larva of Newt. (After Piersol.) A, resting nucleus ; £, close skeins ; C, loose skeins ; D and E, mother stars, seen from the polar field and appearing as the wreath stage ; r, mother star from the side ; C, migration of segments ; H, daughter stars ; /and/, segments grouped about new polar fields (in /this protoplasm exhibits constriction) ; K, daughter skeins (division of nucleus complete, with slight constriction of cell- body) ; L, complete division of nucleus and protoplasm. peripheral loopings with the center of the mother nucleus unoccupied. The next change of the nucleus is from the wreath-like arrangement of the filaments to that of a star-form or asterisk, with double rays, and the peripheral loops later divided at their free extremities. Following this the double rays divide longitudinally, and a considerable contrac- tion of the whole star-form takes place. The single-rayed star thus formed next divides through the equator into two equal polar seg- ments. This division is accompanied by the formation of a transpar- ent equatorial plate (Strasburger's cell-plate), which is often marked by a line of five points. Later the polar segments move asunder WOUNDS. i6i toward opposite poles, and assume an appearance resembling a "half- barrel" or a "basket form." These now represent the daughter nuclei, which soon pass into the star-form, and this into the wreath-form, by a fusion of the ends of the star-rays. At the same time a constriction of tlie cell-protoplasm commences. The wreath-form of the daughter nuclei now shrinks, and its filaments become more and more sinuous, until it assumes the coil-form. The constriction of the cell-protoplasm has also by this time been completed. In the last stage the coil-form becomes more loose and regular, and finally develops into the nuclear network or reticulum, like that of the mother nucleus. Fig. s6. Karyokinesis— Loose Skein. X 1500. The severance of the cell-protoplasm completes the process of karyokinesis, and the new-formed nuclei enter the resting state corre- sponding to the resting state of the mother nucleus. During the pro- cess of subdivision the nucleus is surrounded by a clear intermediate substance. This substance during the active stages of subdivision is not susceptible to staining reagents, but in the resting state it is readily stained. Figs. 56, 57, 58, are photo-micrographs of the three principal stages in the process of karyokinesis, — the formation of the loose skein, the equatorial plate, and the separation into daughter asters or stars; the outline of the cell-protoplasm being distinctly seen. Sometimes segmentation of the nucleus takes place without sub- division of the cell-protoplasm, thus forming a binucleated cell; or if the process of segmentation goes on, a multi-nucleated or giant cell is formed. The giant cells, however, may later break up into uninu- 1 62 SURGERY OF THE FACE, MOUTH, AND JAWS. cleated cells, the protoplasm gathering around the individual nuclei and dividing along the boundaries so defined. Fig. 57. Karyokinesis- Equatorial Plate. X 1500. Fig 58. Karyokinesis— Daughter Asters. X i5°°- Regeneration of tissue includes the reparative process which takes place in the healing of traumatic wounds, and the reproduction of tissue lost from inflammatory processes. WOUNDS. 163 All reparative processes are brought about by cell-proliferation, "each after its kind." This is a histogenetic law which has been abundantly demonstrated, and generally accepted. Every normal cell is endowed with an inherent tendency to reproduce itself, and to trans- mit its own peculiar function of tissue-building. This function is never perverted to the production of a tissue with a materially different histologic structure, but always reproduces a tissue which is anatomi- cally and physiologically like the tissue of which it formed a part. Nerve-cells produce nerve-cells; epithelial cells are only produced by epithelial cells; bone-cells by bone-cells; enamel-cells by enamel-cells, etc. All wounds, whatever their anatomical structure, heal by cell-pro- liferation, — by the production of new material from the fixed-tissue cells of the immediate neighborhood. The fixed-tissue cells being endowed with the power of adaptation to conditions which surround them, begin, immediately after the injury has been received, to inaugurate the process of repair. This consists of rapid segmentation of the pre-existing tissue-cells, thus forming embryonal cells; these cells gradually assume the character of mature cells, as the process of healing progresses, until finally they represent the tissues from which they had their origin. Methods of Healing. — The processes by which wounds heal are generally classed under three heads: First, union by primary adhesion, or first intention; second, adhesion by granulation, or second intention; third, secondary adhesion, or third intention. Healing by Primary Adhesion^ or First Intention. — To secure union by this process the surfaces of the wound must be accurately approxi- mated, and shielded from all forms of irritation. Under such circum- stances the exudate will be of minimum quantity, and absorption of the red blood-corpuscles will occur; at the expiration of twenty-four hours adhesion between the surfaces has taken place, and at the end of two or three days the new-formed material (plastic lymph) which binds them together will be traversed by blood-vessels. John Hunter believed that the process of primary union might be accomplished in a few hours in incised wounds where perfect coap- tation of the parts could be secured, without the interposition of new material. He has been supported in these views by Macartney and Sir James Paget, and later, among the more modern pathologists and surgeons, we find Thiersch holding the same views. The process of primary or immediate union is usually accomplished with only the slightest manifestations of inflammation, rarely pro- gressing beyond a little hyperemia, puffiness, and tenderness about the edges of the wound, and leaves little or no scar. In primary union there is restoration of continuity, a coaptation of 164 SURGERY OF THE FACE, MOUTH, AND JAWS. divided tissues, part with part, — an organic union, vessel with vessel, and nerve with nerve. In deep wounds, where important nerve-trunks are severed, it is necessary to bring the divided ends of the nerve to- gether by suturing, and some surgeons maintain that nerve function is occasionally restored in a few hours after this operation. Restoration of function in the circulation and nerve-supply, even under the most favorable circumstances that can possibly surround an incised wound, rarely occurs under six to eight days. Wounds which heal by first intention are always aseptic. Fig. 59. Fibroblasts. Fibroblasts. Fibrinous exudate. Inflammation— SHOWING Fibroblasts in Regeneration of Tissue. ,,< 50. Healing by Second Intention, or Adhesion by Gramdation. — This process takes place in those wounds in which the surfaces have not been accurately brought together, or have been subjected to irrita- tion of a mechanical, chemical, or septic nature. Under these cir- cumstances the exuded material becomes excessive, death of the blood- cells and the newly-formed embryonal cells takes place, resulting in suppuration. On the removal of the source of irritation, the inflam- WOUNDS. 165 matory process quickly subsides, and is immediately followed by cell- proliferation, which soon fills the gap with granulations, and later covers the surface with a modified epithelial structure which forms a scar. During the formation of the granulation-tissue, the fixed-tissue cells are in an active state of multiplication by subdivision, and from these embryonic cells the new tissue is formed to replace that which has been lost (Fig. 59). Fig. 60. Fibroblasts Blood-vessels. Inflammation— SHOWING Fibroblasts and Vascularization in Granulation-Tissue. X 50. Ziegler defines granulation-tissue as "a structure fashioned out of the cellular material gathered by the blood from the system in general, and utilized to make good a defect which the fixed-tissue cells of the injured region are unable to repair." The tissue formed by the pro- cess of granulation is cicatricial tissue, and is devoid of all specialized structures except blood-vessels. (Fig. 60.) All specialized tissues like epithelium, muscles, bones, nerves, and blood-vessels can be repro- duced only by a regenerative cell-proliferation of identical, pre-exist- ing tissues. None of these can be reproduced from granulation-tissue. l66 SURGERY OF THE FACE, MOUTH, AND JAWS. Healing by Third Intention, or Adhesion of Granulating Sur- face. — This process takes place in amputation flaps which have failed to unite by first intention, in large abscess-cavities where it is impos- sible to bring the walls together, and in those cases where large por- tions of tissue have been lost by gangrene or traumatisms. In this form of healing, the granulation-tissue reaches out from all surfaces of the wound, gradually encroaching upon the space until they meet and unite. The process of healing may extend over weeks and months, depending upon the character and extent of the tissue to be restored and the condition of the wound. Under a strict antiseptic regime such wounds heal much more readily than when these precautions are omitted. The extent of the scar will depend upon the character of the tissue which has been lost and the amount of tissue to be restored. Senn classes all forms of healing under two heads, — Union by Primary Intention, and Union by Secondary Intention. The first he would have include all wounds which heal without septic manifesta- tions; in other words, all aseptic wounds, no matter whether they heal in three or four days, or require as many months; while in the other class he would place all wounds which have given evidence of septic inflammation. He does not believe it is correct, from a pathologic or from a practical standpoint, to class aseptic wounds, which, on ac- count of failure of approximation or loss of tissue, must heal by granu- lation, with infective wounds, in which the reparative process has been disturbed and retarded by suppuration. Surgical Cleanliness. — Absolute cleanliness in surgical operations is of such great importance in the successful treatment and final issue of all surgical cases, that too much stress cannot be laid upon its strict observance in every detail. The student particularly needs to be im- pressed at the very outset of his studies in surgery, not only with the fact that wounds do better when such precautions have been taken, but that the dangers to life from complications arising from septic infection are thereby reduced to the minimum. The question of the value of asepsis and antisepsis in all surgical operations, and in the treatment of all surgical diseases, is no longer one of controversy. The statistics of surgical operations of all kinds before the days of Lister, contrasted with those of the last two decades, are the best proof of the value of asepsis and antisepsis in surgery. The best surgeons the world over admit their value, and attempt as far as possible to carry out the principles of this method of treatment. The laboratory proofs that suppuration, septicemia, pyemia, erysipelas, and kindred dangers arise from the pyogenic micro-organisms are now considered so com- plete that no really unbiased mind can doubt them, while the clinical proofs are equally convincing. Success does not always perch upon the banners of the most brilliant surgeons, but rather upon the stand- WOUNDS. 167 ard of him who is the most careful and painstaking, and whose tech- nique is most perfect in all its details. Carelessness in some appar- ently minor matter may ruin an otherwise successful operation, or endanger the life of the patient. Cleanliness, above all things, is necessary to a successful treatment of wounds. Not ordinary clean- liness, in its general acceptation, but surgical cleanliness, and there is a vast diflference between them. To be surgically clean means to be germ-free. The part to be operated upon must be freed from micro-organisms bv thorough washing with soap and water, and irrigating with anti- septic solutions. The hands of the operator, assistants, and nurses must be cleansed in a like manner, and the accumulations under the finger-nails removed. This should be done before bathing them in the antiseptic solutions. All instruments must be first scrubbed with soap and water, and then boiled in water. The ligatures and the drainage- tubes should be kept in antiseptic solutions, and the sponges and dress- ings of every kind sterilized by heat and antiseptics. By following such a regime as this, all wounds capable of being protected against the entrance of micro-organisms or other foreign elements will heal without inflammatory symptoms, provided they are shielded from mechanical irritation from the sutures and dressings, and the general health of the individual is fairly good. Wounds sometimes do badly from defective nutrition, either local or general. The former is usually caused by tension or a bad posi- tion. These can easily be remedied. But it may occur as a result of the necessary ligation or injury of some important artery, and failure in the establishment of an adequate collateral circulation. General defective nutrition is the result of a debilitated condition of the system, arising from illness, insufficient or improper food, or excesses, particularly the drink habit. As a rule, fractures of the bones do not unite as readily in the confirmed drunkard as in other persons, and injuries to the tissues are much more liable to result in gangrene and necrosis. CHAPTER XVIII. TREATMENT OF WOUNDS. The Treatment of Wounds consists of — First. Asepsis. Second. The arrest of hemorrhage. Third. Accurate approximation of the divided surfaces. Fourth. Providing for drainage. Fifth. Physiological rest. Sixth. Proper dressings. Fig. 6i. Various Forms of Bacteria from the Mouth. fl, c,^, screw-forms ; 6, cocci; rf, rods; f, coccus-chain with sheath ; ?', coccus-chain (streptococci) ^, rod-chain ; A, various thread-forms. (After Miller.) Asepsis. — The first consideration in the treatment of all wounds is that of establishing aseptic conditions. To accomplish this end, the wound must be freed from all extraneous substances and foreign bodies, and thoroughly irrigated with antiseptic solutions. When the wound is upon the external surface of the body, the skin about the injured part should be carefully cleansed with soap and water; if hair TREATMENT OF WOUNDS. 169 be present, it should be removed with a razor, and the wound again carefully irrigated. When the wound is upon a mucous surface, the same precautions as to asepsis should be rigidly carried out; and when associated with the oral cavity, a determined effort should be made to place the mouth and teeth, as far as possible, in an aseptic condition; but this is not an easy task in those cases where the words oral hygiene, or their equiva- lent, have formed no part of the vocabulary of the individual. The removal of the salivary calculus and deposits of food upon the teeth, and a thorough irrigation of the mouth with suitable antiseptic solutions, is the only proper method of rendering this cavity approx- imately germ-free; approximately, because absolute sterilization would be impossible of accomplishment with solutions that would not cause serious irritation to the mucous membrane, and though, meta- phorically speaking, rivers of these solutions were turned through it. still it would not be germ-free. Fig. 6i shows some of the various forms of bacteria found in the human mouth. Triolo is authority for the statement that fresh sterile saliva will kill all the germs of the staphylococcus aureus, the bacteria of the air, of diphtheria, typhus, etc., in five-day cultures, and greatly reduce their numbers in eighteen-hour cultures, but that filtered saliva has no bac- tericidal power. Wounds of the soft tissues of the mouth, in healthy persons of cleanly habits, very rarely suppurate ; but when associated with com- pound fractures of the jaws, the cases are rare in which suppuration does not occur. This difference is largely due to the great difficulty in securing or maintaining an aseptic condition. Arrestation of Hemorrhage. — Hemorrhage is from three sources, viz : from the Arteries, Veins, and Capillaries. Arterial Hemorrhage is characterized by the bright red color of the blood, by its flowing in jets from the wound, and by the arrestation of the bleeding by pressure above the wound upon the arterial trunk. Venous Hemorrhage is known by the dark color of the blood, its steady flow, and its welling up from the bottom of the wound, while pressure below the wound, upon the venous trunk, arrests the hemor- rhage: Capillary Hemorrhage is recognized by the oozing of the blood from the surfaces of the wound. Primary Hemorrhage is the bleeding which takes place at the time of the injury. Secondary Hemorrhage is the bleeding which comes on after reac- tion is established, or later, from the sloughing of ligated vessels and other tissues. Internal Hemorrhage is the bleeding which takes place in the various cavities of the body. 170 SURGERY OF THE FACE, MOUTH, AND JAWS. Extravasation is the escape of blood into the connective tissue. Severe hemorrhage produces marked constitutional effects, char- acterized by a feeble, fluttering, rapid pulse, which is in the later stages only recognized in the large arteries. The lips are colorless, and the surface of the body is blanched, cold, and clammy. The respiration is slow and sighing. Faintness and nausea are prominent symptoms, accompanied by great restlessness, roaring in the ears, and darkness before the eyes. A fatal syncope may follow, or the patient may recover. Fever usually follows recovery from a severe hemorrhage. Sudden and severe hemorrhage is more likely to prove fatal than one that is slow and continuous. Infants are much more seriously affected by the loss of blood than older persons. The complete arrest of all hemorrhage is an important factor in the healing of wounds. Blood-clots between the lips of a wound are objectionable, for the reasons: First, that they prevent perfect apposi- tion of the wounded tissues; second, they are excellent soil for the growth of micro-organisms; third, by their presence they cause tension and pain. There are various methods of arresting hemorrhage, viz: By ligation, torsion, pressure, cautery, heat, cold, position, acupressure, forcipressure, styptics, and constitutional treatment. The most com- mon method of arresting arterial or venous hemorrhage is by ligation. This is accomplished by picking up the end of the bleeding vessel with the hemostatic forceps, and tying a ligature around it. Small arteries may be controlled by forcipressure — crushing the end of the artery by grasping it with the hemostatic forceps — or by torsion; this is accom- plished by twisting the vessel while in the grasp of the forceps. Acu- pressure consists of passing a pin or needle under the vessel, bringing the ends of the instrument above the external tissues, and causing pressure by passing a ligature around the ends in the form of the figure 8. Severe hemorrhage should be checked, when possible, by pressure upon the arterial trunk, above the wound, by a tourniquet, or an Esmarch bandage (rubber bandage), until the severed arteries in the wound can be ligated. In wounds of the face, appliances of this character have no place; consequently the bleeding vessels must be gathered up and secured as quickly as possible by ligatures. If, however, the vessels cannot be reached, as sometimes happens in compound and comminuted frac- tures, or following operations for the removal of malignant tumors, etc., they may be controlled by ligating the external carotid artery. Some surgeons prefer to take this precaution prior to performing any capital operation upon the maxillary bones. To the writer the latter procedure does not seem necessary, for in his personal experience the simpler methods have always proved sufBcient. TREATMENT OF WOUNDS. I7I Capillary hemorrhage may be controlled by the application of a jet of cold water thrown upon the bleeding surfaces, or by hot water applied with sponges or compresses. When the wound is in an ex- tremity, the elevation of the limb will often control this form of hem- orrhage. If the foregoing measures fail, then recourse must be had to the actual cautery, electro-thermal cautery, or styptics. The latter, however, are to be avoided when possible, as they increase the dangers of secondary hemorrhage, by causing sloughing of the cauterized tissues, and preclude the possibility of immediate union. When capillary hemorrhage or oozing is persistent, the adminis- tration of ergot will often prove useful in checking it. The fluid extract may be given in doses of 20 to 30 drops every twenty minutes until three doses are taken, or the wine of ergot may be substituted, dose floj to ij. Care must be taken in administering ergot to pregnant women not to bring on contractions of the uterus. Coaptation. — Accurate approximation of the surfaces is of prime importance in the JicaUng of zvounds, and the surgeon should be prepared not only to bring the lips of the wound together, but to unite tissue to tissue. If a nerve-trunk or tendon is divided, it should be brought together by means of a sterilized animal suture. In deep wounds, the lower portions should be brought together by means of deep sutures, — sutures of approximation. The buried suture of sterilized catgut or silk is also used to bring together the deeper parts of the wound. The edges of the wound are to be closed by superficial sutures of the sam.e material. Superficial wounds are closed by adhesive plaster or collodion dressings. Drainage. — In all deep wounds drainage must he provided for, as the exuded serum is usually considerable in amount, and if it has no way of escape, produces tension and pain, and ofifers a fertile soil for the growth of micro-organisms. Drainage is secured by sterilized rubber tubing, decalcified chicken-bone, glass tubes, strands of catgut, silk, horse-hair, or strips of gauze. Drainage-tubes are rarely ever necessary in the region of the face. The use of drainage-tubes increases the liability to the formation of scars, hence they should be dispensed with as far as possible in opera- tions upon the face. In capital operations, traumatic wounds, and operative wounds involving the antrum of Highmore, drainage-tubes often become necessary. Physiological Rest. — Rest of the injured part, and of the entire body, is imperatively demanded in the treatment of all serious wounds, and is of great value in all classes of wounds. Rest in great measure prevents inflammation, as taught by Hilton. 172 SURGERY OF THE FACE, MOUTH, AND JAWS. The position of the injured part should be such as to favor a normal blood-supply, while immobility adds greatly to the rapidity of the healing process. Wounds in parts which on account of their particular function it is difficult to keep at perfect physiological rest, — like surgical wounds of the lip, following operations for hare-lip and cleft palate in nursing infants, — do not always give as perfect results as do wounds in other locations that can be controlled. Anything like perfect rest of the lips or palate in such children is an impossibility; feeding and crying are among the principal occupations of the normal baby when not asleep. The motions incident to these functions more or less disturb the process of healing, and as a consequence the best results are not always obtainable. Dressings. — The character of the dressings and their adjustment are matters of considerable consequence in the healing of wounds. In these days of antiseptic surgery, no intelligent surgeon would think of using other than aseptic dressings. The main objects of dressings are, to support the wounded tissues during the process of healing, to absorb the discharges, and to prevent the ingress of all substances to the injured tissues which cause or favor septic infection. Antiseptic dressings, like the plug of cotton inserted into the mouth of the test-tube filled with sterilized bouillon, obstruct the entrance of the septic micro-organisms found in the dust and atmosphere almost everywhere, and thus prevent the establishment of putrefactive fermentation. Wounds, like the unprotected bouillon when exposed to the atmosphere, soon become the seat of colonies of septic bacteria. If the resistance of the tissues is impaired, or the environment of the wound is such as to favor their rapid development, the tissues are soon overwhelmed, the reparative process is impeded or entirely suspended, the leucocytes and embryonal cells lose their vitality, and suppuration is the result; while, on the other hand, these conditions do not obtain if the wound has been dressed according to the best aseptic methods. The adjustment of the dressings must always be governed by the extent, location, character, surroundings, and seriousness of the wound. Thicker dressings are required in cases with copious dis- charges than in those with little or no discharge. The covering, how- ever, should always be sufficiently thick to protect the wound from infection from the outside. In applying the dressings, care must be exercised not to produce uncomfortable pressure, as this soon becomes painful, and may estab- lish inflammatory symptoms from mechanical irritation, and thus jeopardize the healing of the wound. In operations upon the lips and face impervious dressings are the best; the collodion dressing has the preference. CHAPTER XIX. GUNSHOT WOUNDS. Under the term Gunshot are included all those wounds which are caused by projectiles that have been propelled by the elastic or ex- plosive power of gunpowder, dynamite, nitro-glycerin, etc. To the injuries inflicted by these missiles may be added the wounds caused through the concussions of the explosives themselves by fragments of wood, iron, or stone, by portions of the body of a comrade, — pieces of bone or teeth, — or portions of accoutrements or clothing. The pro- jectiles used by civilized nations in modern warfare are buckshot; bullets, round and conical; shrapnel, grape and canister, chain or bar- shot; solid cannon-balls, shells, slugs, explosive musket-balls, hand- grenades, and torpedoes. These missiles are projected with great velocity and force. The wounds, therefore, which are inflicted by them are classed as con- tusions, lacerations, penetrations, perforations^ simple fractures, partial fractures, complete fractures, with various degrees of comminution and destruction of substance. The great majority of gunshot wounds are produced by the ball or bullet, either the round or conical. At the commencement of the War of the Rebellion, both opposing armies were obliged to employ the round ball to a greater or less extent, on account of the construc- tion of the firearms. Later, through the introduction of the rifle arm, the conical bullet superseded the round ball. The rifled arms most commonly used were the Enfield, the Austrian, and the Springfield. The Enfield carried a shot weighing 450 grains; the Austrian, one weighing 460 grains, and the Springfield, one of 500 grains. Hamilton says, "Some idea of the velocity and power of the conical shot can be obtained from the following statement: When fired from a Springfield rifle, with a charge of 60 grains of powder, at 200 yards, it will penetrate eleven one-inch pine planks, separated by inter- vals of one and one-half inches; while at a distance of 1000 yards it will penetrate one such plank, and enter the second to the depth of one- quarter of an inch." The preponderance of gunshot injuries over other wounds during 173 174 SURGERY OF THE FACE, MOUTH, AND JAWS. the Civil War is shown by the report of the Surgeon-General of the army. There were treated in hospitals during that period 246,712 cases of wounds caused by weapons of war. Of these, 245,790 were gunshot wounds and 992 were bayonet and sabre wounds. And from the same report it is found that by far the greater number of gunshot injuries were inflicted by projectiles from small arms, the rifle or pistol. The number of cases in which the nature of the missiles was with certainty ascertained was 141,961. Of these, 127,929, or 90.1 per cent., were caused by shot from small arms. Among the casualties of the War of the Rebellion there were re- corded as occurring from explosive bullets 130 cases of wounds. In- juries from this form of projectile are much more serious than from the ordinary round or conical bullet. The destruction of the soft parts is greater, the bony parts are more extensively shattered, hemorrhage, both primary and secondary, is much more common, sloughing of an ex- tensive character is more likely to occur, and the process of repair is slow and unsatisfactory. Diagnosis. — Small fragments of exploded shell, case and canister shot, produce effects which do not materially differ from the injuries caused by missiles from small arms. Large fragments of shell produce great laceration and destruction of tissues. When of sufficient size and velocity, they may carry away a portion of the trunk, or an extremity. Under such circumstances the laceration and contusion may be very great. Wounds made by conical bullets are frequently of irregular shape at the points of entrance and exit. Sometimes the entrance is indicated by a mere slit, or it may be irregularly round or oval, or broadly lacer- ated; while the wound of exit is always larger and still more irregular. The track of the wound also gradually increases in size as it reaches the point of exit, thus giving it a somewhat conical form. Wounds caused by round balls are quite generally round, the wound not larger than the missile; the surface depressed at the point of entrance, and the edges discolored. The wound of exit is irregu- larly round, and somewhat larger, while the surface is elevated and the edges everted. The round bah is not so destructive to tissue as the conical shot, which, on account of its increased weight and velocity, meets with little resistance from any of the structures of the body at ordinary range, and is seldom deflected from a straight line, crushing, tearing, and comminuting everything in its path. The wounds of en- trance ajtid exit will correspond in most cases with the line of projec- tion. Hamilton mentions a peculiar exception to this rule, to be found in the Army Medical Museum at Washington: "A conical ball, marked 4622, entered the thoracic parietes on one side, made a semi-circuit of the body, and emerged at a point corresponding to the place of en- trance on the opposite side." GUNSHOT WOUNDS. 175 Round balls, from their shape and decreased velocity, are more liable to be deflected from the line of projection at the point of contact with the surface of the body, or of their passage through the various tissues. Leaden bullets, when they come in contact with bony tissue, often become deformed or split into fragments, the pieces tearing through the tissues at a tangent from the line of projection, causing several wounds of exit. When the momentum is sufficient to cause penetration of bony tissue, it is usually badlv comminuted or more or less splintered. Experiments made with steel- jacketed bullets by the Army Medical Department and exhibited at the World's Fair at Chicago, in 1893, proved conclusively that projectiles made of metal which retained its form, in passing through the epiphyses of long bones or other spongy bone, would in a majority of cases, under their full momentum, pene- trate without fracture, and rarely fissure or comminute this tissue. When passing through the shaft of these bones fracture was the usual result, but with less comminution and splintering. In the Report of the Surgeon-General, U. S. Army, 1893, atten- tion is called to a series of experiments conducted at Frankford Ar- senal, Pa., by Capt. L. A. LaGarde, in connection with the Ordnance Department of the Army : "The weapons used in the experiments were the Springfield rifle, caliber 0.45, and an experimental Springfield, caliber 0.30; the former giving an initial velocity of 1301 feet per second to 500 grains of com- pressed lead of cylindro-conoidal form, cannelured and lubricated; the latter impressing a velocity of 2000 feet per second on a bullet weighing 220 grains, and consisting of lead incased in a jacket of German silver. The penetration of the latter was found to be greater than that of the old arm and bullet at all ranges, and the amount of shock correspond- ingly less. Explosive effects at short ranges differed but little for the two projectiles, but the explosive zone of the smaller bullet extended to 350 yards, or 100 yards farther than the other. Beyond the limits of the explosive zone the destructive effects of the smaller bullet became less than those of the larger, and this difference was especially notice- able from the 500 to the 1500 yard ranges, and in the wounds inflicted on the joints and soft parts. The lessened severity of wounds at these ranges is attributed in part to the small amount of flattening or other deformation found in the jacketed bullet after impact even with bone. At longer ranges, where velocity became lessened, the small bullet again produced extensive comminution of bones and disorganization of soft parts, attributed to a sideways impingement. Dr. LaGarde's experiments show that the heat imparted to a projectile by fhe ignition of the powder, the resistance in the barrel, etc., has been much ex- aggerated. It is certainly insufficient to render a bullet aseptic. 176 SURGERY OF THE FACE, MOUTH, AND JAWS. Lesions in wounds cannot be attributed in any way to the heat im- parted by the bullet, but they may be caused by septic infection before firing. Of the jacketed missiles the cupro-nickeled steel bullet is cer- tainly the best, as its mantle does not part from its nucleus on impact with bone. As its penetration is not lessened by deformation its mili- tary efficiency is greater than that of other missiles; and while it is capable of disabling more men than a bullet which becomes impaired in form, the wounds occasioned by it are less destructive to the individual." Dr. LaGarde says, in speaking of explosive effects: one should not confound the term explosive effects with explosive action. The latter term should be restricted to those wounds caused by an explosive bullet — ^that is, a projectile that explodes on impact. Such a projectile is hollow, charged with explosive materials which ignite when the bullet strikes against a hard substance, like bone. The bullet is thus torn asunder, causing usually an extensive lacerated wound. On the other hand the projectiles possessed of superior velocities do not explode on impact. They are solid, and at most seldom become altered in shape. Indeed, those of the small caliber, inclosed in a mantle of the hardest steel, do not even deform when they collide with the most resistant parts of the human body ; and yet they are proverbial for their explosive effects in the proximal ranges. Explosive effects are well exhibited by firing the projectile of the old and new arm mto tin cans at close range. For the purpose of com- parison, if the experiment is done by firing into tins when empty, and into another set of tins of similar capacity filled with water, the empty cans will exhibit no alteration in shape. The orifice of entrance and exit of the bullet will correspond in size to the sectional area of the projectile; on the other hand the tins that were filled with water will show great alteration in shape. The sides of the vessels will exhibit a bulging as if some interior force had exerted an outward pressure in all directions. The orifice of entrance will usually correspond to the caliber of the projectile, while the orifice of exit will be marked by a large irregular opening with everted edges. If the experiments are continued upon a cadaver at close range, impact with a resistant bone will present certain characteristic features : The wound of entrance in the skin will correspond in size to the diameter of the bullet ; the wound of exit will be marked by a bursting forth of the skin. "The track leading to the bone is conical in shape, the base of the cone corresponds to the wound of exit in the skin, and the apex of the cone corresponds to the seat of fracture. The bone is finely comminuted. A close inspection shows that the bony particles have been driven into the tissues at right angles to the bullet track; while it is not uncommon to find bony sand in the wound of entrance." "Five theories have been advanced to explain these explosive effects : GUNSHOT WOUNDS. 177 Hydraulic pressure. Compressed air, or the projectile air. Rotation of the bullet. Deformation of the bullet. Heating- of the bullet. 1. Hydraulic Pressure. — "'The term 'hydraulic theory' has been employed by many writers to explain the highly destructive effects often found in gunshot wounds at the proximal ranges. It is based on the principle of Pascal. This principle is only applicable to a closed vessel filled with liquid. In accordance with this principle if a certain pressure is made upon a given area of the imprisoned liquid a similar pressure w-ill be exerted within on like areas of the vessel walls." The experiments of Coler, Stephenson, and others have effectually disproved this so-called hydraulic theory. They have show'n that the highly destructive eft"ects noted bv firing into sealed vessels filled with liquid w^ere to be noted in the same way when the vessels were unsealed. Ordinary tin buckets filled with water, w^hether the tops w^ere in place or not, sustained the same amount of destruction. 2. Compressed Air, or Projectile Air. — This is called the projectile air of ]\Ielsens, because it is he who recently revived this theory of projectile air in explanation of the destruction in w'ounds that so often suggests explosive action. Boys has succeeded in making exact photo- graphs of bullets in transit. He caused the bullet to cross an electric circuit. At the moment of contact wnth the circuit the bullet and the immediate vicinity of its trajectory are illumined by a spark which serves to throw' the image upon a photographic plate, A study of the views thus obtained distinctly shows a pad of compressed air in front of the projectile. ]\Ielsens believed that this cushion of air entered the tissues at the moment the skin was penetrated or before, and that the destruction of tissues w'as to be accounted for by the explosion which occurred when the compressed air again regained its normal volume. The tissues fail to show- any evidence of air having been forced into them, such as one might infer from the presence of emphysema, and altogether it may be said that the theory of projectile air has but little to recommend it to consideration. 3. Rotation of the Bullet. — The rotation of a rifle bullet is im- parted to it by the twist in the barrel. The longer the bullet the sharper must be the twist. The old Springfield 0.45-caliber bullet, which was but tw-o calibers in length, and which revolved 800 turns per minute at the muzzle, described one complete turn in 22 inches, because the twist in the barrel corresponded to one complete turn in 22 inches. In the present rifle the twist is sharper, viz, one turn in about 10 inches, and the rate of revolution is estimated at 2400 turns per minute. It is generallv admitted by ballisticians that the velocity of rotation is well 13 17^^ SURGERY OF THE FACE, MOUTH, AND JAWS. maintained, — that it does not diminish with the velocity of translation. Taking for granted that the projectile makes a complete turn in ten inches, we must admit that the rotation of the bullet can have but a minimum amount of effect to display in traversing a thigh bone which may be but one inch in diameter, because in traversing it the ball is making only one-tenth of a turn. 4. Deformation. — The fact that the old leaden bullet became de- formed when colliding with a resistant bone, especially at short range, added greatly to the amount of destructive effects. Deformation can find no plea as a cause of destructive effect in all cases since the steel- clad bullet that does not deform is proverbial for the creation of ex- plosive effects. 5. Heating. — Heating of the bullet by the act of ignition to ex- plain explosive effects found adherents long ago, and it was not until recent years that this erroneous notion was set aside. We were able to show in 1892 that the heat on a bullet caused by the ignition of the powder is not sufficient to destroy the ordinary septic germs. The ex- periments were conducted with missiles from low-velocity rifles and the weapons of reduced caliber with the same result. To speak briefly, we can truthfully say that the heat of a missile cuts no figure in gunshot wounds. The true cause of explosive effects is the superior energy possessed by the bullet at the moment of impact. The bone, and even the soft parts, receive a large amount of this energy and move "outwards in lines radiating from the long axis of the bullet-track with such a degree of force that they act as secondary missiles on the neighboring tissues and cause still further smashing and pulping of the tissues. Even fluid particles participate in this secondary action, but it is all the more marked when fragments of bone are driven apart in this manner." (Stephenson.) The wound of exit of the small-caliber bullet was generally larger than the wound of entrance, and beyond the zone of explosive effects especially it was generally round, marked at times by a mere slit ; again it was star-shaped, T-shaped, semicircular, etc. ; the edges were gen- erally turned out. Upon the whole, the gunshot injuries by the Mauser, the reduced- caliber rifle of the Spaniards, were in keeping wath those humane effects so confidently predicted by experimenters generally. The wounds of soft parts healed without suppuration. The lesions of bone that formerly caused such a high mortality in the statistics of wars were most successfully treated by antiseptic dressings and the proper use of immobilizmg materials. Comminution and fissuring were noticed in the diaphyses. It was, however, seldom necessary to cut down for the purpose of removing spiculse of bone, as the displacement of fragments GUNSHOT WOUNDS. 179 (lid not rctiuirc this amount oi interference. The clean-cut perforations of the epiphyses, without fracture, rendered joint injuries the most favorable of all bone lesions for rapid healinf^, with little or no loss of function. This was especially true of gunshots of the knee. The English in the Soudan, and in the Ashantee campaign, were so doubtful of the efficacy of this small-caliber missile to arrest the impetus of savage tribes that they resorted to the practice of making their ■ missile explosive by tiling the nose through the steel casing enough to expose the lead core. This is the famous Dum-Dum bullet, which takes Its name from the place of its manufacture in India. When the lead is exposed, as stated, the projectile disintegrates on impact with a resistant structure. The fragments of the steel mantle and lead core acting as individual missiles, add greatly to the destructive effects in the foyer of fracture. Among the general conclusions of the report of these "Experi- ments with Projectiles of Hard Exterior" are the following: "The differences between the effects of the bullets of hard exterior and the leaden projectiles lie in the greater penetration of the first, and this in turn is due to greater velocity, diminished frontage, and the hard envelope which diminishes the chances of deformation. "For the two bullets, especially when a resistant bone is struck, the amount of lesion is in proportion to the velocity. "The shock impressed upon a member increases with the velocity, whether a bone is traversed or not. It is, however, always greater with the leaden projectiles. "The explosive effects at very short range are about the same for the two projectiles. They continue, however, up to 350 yards wdth the smaller projectiles and cease at about 200 yards with the leaden pro- jectiles. "The smaller frontage of the hard mantle projectiles causes them to inflict injuries something after the manner of a subcutaneous wound, when the soft parts alone are traversed, and the small wounds of entrance and exit and the narrow track of the missiles are favorable circumstances to a rapid healing. "A wound of exit the diameter of a finger or thumb in area in- dicates for either bullet fracture of bone with splintering, and in accord- ance with the observations of Delorme and Nimier, who experimented with the projectile of the Gras as compared with the effects of the Lebel projectile, tears of similar extent in the clothing are alike in- dicative. "Injuries inflicted outside the zone of explosive effects upon the diaphyses of long bones always show less comminution with' the small bullets of hard exterior. The fissures are often subperiosteal and the fragments are larger. l8o SURGERY OF THE FACE, MOUTH, AND JAWS. "Beyond the zone of explosive effects the projectiles of hard ex- terior almost invariably perforate or clutter the joint ends of bones, and the lesions of the articulations are never so grave. "The projectiles of hard exterior lodge more rarely in the tissues than the leaden bullets. The latter more often leave fragments of lead in the foyer of fracture. "The projectiles of hard exterior are more humane than the old. Resections and amputations will not be so often required hereafter. Soldiers will be more often restored to the state useful members of the community instead of cripples and pensioners, and in point of economy the new projectiles confer a great advantage. "As the projectiles of smaller caliber with hard mantles are less apt to lodge or to carry foreign substances into the wounds, we will expect to find fewer cases of suffering due to the remote effects of unextracted foreign bodies. This, w'e should bear in mind, is one of the most fre- quent sources of protracted suff'ering after gunshot wounds. "The frontage of the new armament bullets being much less, and the fact that the bullets seldom lodge, will contribute to increase the percentage of recoveries in gunshot wounds of the lungs, and this will be especially true in the wounds of this class which may be inflicted beyond the zone of explosive effects. "When the new bullets do become lodged they w'ill be less apt to cause irritation, for two reasons — they are lighter in weight and seldom deform." [Fig. 62 shows a Roentgen-ray picture of a Mauser bullet lodged in the neck of a returned soldier from the War m the Philippines (taken from the collection of the U. S. Army General Hospital, Presidio of San Francisco).] "Wounds of the face from the new projectiles will cause less dis- figurement. "Fatal Primary Hemorrhage in the Field. — There are no statistics bearing on the percentage of cases of fatal primary hemorrhage in battle, because, as a rule, the surgeons are so busy in caring for the wounded that there is no time to devote to the dead, but it is generally admitted that the number of cases of fatal primary hemorrhage is large. When the leaden projectile encounters resistant bone, pieces of lead are nearly always detached at the moment of impact. If the momentum of the projectile is still sufficient the pieces of lead and splinters of bone act as secondary projectiles, and the danger of w^ounding neighboring vessels is consequently increased. Since the new projectiles, outside the zone of explosive eft'ects especially, cause less shattering, and as they seldom deform, the amount of danger to blood-vessels will not be so great, hence the cases of fatal primary hemorrhage in future battles will be less." The report of the Surgeon-General, U. S. Army, for 1900, in re- GUNSHOT WOUNDS. l8l ferring to the gunshot wounds of the late war with Spain ( iSyS and 1899), says: "Of the 4919 men injured by gunshot during the years 1898 and 1899, 586 were killed and 4333 were wounded and received into the field and other hospitals. The killed constituted 11.9 per cent, of those struck, the wounded 88.1 per cent. In other words, i man was killed for every 7.4 wounded. The ^lauscr bullet must therefore be regarded Fig. 62. Mauser Bullet lodged in the Tissues of the Neck. as less deadly than the larger missile used during the Civil War. The Medical and Surgical Historv of the Civil War shows the following casualties : Killed. Wounded. United States troops 59-86o 280,040 Confederate troops 51425 '227.871 Total 111,285 507.911 l82 SURGERY OF THE FACE, MOUTH, AND JAWS. "In percentages the casualties were : Killed, 17.97 ; wounded, 82.03 ; or one man killed to every 4.56 wounded. The relative proportion of killed was therefore considerably larger during the Civil War than dur- ing our recent experiences. It is to be noted, also, that many of the wounds of the past two years were made by missiles of large caliber. Of those reported in 1899, 471 were specially stated as having been caused by the Remington bullet of caliber 0.45. It is safe to say that had the whole number of wounds received been inflicted by the smaller Mauser or Krag-Jorgensen bullet the percentage of immediately fatal wounds would have been materially lessened. "The less deadly character of the injuries inflicted by the modern bullet is manifested, also, when we exclude the killed and regard only those wounds which came under the care of the surgeons. Of these, during the two years, there were 4333, and 259 of the patients, or 6 per cent, of the whole number, died. The corresponding percentage from the records of the Civil War was 14.3. The Medical and Surgical His- tory of the War of the Rebellion shows that among the white troops of the Army there were borne on the reports of sick and wounded 230,018 gunshot wounds, of which 32,907, or 14.3 per cent., proved fatal. The marked reduction of the ratio of killed to wounded may be placed to the credit of the small caliber bullet ; but the lessened mortality among the cases which came into hospital may not wholly be attributed to the humane character of the wounds inflicted by the missile. Due credit must be given to the improved surgical methods of the present day. Wounds of any region of the body may be taken in comparison and the result will always be found to show a decided lessening in the percent- age of cases ending fatally among those of the past two years as com- pared with those of the Civil War "Not only limbs but lives were saved by the surgical practice of the past two years. In the 82 gunshot fractures of the femur the upper third was involved in 32, of which 5 were fatal ; the middle third in 27, of which 3 were fatal ; and the lower third in 2^, of which i was fatal. The mortality varied from 4.3 per cent, of the cases in which the lower third was fractured to 15.6 per cent, of the cases in which the upper third was the site of the injury, whereas the corresponding percentages of fatal cases during the Civil War were, respectively, 42.8 and 49.7. The whole of the lessened mortality in these serious fractures may be credited to the protection given to the wound by the first-aid dressing and to the care exercised in the subsequent aseptic treatment of the fractured limb. "In penetrating wounds of the thorax the rate of mortality fell from 62.6 per cent, during the Civil War to 27.8 per cent, during the years 1898 and 1899. The Civil War reports show 8403 cases in which the results were determined ; 5260 deaths occurred among the number. GUNSHOT WOUNDS. 183 The reports for the later years, as already stated, show 198 cases, of which only 55 were fatal. "There were durin.e- the Civil War 3475 penetrating wounds of the abdomen in which the ultimate results were determined; 3031 of these, or ^j.2 per cent, of the total, proved fatal. During the years 1898 and 1899 116 cases — 81 fatal — were recorded, the fatal cases constituting 70 per cent, of the total. Of 10 cases in which laparotomy w^as performed, 9 were fatal. "The alteration in the percentages of mortality in fractures of the cranium is less marked than in wounds of other parts of the body. Of 4243 cases of cranial fracture during the Civil War 2514, or 59.2 per cent, were fatal. In 1898 and 1899 68 cases were recorded, with 37 deaths, the latter forming 54.4 per cent, of the whole number." CHAPTER XX. GUNSHOT WOUNDS OF THE FACE. Many of the bones of the face are so thin and shell-hke, and the parts so exceedingly vascular, that gunshot injuries with the leaden bullet are likely to cause great comminution of the bones, and serious hemorrhage, both of a primary and secondary nature. Laceration of the soft tissues, with hemorrhage of a more or less serious character, is a constant accompanying feature of this form of gunshot injuries of the face, while the mortality is exceedingly high, both from the immediate effects of the injury and from secondary hemorrhage. According to the report of the Surgeon-General of the Union Army, the principal cause of fatalities from injuries of this class was secondary hemorrhage, and this seems to be the general opinion of all surgeons who have had any considerable experience in military sur- gery. 1 The fact that secondary hemorrhage is so common in gunshot injuries of the face is explained by the inaccessibility of the vessels to ligature, while ligation of the carotid does not always prove successful in preventing it on account of the free anastomosis with the vessels of the opposite side, and of the same side. During the War of the Rebellion, there were reported 9416 gun- shot injuries of the face. Of these, 4914 were flesh wounds, with 3706 recoveries, 58 deaths, 11 50 undetermined results, and 1.5 percentage of fatalities. The remaining 4502 were complicated with fractures of the bones; 3700 recovered; 404 died; 398 results undetermined, and percentage of fatalities, 9.8. The mortality is always very much higher in all cases of gunshot injuries complicated with fractures of the bones. The effects of the injuries from the rifled firearm, with its heavier missile, greater velocity, and surer aim, contrast very unfavorably, from this stand- point, wdth the round bullet and smooth-bore musket. During the Crimean War there were 533 wounds of the face; 107 were complicated with bone injury; 445 recovered, and reported for duty; 74 were invalided, and 14 died; percentage of fatality, 3.8. Wounds of the face from gunshot injuries made bv the leaden GUNSHOT WOUNDS OF Tllli: FACE. Io5 bullet often cause great distij^urenient from the loss of tissue ; but as a rule, laving- aside the fatalities from the immediate injury and s:condary hemorrhage, thev generall\- do well: the soft tissues heal kindly, and it rarely happens that there is an}- extensive necrosis of the bones. Solid shot and fragments of shell striking the face usually prove fatal, but occasionally an individual will survive after having a consid- erable portion of the face carried away. Heath mentions some very interesting cases, which it will pay the student who is specially inter- ested in such matters to carefully read. Quoting again from the report of the Surgeon-General U. S. Army for 1900 : "During the calendar year 1898, there were reported from the regular Army 1457 gunshot injuries. 1320 of which were battle casual- ties and 137 the result of accidents, quarrels, attempted suicide, etc. "Of the battle wounds, 1221 were said to have been caused by bul- lets, 83 by shell, and 16 by shrapnel. In 57 cases the site and extent of the wounds were not stated. Flesh wounds in various parts of the body numbered 860, constituting 68.1 per cent, of the total number in which the site of the wound was stated ; 85 were penetrating wounds of the thorax or abdomen ; 41 fractures of the cranial or facial bones, and 7 of the spine ; 140 fractures of the upper extremity, in 86 of which only the metacarpus or lingers were involved; 130 fractures of the lower ex- tremity, the shaft of the femur being involved in 26. the knee joint in 17, the leg and ankle in 34, and the metatarsus and toes in 53. ■'In the volunteer force during the calendar year 1898, 689 gunshot injuries were reported. Eighty-nine of these were immediately fatal and were not taken up on the reports of sick and wounded. "Of the 600 cases taken on sick report, 29, or 4.8 per cent., ended fatally; 4 ended in death, but from other causes than the gunshot in- jury; 437 were returned to duty; 18 were discharged on certificates of disability in 1898, and 8 others in 1899 ; 7 were discharged by order, and the injured in 97 cases were mustered out with their regiments. ''Of the 600 cases, 362 were battle \vounds, 250 of which ended in return to duty, 12 in death as the result of the wounds, and 4 in death from other causes. Six of the wounded men were discharged on certif- icates of disability in 1898 and 3 others in 1899. Three were dis- charged by order and 84 were mustered out with their regiments. "Of 8 fractures of the bones of the cranium 4 terminated fatally. Of 6 fractures of the bones of the face i proved fatal from secondary hemorrhage after ligation of the lingual artery. Of 13 wounds of the neck 3 were fatal. "During the year 1899 there were reported from the x\rmy, regu- lars and volunteers, 2276 cases of gunshot injury, with 149 deaths or 6.5 per cent, resulting from the wounds, and 4 deaths from causes other lS6 SURGERY OF THE FACE, MOUTH, AND JAWS. than the wounds; 1714 were returned to duty, 180 were discharged on certificates of disability, 134 by order, and 80 by muster out or expira- tion of term of service, while 15 remained on sick report at the date of the latest reports. "In addition to these cases, there were killed by gunshot 391 men whose names were not on sick report at the time of their death. "Of the 2276 cases, 1759 were wounds received in action; 517 were not battle wounds, but 411 of them were received in the line of duty. One hundred and sixteen of the battle wounds, or 6.6 per cent., had a fatal ending, and 136 terminated in discharge for disability. "Of the 2276 gunshot wounds on the sick reports of the Army, regulars and volunteers, in 1899, ^^^ ^^^^ o^ injury in 8 cases is not stated. In 2268 cases in which the injured part is specified, the head, face, or neck was w^ounded in 257 cases, or 11.4 per cent. ; the upper ex- tremity in 763 cases, or 33.6 per cent., and the lower extremity in 846 cases, or 37.3 per cent. But if the 369 cases of death from gunshot in which the site of the fatal wound is specified be added to these 2268 cases, we have 2637 cases of gunshot injury, of which 431 injuries of the head, face, and neck constituted 16.4 per cent, of the total ; 590 of the trunk, 22.4 per cent. ; 763 of the upper extremity, 28.9 per cent., and 853 of the lower extremity, 32.3 per cent. "But a more accurate view of the relative liability of various parts of the body to gunshot injury may be obtained if to the gunshot injuries received in 1899 be added those incurred by the regular and volunteer troops during the year 1898. This gives a total of 4919 injuries, 845 of which were fatal. The aggregate number of cases in which the location and character of the injury were stated amounted to 4756, with 757 deaths. "Among the 2276 gunshot wounds entered on the registers during the calendar year 1899 were 197 injuries of the head and face; 141 of these were flesh wounds, 29 fractures of the cranial bones, and 2"] frac- tures of the bones of the face. No flesh wound was fatal, but the eye had to be enucleated in one of the cases. Fifteen of the patients with cranial fractures died (i of these in 1900) and 5 recovered, so as to be able to resume their military duties. Depressed bone was removed in two cases, one of which was fatal. Enucleation of the eye was per- formed in I case, and the wound is reported as having been closed by sutures in i case. Of those who suffered fractures of the facial bones 7 resumed their military duties and 2 died. The recorded surgery in fractures of these bones consisted of the removal of fragments of bone and of portions of a jNIauser bullet in one case, which ended fatally ; the removal of a bullet through the floor of the mouth in one case, and enucleation of the eye in one case. "Of 60 cases of wound of the neck 41 were returned to duty and 12 GUNSHOT WOUNDS OF THE FACE. 187 died. Tlie only snrqical work recorded was the removal of the missile in 2 cases." The fatalities from gunshot fractures of the bones of the face were therefore 13.50 per cent. The experiences, then, of the Spanish- American war prove very conclusively that wounds of the face made with the small-caliber steel- jacketed bullet when traveling' at its maximum velocity cause very little fracture or comminution of the bones, and rarely produce explosive effects ; while the tissues heal kindly and cause very little disfigurement or deformity. The steel-clad bullet is, however, sometimes very destructive to the soft tissues and to the bones. These effects are stated by experts to occur when the missile has lost its high velocity and the rear end of the bullet begins to oscillate, or drops slightly, causing it to strike more or less with its side. The destruction wrought under such circumstances is often very great, especially when coming in contact with a resistant tissue like bone. Wounds of this character present considerable con- tusion of the soft tissues and great splintering and comminution of the bone. The experiences of the Boer War with the use of the small-caliber jacketed projectile coincide very closely with those of the Spanish- American War. G. W. Alakins in his work entitled "Surgical Experiences in South Africa," which covers the campaigns of 1899-1900, conveys the same ideas as to the character of the wounds produced by the jacketed bullet : "The most severe w'ounds were those produced by the unjacketed jNIartini-Henry large-caliber bullet (480 grs.) — the wounds from which were about 10 per cent, of the whole — and the Mauser and Lee- Metford bullets (215 grs.) which had been tampered with by cross- cutting the tips and slitting them down to the mantle. This caused the bullets to expand on impact, and greatly increased their destructive effects." Such treatment of bullets is an abomination and a grievous sin against humanity. Explosive effects were rarely observed as occurring in the soft parts only. Makins saw no cases which he thought substantiated the opinion that such effects took place in soft tissues only, but believed that in most cases presenting explosive effects the bullet had come in contact with bone or else the missile was one of the unjacketed varieties of projectile. The statistics of killed and wounded in this campaign comprise the battles of Belmont, Graspan, Modder River and Alagersfontein. "The approximate total of men engaged in these battles was 12,420. Of this number 1959, or 15.06 per cent., were reported as killed, l88 SURGERY OF THE EACE, MOUTH, AND JAWS. wounded, or missing: thus, killed, 315 or 2.53 per cent. ; wounded, 15 12 or 12.17 P^r cent. ; missing, 132 or 1.06 per cent. If to these figures of fatalities the death from wounds occurring within forty-eight hours after they were received are added to those dying on the field, the per- centage of mortal injuries is considerably increased. Thus, if the num- bers are massed (omitting the missing) we find that in the four battles 1827 men were hit, of whom 315 or 17.24 per cent, were killed. Among the wounded carried from the field, however, 49 received mortal in- juries, and if these be added to the 315, we find that the proportion of mortal injuries reaches 19.92 per cent. "The proportion of men killed to those wounded was as follows : Killed, 315; wounded, 1512 or i to 4.8. If we add to these men killed on the field of battle, the 49 dying in the next forty-eight hours, the pro- portion of fatalities is increased to i to 4.1=;. The higher of these pro- portions is certainly the correct one." He further says : "With regard to the general accuracy of the num- bers given above, a comparison of those published for the campaign up to September 15, 1900, is of value, as the two series substantially tally. "Thus, up to date 17,072 men were hit, and of these 2998 were killed. The proportion killed to wounded was therefore i to 4.69." These figures show that the fatalities were a trifle lower than in the Crimean War, and nearly correspond with those observed in the Franco- German campaign. He thinks that in view of these facts there is little ground for assuming that the change in the nature of the weapons em- ployed has materially influenced the deadliness of modern warfare. In a few cases of wounds of the calf of the leg and of the buttock which came under his observation, fairly typical explosive effects were observed, but in some of these later developments, — secondary hemor- rhage, or suppuration, — which necessitated opening the wound, injury to the bone was discovered. Wounds of the Face. Wounds of the Nose. — "Injuries of these parts were comparatively common. Those which involved the external parts with perforating wounds of the cartilages were remarkable for their sharp limitation and simple nature." One case in the Irish Hos- pital in Bloemfontein is introduced as an illustration, in which at the end of the third day small symmetrical vertical slits in each ala had already healed and were scarcely visible. In another case a bullet was retained in the upper portion of the nasal cavity. This accident was naturally a rare one ; in another in- stance the bullet had only retained sufficient force to insert itself neatly between the bones. Wounds crossing the nasal fossae were comparatively common. Interference with the sense of smell often results from this form of injury. GUNSHOT WOUNDS OF THE FACE. 189 Wounds of the Molar. — Wounds of the malar bone were not infre- quent. The small amount of splintering was somewhat remarkable con- sidering the density in structure of this bone. "In this particular the behavior of the malar corresponded with what was observed in the flat bones in general, viz. the capacity of the hard edge of the bone to check the course of the bullet, and cause considerable deformity and fissuring of the mantle." JJ'ouiids of tJic Upper Jozc. — "A large number of tracks crossing the antrum transversely, obliquely, or vertically were observed. In the first the nasal cavity, in the others the orbital or buccal cavity, was generally concurrently involved. It was somewhat striking that trouble was never observed, either immediate or remote, from these perforations of the antrum. If hemorrhage into the cavity occurred, it gave rise to no ultimate trouble. An instance was never observed of secondary sup- puration, even in cases where the bullet entered or escaped through the alveolar process with considerable local comminution. The branches of the second division of the fifth nerve were sometimes implicated. In one instance a bullet traversed and cut away a longitudinal groove in the bones, extending from the posterior margin of the hard palate and ter- minating by a wide notch in the alveolar process." A good example of troublesome transverse wounds of the bones of the face is afforded by the following instances : "Entry (Alauser), through the left malar eminence, i inch below and external to the external canthus of the eye ; exit, a slightly curved transverse slit in the lobe of the right ear. "The injury was followed by no signs of orbital concussion, and no loss of consciousness. There was free bleeding from both external wounds and from the nose. The sense of smell was unaffected, but taste was impaired, and there was loss of tactile sensation in the teeth on the left side, also on the hard palate. There was no evidence of fracture of the neck of the mandible, nor of the external auditory meatus, but there was considerable difficulty in opening the mouth widely or protruding the lower jaw. The latter difficulty persisted for some time, and was still present when patient was last seen. IVonnds of the Mandible. — "Fractures of the lower jaw were fre- quent and offered some peculiarities, the chief of which were the lia- bility of any part of the bone to be damaged, and in the absence of the obliquity between the cleft in the outer and inner tables so common in the fractures seen in civil practice. "Fracture of the neck of the condyle was observed three times ; in each instance permanent stiffness and inability to open the mouth re- sulted. This stiffness was of a degree sufficient to raise the question whether the best course in such cases would not be to cut down pri- marily and remove a considerable number of loose fragments, and thus diminish the amount of callus likely to be thrown out. igO SURGERY OF THE FACE, MOUTH, AND JAWS. "Fractures of the ascending ramus and body were more frequent. They were accompanied by considerable comminution, but all that I observed healed remarkably well, and in good position, in spite of the fact that many of the patients objected to wearing any form of splint. "The most noticeable feature was the occurrence of notched frac- tures. When the fractures were at the lower margin of the bone the buccal cavity occasionally escaped in spite of considerable comminution, the latter confining itself to the basal portion of the bone. "When the base of the teeth, or the alveolus, was struck, a wedge was broken away, and from the apex of the resulting gap a fracture extended to the lower margin of the bone." When fractures of the latter nature resulted from vertically cours- ing bullets much trouble often ensued. Two cases are presented in illustration : "Entry (Mauser), through the lower lip : the ballet struck the base of the right lateral incisor and canine teeth, knocked out a wedge, and becoming slightly deflected, cut a vertical groove to the base of the mandible : exit, in left submaxillary triangle. The bullet subsequently re-entered the chest wall just below the clavicle, and escaped at the anterior axillary fold. The appearance of these second wounds sug- gested only slight setting up of the bullet : the original impact was no doubt of an oblique or lateral character. "The injury was followed by free hemorrhage and remarkably abundant salivation and great swelling of the floor of the mouth. "The patient could not bear any form of apparatus, but was assidu- ous in washing out his mouth, and made a good recovery, the fragments being in good apposition." "Entry (Mauser) over the right malar; the bullet carried away all the upper and lower molars, fractured the mandible, and was retained in the neck. "A fortnight later an abscess formed in the lower part of the neck, which was opened and portions of the mantle and leaden core, together with numerous fragments of the teeth, removed. The bullet had undergone fragmentation on impact, probably on the last tooth of the mandible, and still retained sufiicient force to enter the neck. "This case afifords an interesting example of the transmission of force from the bullet to the teeth, and bears on the theory of explosive action." He further says: "In the treatment of fractures of the upper jaw, surgical interference was rarely needed. The removal of loose frag- ments is necessary in all cases in which the buccal cavity is involved. Experience in fracture of the limbs has shown a tendency to 'quiet" necrosis when comminution was severe, in spite of primary union. This is no doubt dependent on the very free separation of the fragments on GUNSHOT WOUNDS OF THE FACE. IQI the entry and exit aspects from their periosteum. In the case of the mandible, considerable necrosis is inevitable, and much time is saved by primary removal of all actually loose fragments. "A splint of the ordinary chin-cap type with a four-tailed bandage meets all requirements, but the patients often object to them. Cases in which the fragments could be fixed by wiring the teeth were not com- mon, as the latter had so often been carried away. The usual precau- tions as to maintaining oral asepsis were especially necessary." The results of fractures of the mandible were, in so far as his experience went, remarkably good, as deformity was seldom consider- able. The absence of obliquity and the effect of primary local shock were no doubt favorable elements, little primary displacement from muscular action occurring. "Wounds of the neck healed readily, and the same was noticeable of the lips. Wounds of the tongue healed with remarkable rapidity when of the simple perforating type, often with little or no swelling or evidence of contusion. At the end of a few days it was often difficult to localize them. "In connection with this subject a remarkable case which occurred at the fight at Koodoosberg Drift is worthy of mention, although the projectile was a shell fragment and not a bullet of small caliber. "A Highlander was the unfortunate possessor of an entire set of upper teeth set in a gold plate. A small fragment of a shell perforated the upper lip by an irregular aperture, and struck the teeth in such manner as to turn the posterior edge of the plate toward the tongue, which latter was cut into two halves transversely through to the base. "The patient asserted that the plate had been driven down his throat, but nothing was palpable either in the fauces or on external ex- amination of the neck. He spoke distinctly, but there was a dysphagia as far as solids were concerned. "On the second day swelling of the neck due to early cellulitis developed, especially on the left side, and signs of laryngeal obstruc- tion became prominent. Chloroform was administered, but on the introduction of the finger into the fauces, respiration failed and a hasty tracheotomy had to be performed. No foreign body was palpable with the finger in the pharynx. "Tracheitis and septic pneumonia developed, and the man died of acute septicemia thirty-six hours later. Death occurred just as the division received marching orders, and no post-mortem examination was made. As a result of palpation at the time of tracheotomy, the probabilities seemed against the presence of the tooth-plate in the pharynx, but the absence of positive evidence scarcely allows the case to be certainly classed as one of the cellulitis and septicemia secondary to wound of the tongue." 192 SURGERY OF THE FACE, MOUTH, AND JAWS. Leaden bullets penetrating the face sometimes lodge in the antrum or nose, and remain there for a considerable time, and may finally be- come encysted. Fig. 63, a Roentgen-ray picture of the face of a soldier recently returned from the War in the Philippines, shows a leaden bullet of Fig. 63. Bullet lodged in the Malar Process of the Superior Maxillary. small caliber lodged in the malar process of the superior maxillary bone. The missile entered from the opposite side. Fig. 64, also a Roentgen-ray picture,^shows another leaden bullet, considerably deformed, which entered the front of the face just below the orbit and lodged in the muscles of the soft palate, and could be felt GUNSHOT WOUNDS OF THE FACE. I93 in these tissues by passing the linger into the mouth. Wliile making such an examination, the missile was dislodged and two days thereafter it fell into the fauces through the naso-pharyngcal opening and was spit up by the patient. Fig. 64. Bullet lodged in Muscles of the Soft Palate. Gunshot wounds of the superior maxilla, occurring through the mouth, are usually the result of a suicidal intention, though such injuries do occasionally occur from accidental causes, and are usually immediately fatal. Sometimes, however, the injury is not very severe, and the patient recovers. Fig. 65 is the cast of a case from the writer's 14 194 SURGERY OF THE FACE, MOUTH, AND JAWS. collection, showing result of gunshot injury of the upper jaw from the accidental discharge of a shotgun. Missiles striking the lower jaw invariably produce fracture, and often considerable comminution and loss of tissue, while hemorrhage is quite likely to be severe, especially when the facial artery is involved in the wound. Symptoms. — The immediate symptoms of gunshot injuries are pain, shock, and hemorrhage. Pain as a first symptom is rarely absent. The degree of pain will depend upon the location of the wound, its nature, the tissues involved, and the mental condition of the individual. Nerves when injured or Fig. 6= Result of Gunshot In"jurv of the Upper Jaw. contused are productive of severe pain, which is referred generally to the region supplied by the injured nerve. When a nerve is completely divided, there is a total loss of sensation in the part supplied, and more or less complete paralysis of motion. The degree of shock depends upon the temperament of the indi- vidual, the physical condition at the time of the injur}-, and the region of the body in which the wound has been received. In wounds of the abdomen, shock is more profound and persistent than in wounds in any other part of the body. Injuries which pro- duce considerable splintering and comminution of the long bones are usually followed by shock of severe degree. Hemorrhasre will be slight or severe, according to the extent of GUNSHOT WOUNDS OF THE FACE. 195 the injury to large blood-vessels and the vascularity of the soft tissues involved. Wounds of large arterial trunks speedily terminate fatally. Treatment. — The first thing to be done in gunshot wounds of the face is to arrest the hemorrhage if it is in any way alarming. The hemorrhage may be controlled by tying the bleeding arteries where possible to reach them, and, when inaccessible, by packing the wound with antiseptic gauze; where packing cannot be utilized, as in the case of large surface wounds, or where portions of the face have been carried away by fragments of shell, stone, etc., recourse must be had to styptics. Compresses, wrung out of hot antiseptic solutions preferably, should be applied as hot as can be borne. Persulfate of Fig. 66. Gunshot Fracture of Lower Jaw with Loss of Boxe from A to B. Treated by Inter- dental Splint Bridge. (After Patterson.) iron is frequently used in these cases, but it has the disadvantage of occasionally causing extensive sloughs, and is sometimes followed by secondary hemorrhage. The missile should be searched for and removed as soon as pos- sible, together with all detached fragments of bone, and foreign sub- stances, which may have entered the wound. Loose fragments of bone which are still attached to the soft tissues should under no circumstances be removed, but placed as nearly as possible in their normal positions, and retained by means of sterilized packing or other suitable support Bullet injuries of the upper part of the face, which at first seem likely to result in extensive deformity, often recover with so little dis- figurement as to be a surprise to all concerned, provided care has been taken to preserve every fragment of bone which, by reason of attach- 196 SURGERY OF THE FACE, MOUTH, AND JAWS. ment to the soft tissue, gives hope of sustaining its vitaHty and making a union with its fellows. Gunshot injuries involving the lower jaw are usually complicated with multiple fractures, great comminution, and many times with ex- tensive loss of bone-tissue, which was carried away. The successful management of these cases will depend largely upon the skill and the inventive genius of the surgeon. A wise conservatism, however, is nowhere of greater value than in the treatment of this class of injuries. In those cases where there has been a considerable loss of bone- tissue, it is important that some kind of a support be applied to pre- vent the free ends of the jaw from falling together, which would other- wise cause a serious disfigurement, and destroy the occlusion of the remaining teeth. When teeth remain on either side of the gap, gold or platinum bands can be titted to them, and extension and immobility secured by soldering a gold wire to the approximal surfaces of the bands, and the Fig. 67. Interdental Splint Bridge. (After Patterson.) appliance cemented to the teeth with the ordinary oxyphosphate cement. To provide for further extension or approximation, the wire can be divided in the center, and be fitted with a double screw nut, and the appliance lengthened or shortened at the will of the operator. Figs. 66, 67, illustrate a case of this character reported by Patterson, in which a large fragment of bone was lost by a gunshot wound, and the contour of the jaw restored and the remaining fragments held in a norm-al position by an interdental splint bridge cemented to the remain- ing teeth. If the jaw is edentulous, the same result may be obtained by introducing a gold wire of the proper length, having a collar of the same material attached one-eighth of an inch from each end, and this inserted between the free ends of the jaw, holes having been made in them for the reception of the wire, and the tissues closed over it. as suggested by Cervera, Figs. 68, 69. Such an appliance will generally become encysted, and is then not likely to give future inconvenience. After the wound has healed and the cicatrix hardened, the gap GUNSHOT WOUNDS OF THE FACE. 197 may be filled with a suitable piece of bridge-work, or a removable denture. Loss of extensive portions of the superior maxilla is a not infre- quent result of g'unshot injuries upon the field of battle, from accidents while hunting, and from attempts at suicide. Restoration of the contour of the face can many times be accom- plished — when the soft parts are intact, or can be made so by a plastic operation — by the construction of supports to the soft tissues repre- senting the portions of lost bone, and attaching them to the remaining teeth. Fig. 68. Fig. 69. Prosthetic Wire Arch for Partial Rksection of Lower Jaw. (After Cervera.) Attempts have been made to bury such appliances in the soft tissues, but with only indifferent success, as sooner or later they cause ulceration, and have to be removed. The materials which have been used for this purpose are vulcanite, gold, platinum, and aluminum. One such case as first described, in which the superior maxillary bone was lost from the median line back to the second molar, involving the palate process nearly to the median line, and the body of the bone to the orbital plate, was successfully treated by the writer by means of an appliance constructed of gold and vulcanite combined, and retained in position by clasps attached to the remaining teeth. The discussion of fractures of the maxillar)^ bones and their treat- ment will be reserved for a later chapter. CHAPTER XXI. FRACTURES OF THE INFERIOR MAXILLA. Definition. — Fracture (Lat. fractnra, a break). The breaking of a bone, either by external force or by the action of the muscles of the body. Plate II is a Roentgen-ray picture, showing a simple fracture of the ulna. (From the collection of the U. S. Army General Hospital, Presidio of San Francisco.) Fractures of the jaws are of quite common occurrence, and are generally the result of blow^s upon the face from the fist, kicks of large animals, the impact of some heavy missile propelled with considerable velocity; gunshot injuries; the extraction of teeth; a fall from a bicycle, a horse, a building, or other considerable height; passage of a wheel over the face; injuries from passenger or freight elevators, or other crushing force. Fractures of the superior maxilla are much less frequent than frac- tures of the inferior maxilla, on account of the fact that the superior maxillary bones are, by reason of their location and shape, less ex- posed to injury. When fractures of these bones do occur, they are generally the result of a severe traumatism. The inferior maxilla, from its size, shape, and location, is more often fractured than any other bone of the face. In size, it is the largest of all the bones of the face. Its shape makes it liable to fracture in the anterior portion or at the angle, when blows are received upon the side of the face, and through the ramus or at the neck of the con- dyle when the blow is received upon the chin. The weakest point of the lower jaw is just anterior to the mental foramen, through the alveolus of the cuspid tooth. In edentulous jaws this weak point would be through the mental foramen (Fig. 70). Its location is exposed, and it is therefore more liable to receive an injury than those parts which are better protected. Fractures of the lower jaw are ten times more frequent in males than in females. This is largely due to the difference in the occupations and the degree of exposure to accident between the sexes. Fractures of the maxillary bones are classed under two general forms, viz: Simple and Coniplicafcd. 198 FRACTURES OF THE INFERIOR MAXILLA. 199 FRACTURES OF THE INFERIOR MAXILLA. 201 Siviplc fractures are those in which there is a single fracture of the bone, without injury or break in the continuity of the external tissues. Coinplicafcd fractures include all other conditions associated with a fracture of the bone, such as injuries to the external tissues, to ves- sels, to nerves, to teeth, to a comminuted condition of the bone itself, or any other condition which complicates a simple fracture. Complicated fractures may be divided into Multiple, Comminuted, and Compound. Multiple fractures include those in which there is more than one break in the continuity of the bone. Double and triple fractures would be classed under this head. Fig. 70. The Inferior Maxillary Bone, External Surface of the Right Side. M, Mental process; I, Incisive fossa; F, Mental foramen; L, External oblique line; G, Groove for facial artery ; A, Anterior or coronoid process ; P, Posterior or condyloid process. Comminuted fractures are the result of crushing injuries or gun- shot wounds, which cause splintering and crushing of the bone into small fragments. Compound fractures are those which have associated with them injuries of the soft tissues, causing exposure of the fractured ends of the bone. Fractures of the Alveolar Process. — The most common frac- tures of the jaw are those of the alveolar process, and they are gen- erally associated with the extraction of teeth. These fractures rarely involve more of the process than the external plate lying immediately over the roots of the tooth extracted, and perhaps a small portion extending over those adjacent to it. 202 SURGERY OF THE FACE, MOUTH, AND JAWS. Fractures of the alveolar process frequently occur as a result of falls or of blows upon the chin which have an upward direction, driving the teeth into their sockets, and splitting the process on a line with the alveoli. These accidents most frequently occur among men engaged in the building trades, as the result of falls from buildings and scaffolding. When this accident occurs to the upper jaw, the external plate of the alveolar process is usually the part to give way; the internal plate is supported by the palate process, hence its greater power of resist- ance. When the same accident occurs to the lower jaw, the external and internal plates of the process are usually both fractured and sep- arated. Fractures of the Body of the Lower Jaw. — Fractures of the body of the bone most frequently occur as foUow^s : First. In the region of the cuspid tooth (Fig. 71, i). Second, At points between the cuspid tooth and the angle of the jaw (2). Fig. 71. 3 ~T. Fracture of the Body, Condyles, and Coronoid Process of the Lower Jaw. (After Fergusson.) Third. In locations between the symphysis of the jaw^ and the cuspid tooth (3). Fourth. At the angle of the jaw (4). Fifth. Through the symphysis (5). Sixth. At points through the ascending ramus (6). Seventh. At the neck of the condyle (7). Eighth. Through the coronoid process (8). Fractures located above the angle are exceedingly rare. Out of fifty-five cases of fracture of the low"er jaw reported by Hamilton, only three were above the angle. Fractures of the body of the jaw, through the cuspid, bicuspid, or molar regions, the angle or symphysis, are usually the result of injuries received upon the side of the face, while fractures of the ascending ramus and the neck of the condyle are usually caused by injuries received upon the chin, — as blows or falls. Out of the fifty-five cases just mentioned as reported by Hamilton, four only were through the FRACTURES OF THE INFERIOR MAXILLA, 203 symphysis. The great majority of the fractures of the lower jaw are compounded, generally into the mouth. Fig. ']2 is a Roentgen-ray picture showing a fracture of the body of the lower jaw just anterior to the angle, with displacement of the Fig. 72. Fracture of the Lower Jaw anterior to the Angle. ramus into the mouth and forward, causing the fractured ends of the bone to lap upon each other. It will be noticed also that th^ fracture is vertical. (From the collection of the U. S. Army General Hospital. Presidio of San Francisco.) 204 SURGERY OF THE FACE, MOUTH, AND JAWS. Displacements. — In fractures through the symphysis, displace- ment is usually very slight, on account of the attachment of the muscles of the lateral halves of the jaw, and their equalized action. Such a fracture may occur and not be recognized by the patient, except from the crepitation produced when attempting to masticate food. In fractures at the neck of the condyle, the displacement, as a rule, is not very great. The direction of the displacement when it does occur will be forward, on account of the action of the external pterygoideus, which drags the body in this direction. Fractures at the symphysis, through the ascending ramus, or the neck of the condyle, are rarely compounded into the mouth; fractures at these locations are, however, sometimes compounded externally from laceration of the covering tissues at the point where the injury was received. Fig. -jz. Fractures of the Lower Jaw with Displacement. (After Malgaigne.) Simple fractures are not subject to the same amount of displace- ment as are multiple and compoimd fractures. A simple fracture through the cuspid regions will not cause so great a displacement as when the same character of fracture is com- pounded into the mouth, for the covering tissues combat to a certain extent the tendency of the muscles to draw the ends of the fractured bone out of position. When the continuity of the covering tissues is broken, the muscles have full play, and cause a displacement com- mensurate with the location and the character of the injury. Multiple fractures are subject to the greatest amount of displace- ment. Fractures occurring upon both sides of the jaw at the same time always present the greatest degree of displacement. In fractures occurring in the anterior portion of the jaw, and upon both sides, through the cuspid or bicuspid region, the central portion would be dragged downward and backward by the action of the genio- hyoid, genio-hypoglossus, and digastric muscles. When the fracture occurs at the cuspid region, and through the body or ascending ramus, the intermediate fragment will be displaced FRACTURES OF THE INFERIOR MAXILLA. 20 = inward by the action of the niylo-hyoideus, upward by the masseter, and forward by the action of the external pterygoideus (Fig. 73). In single compound fractures occurring in the region of the cuspid tooth, or just anterior or posterior to it, the displacement is sometimes considerable. Lines of Fracture. — The lines of fracture may be vertical, oblique, or horizontal. It sometimes occurs, however, that the lines of frac- ture may be combined, as, for instance, vertical and oblique, vertical and horizontal, double oblique, etc. When the fracture is through the symphysis, it is almost always vertical (Fig. 74). In the four cases of this class reported by Hamilton, the fractures were all vertical. Two cases seen by the writer, occurring in elderly people, were both vertical. Fractures of the alveolar process are generally vertical and oblique combined; as, for instance, when the external plate of the process is split off in the extraction of teeth, or as the result of upward blows upon the chin. Fig. 74. Fracture through the Symphysis. (After Angle. The great majority of the fractures of the body of the bone, how- ever, are oblique. According to ^lalgaigne, the thickness of the bone is also divided obliquely, so that generally the fracture occurs at the expense of the internal plate of the anterior fragment and the external plate of the posterior fragment. \\'hen the fracture is very oblique, there is usually considerable overlapping and locking, making reduc- tion sometimes verv difficult, as in Fig. 73. Out of forty cases of fracture of the body of the bone reported by Hamilton, eighteen were demonstrated to be single oblique, and thir- teen double and triple fractures. Nearly all fractures of the body of the bone have a perpendicular direction through the alveolar process. The direction of the line of 206 SURGERY OF THE FACE, MOUTH, AND JAWS. fracture outside of this may be obliquely forward or backward. There is considerable difficulty, however, in positively demonstrating this fact in the living subject, and as the mortality from this class of injury is very low, the opportunities for post-mortem examinations are rare. The specimens preserved in the various museums would seem, however, to corroborate the general opinion that the majority of the fractures through the body of the bone are oblique. Heath mentions a case in the museum of King's College, London, as being obliquely forward and backward. Symptoms. — The symptoms of fracture of the lower jaw are gen- erally well marked, except in simple fractures through the symphysis. The special diagnostic signs of fracture are crepitus, more or less de- formity in the contour of the lower part of the face, and unnatural or excessive mobility. Pain is always present, and is increased by the movements of the jaw. In the majority of the cases, the mucous mem- brane is lacerated, giving rise to more or less hemorrhage. The saliva is secreted in excessive quantity, and, being mixed with dis- charges from the wound, decomposes and causes a fetid odor of the breath. Changes in the normal occlusion of the teeth are generally well marked at the point of injury. The teeth upon either side of the fracture are commonly loosened, and sometimes entirely luxated. Erichsen mentions a case in which the tooth had been detached from its alveolus and become lodged between the fragments of the jaw, pre- venting adjustment of the fracture until it was found and removed. Considerable inflammation, as a rule, follows fracture of the jaw, accompanied by swelling and infiltration of the face and neck, and followed not infrequently by troublesome abscesses and necrosis of splintered portions of the bone. This is explained by the fact that such fractures are generally compounded and often comminuted, making infection certain. Among the possible complications of fractures of the lower jaw are hemorrhage from wounding the inferior dental arter\', paralysis of the lower lip and chin from injury of the inferior dental nerve, salivary fistula, abscess, necrosis, septicemia, and pyemia. Diagnosis. — The diagnosis of fractures of the lower jaw is gen- erally a simple matter, but occasionally difficulty is experienced in locating the exact seat of the fracture, especially if it is a simple one, without displacement. Wlien doubt exists, seat the patient upon a low chair, taking a position behind him; then grasp the jaw with both hands, the thumbs upon the ends of the teeth and the fingers under- neath the chin, and test, by alternately depressing and elevating first one side, then the other. If fracture exists, crepitation will be dis- covered at the point of injur}^ If the fracture is through the coronoid process only, the diagnosis will be made from the inability of the patient to properly close the jaw upon this side. FRACTURES OF THE INFERIOR MAXILLA. 2.0"] Prognosis. — The prognosis of fracture of the lower jaw is, as a general rule, very favorable. The mortality from this injury is ex- ceedingly low; a fatal termination would be due, in all prol^ability, to other conditions arising as complications, of which septic poisoning would be an example. Simple fractures of the lower jaw unite in from four to six weeks. Compound, multiple, and comminuted fractures are often retarded considerably beyond this period, two to three months not infrequently being required for a good union to be formed. The callus formed about the fractured ends of the bone fre- quently causes considerable deformity; this, however, is only tempo- rary, for it is eventually removed by absorption, and the contour of the face is restored to its orisfinal lines. CHAPTER XXII. FRACTURES OF THE INFERIOR MAXILLA (Continued). Treatment. Two conditions are absolutely necessary to the successful treat- ,ment of fractures, no matter where located: First. Accurate adjustment of the fractured portions of the bone. Second. Complete immobility of the parts until union has taken place. FiG. 75. Four-tailed Bandage for Fracture of the Lower Jaw. (After Heath.) Various methods and appliances have been introduced for the purpose of fixation of fractures in the lower jaw, from the simple four- tailed bandage to the most elaborate interdental splint. The particular method to be adopted in each individual case must be determined by the location and extent of the fracture, and the complications attending it. Fractures complicated with laceration of the soft tissues, or with hemorrhage, must be treated upon the common ground of wounds in general, viz: to arrest the hemorrhage, render the wound aseptic, and close the soft tissues; after which the fracture may be reduced and the 208 FRACTURES OF THE INFERIOR MAXILLA. 209 appliance adjusted which has been selected tQ maintain the immobility of the parts. Simple fractures, with only slight displacement, may be reduced and usually maintained in position by a simple four-tailed bandage (Fig. 75), or the Barton or Hamilton bandages (Figs. 76, yy), some- FiG. 76. Garretson's Modification of the Barton Bandage. (After Garretson.) Fig. 77. Hamilton Bandage for Fracture of the Lower Jaw. (After Hamilton.) times combined with an external splint molded to the chin; or wires may be twisted around the firm teeth upon either side of the fracture (Fig. 78), the wires to be passed through the approximal spaces at the margin of the gums; but, better still, the Angle fracture bands and screws or wire. The Angle appliance consists of platinum or German silver bands,. 15 2IO SURGERY OF THE FACE, MOUTH, AND JAWS, which pass around the teeth in the form of a loop and are retained in position by means of a set-screw, which passes through the tubes soldered to the ends of the band, and which are drawn together by the screw until it securely grips the tooth (Fig. 79). One of these bands is fastened to a firm tooth on either side of the fracture; a screw is then passed through tubes prepared for its recep- tion upon the side of each band, and the fracture approximated and maintained in position by tightening the screw (Fig. 80). Method of Holding Detached Pieces of the Ramus in Apposition with other Frag- ments OF the Jaw. (After Vinke.) Fig. 79. Angle Apparatus Applied. Another method is to solder small metallic buttons upon the side of the bands, and approximate the fractured ends of the bone by pass- ing binding wire around the buttons in the form of the figure 8 (Fig, 81). This method is applied to single fractures in all locations of the jaw, but in comminuted or multiple fractures, where the displacement is considerable, and difficult of reduction, there is constant danger of displacement, while the strain upon the teeth to which the bands are FRACTURES OF THE INFERIOR MAXILLA. 211 fastened soon loosens them in their alveoli, and they become worthless as points of anchorage. In those cases where the teeth have been loosened or dislodged, or the jaw is edentulous, the above method of wiring and the Angle appliance cannot be used. Drilling the maxillary bone and wiring the fractured ends together is the best method in these cases. Wiring the fractured jaw at any point anterior to the first molar can be accom- plished inside of the mouth, but in locations posterior to this, or in the ascending ramus, it becomes necessary to operate from the outside, by laying open the external tissues. Two considerations, however, should be constantly borne in mind in all operations on the jaws: First. To avoid any cutting operations upon the external tis- sues of the face, if the operation can be done through the mouth, that there may be no disfiguring scar left behind. Fig. 8i. SHSi^H^^^^^^^^,^ Angle Apparatus, showing Adjustment. (After Angle.) Second. If it becomes necessary — and this often occurs — to op- erate through incisions in the external tissues, care should be taken that the lines of incision follow the natural lines of the face, and when operating upon the lower maxilla to, as far as possible, keep the line of incision under the lower border of the jaw, for the same reason. In wiring a fracture of the lower maxilla through the mouth, the lip or cheek should be dissected from the bone at the point of fracture to a depth that will permit of the passage of a drill between the roots of the adjacent teeth without injuring them. The size of the drill should be three-thirty-seconds to one-eighth of an inch in diameter. Holes should be drilled through the bone, one upon each side of the frac- ture, between the roots of the teeth, at points sufficiently remote to insure solid osseous structure. A single or double silver wire, or silver-plated copper wire, is then passed through the hole upon one side, back through the hole upon the opposite side, the ends brought together, and twisted until the fractured ends of the bone are approxi- 212 SURGERY OF THE FACE, MOUTH, AND JAWS. mated. The wire is then cut at a Httle distance from the jaw, and bent down, or turned in between the teeth. Another method of securing the ends of the wire is by twisting each end separately in the form of a spiral, as practiced by Thomas, of Liverpool, England (Fig. 82). Fig. 82. Thomas's Method of Wiring Median Fracture of the Lower Jaw. (After Erichsen.) Fig. 83. Tho.mas's Method of Wiring Fracture of the Lower Jaw. (After Erichsen.) Fig. 83 illustrates a method of wire suturing in cases where the fracture is anterior to the third molar and posterior to the bicuspids, by passing the suture around a molar tooth and then through the jaw at some point at the anterior side of the fracture. The writer has adopted a method which he likes better than either of these, viz: that of passing the ends of the wire through lead buttons, and, where the dangers of displacement are considerable, using a lead clamp which reaches across the fracture, having two holes in the ends to correspond with the holes which have been drilled in the jaw. The wire is first passed through the holes in one end of the clamp, then FRACTURES OF THE INFERIOR MAXILLA. 213 through the jaw on one side, back through the other, through the holes in the opposite end of the clamp, and the free ends of the wire twisted until the fracture is brought into position. He has also found it to be an advantage, in those cases presenting considerable displace- ment with a tendency of the fractured ends of the bone to slide upon each other and thus prevent a perfect occlusion of the teeth, to insert izi'o wire sutures about half an inch apart, one as near the lower border of the jaw as possible without impinging upon the contents of the inferior dental canal, and the other through the alveolar process. When the operation is made through the external tissues of the face, it is better to twist the wires, cutting them as short as possible. Fig. 84. Hammond Wire Splint. (After Heath.) without endangering their strength, turn the points down, and after thorough irrigation with antiseptic solutions, to close the wound except at the point directly over the ends of the wire, treating it anti- septically. The wires may be removed in from four to six weeks. Hammond's wire splint is a very useful appliance, exceedingly effective and simple to construct (Fig. 84). An impression of the jaw is taken, and a cast made from this. Upon the cast a strong iron or German-silver wire is fitted, following the outlines of the teeth, at the margin of the gums, upon the lingual and buccal surfaces, and the ends soldered or brazed. This is then slipped over the teeth, being held in position by means of fine wire carried between the teeth, and over the splint (see Fig. 85). To prevent the iron wire from rusting, the appliance should be tinned; the German-silver appliance can be plated with gold. 214 SURGERY OF THE FACE, MOUTH, AND JAWS. The Shotwell fracture clamp is an ingenious adaptation of the principle of the rubber-dam clamp to the treatment of fractures of the jaws (Fig. 86). It is susceptible of being applied to all forms of frac- tures situated in front of the angle. This clamp may be made of steel or German silver. Fig. 8s. Hammond Wire Splint. (After Heath.) Fig. 86. Shotwell Fracture Clamp. Various forms of interdental splints have been devised, and made of many materials, — gutta-percha, vulcanite, and the various metals; the principal feature of all being that they were molded to fit the teeth, and extended to some distance upon each side of the fracture. They are either intended to act as an internal support while the jaw is FRACTURES OF THE INFERIOR MAXILLA. 21 5 firmly held against the upper teeth, or they are secured to the teeth or bone by screws or metal wire, or by external supports in the form of rods fastened to the side of the splint, and coming out at the angles of the mouth. Gunning, Hayward, Kingsley, Bean, Moore, Lonsdale, and Hill have each devised interdental splints, having attachments for outside supports. The Kingsley splint is the one most commonly used, and the de- scription of it will be given in Dr. Kingsley's own words : "Restore to position displaced fragments, as far as can be done without much effort, the only object being that it makes it a little easier to take an impression. I have always used plaster for such an impres- sion, and see no reason for using any other substance, and, indeed, know of no other substance as good. "The impression of the deranged fragments may be taken as a whole in an impression-cup, or, if convenient to do so, it can be taken in sections without any cup. Either course, in my practice, has an- swered equally well. The only object is to obtain casts of all the fragments, either together or separately. Take also an impression in plaster of the upper jaw, and make a cast from it. No dentist should be at all in doubt as to the relation which the fragments of the lower jaw should hold to the upper." The cast of the lower jaw must be separated with a saw upon the line of the fractures, and the pieces readjusted by using the cast of the upper jaw as a guide. He further says, "There are invariably, even if there are but few teeth in the mouth, certain marks of abrasion on the antagonizing surfaces which identify with exactness the position which the frag- ment formerly sustained to the upper jaw, and like means of identifica- tion I have never failed to find, even in the rnouths of children, when they were shedding and erupting teeth; therefore, there is no excuse for failing to reconstruct the model of the lower jaw, and make it iden- tical with the original in its normal condition. "Upon such a model the construction of a splint of vulcanite in- volves no manipulations which are not common. Sheet wax, a single line in thickness, carefully pressed over the teeth, and to a little extent encroaching on the gums, gives the form required. If the fracture is in front, the splint need not cover all the back teeth ; but if it be at the sides, it is better to cover all the teeth of that side. It is also better to set the casts of the upper and lower jaws in an articulator, and thus make prints of the upper teeth in the wax, to be retained in the splint. "One of the easiest things of which to make the arms is a couple of discarded excavators, flattening the ends which are to be imbedded, and curving them with much care around the corners of the mouth; 2i6 SURGERY OF THE FACE, MOUTH, AND JAWS. they should terminate at the angle of the jaw. The flattened ends should be made quite broad, and thoroughly imbedded in the splint, as much strain comes upon them." Figs. 87 and 88 show a device of the writer's which he has found to simplify the making and adjusting of the splint. It obviates the necessity of a specially prepared flask or an extra large vulcanizer in which to vulcanize the splint. The arms are provided with separable sockets or mortises. The sockets are imbedded in the sides of the wax form of the splint, which will then enter any ordinary sized flask. After the splint is finished, the tenon of the arm slips tightly into the socket or mortise. Fig. 87. Author's Arm and Socket (one side) for Kingsley Splint. Fig. Author's Socket for Kingsley Splint in position for attachment of the arm. "The subsequent steps are familiar to every dentist, viz : investing, packing, vulcanizing, and finishing. In finishing, it is better to enlarge the sockets for the teeth a little, so that there will be no impinging upon the crowns when the splint is introduced, and also to make openings through the top or side, against each tooth adjoining the fracture, so that it can be determined when the fragments are fully in their place (Fig. 89). The latter holes will be convenient to use in cleansing the apparatus by inserting in them the nozzle of a syringe. If the splint is properly made, the teeth of each fragment will follow into the indenta- tions prepared for them, without severe pressure ; if they do not, it is quite as well to bind the splint in position, and wait events. It will FRACTURES OF THE INFERIOR MAXILLA. 217 probably be found, a few hours later, that they have gained their place without further aid." The splint is retained in position by passing a narrow bandage over the arm of the splint and under the chin, back and forth, until it is firmly fixed (Fig. 90). The after-treatment is that of wounds of the mouth in general. Kingsley's Interdental Splint. (Alter Kingsley Fig. 90. Kingsley's Interdental Splint Applied. (After Kingsley.) The ordinary duct-compressor may be utilized for the same pur- pose by attaching the splint to the upper arm of the compressor (Fig. 91), and securing it in place by the ratchet device for causing compression. Fig. 92 shows splint in position. Another admirable method of securing the ordinary interdental splint in position is by the use of oxyphosphate of zinc cement. The writer has used this method many times during the past twelve years— in cases where there was moderate displacement— to his entire satisfac- 2l8 SURGERY OF THE FACE, MOUTH, AND JAWS. tion (Fig. 93). The cement should be mixed a little thicker than cream, and the sockets in the splints for the reception of the crowns of the teeth lined with it. The teeth must be thoroughly cleansed before- hand; then dry the surface with bibulous paper, and press the splint into place with the thumb and fingers, holding it in that position until Fig. qt. Interdental Splint attached to Duct Depressor. (After Kingsley.) Fig. 92. Sa.me in Position. (After Kingsley.) the cement has set. To insure adhesion of this cement, the apparatus must be kept free from moisture while the cement is setting. This may be accomplished with bibulous paper or napkins and the saliva ejector. This method, which was first suggested by Heath, who used gutta- percha instead of the oxyphosphate cement, is certainly preferable to the use of retaining screws or wires. FRACTURES OF THE INFERIOR MAXILLA. 219 The Kingsley splint may be made of cast metal, — tin or Weston's metal, — or of silver swaged over metal dies, or by the electro-deposit method. The latter method gives the best adaptation, but has the dis- advantage of requiring a longer time for its construction. It has, however, in the practice of the writer, given the utmost satisfaction. In the selection of the particular method that shall be employed in the treatment of fractures of the body of the jaw, that one should be chosen which will be most likely to secure absolute immobility of the fracture, and at the same time give free use of the jaw. The Kingsley interdental splint, the Angle apparatus, and the bone-wiring operation will all give these results in individual cases. Fig. 93. Interdental Metal Splint Cemented into Position. In charity work, the latter operation is generally chosen as least expensive in the consumption of time and money. It has the disad- vantage, however, of rendering a simple fracture a compound one; but simple fractures are not often found among hospital cases, as nearly all of them are the result of severe injuries, and consequently are usually compound fractures. It has been the fortune of the writer many times to treat this class of injury by wiring the bone, and experi- ence teaches, taking all things into consideration, that it is the most satisfactory method. The hygienic conditions of the mouth are important factors in the treatment of fractures of the jaw, and that method will be most success- ful, other things being equal, w-hich will permit of the most perfect cleansing of the mouth without disturbing the appliance. Interdental splints are of no value in the treatment of fractures of the angle, ramus, coronoid or condyloid processes, if uncomplicated 220 SURGERY OF THE FACE, MOUTH, AND JAWS. with fractures of the body of the bone. In such cases the various forms of bandages, wiring the upper and lower teeth together after the suggestion of Heath, or the Angle appliance, are the best means of treatment. By the Angle method the jaws would be firmly bound to- gether by applying bands to the upper and lower teeth at points oppo- FiG. 94. Angle's Appliance for Fracture through the Angle. (After Angle.) Fig. 95. Angle's Appliance for Fracture through the Angle and Cuspid Region. (After Angle.) site to each other, and the use of the wire ligature in the form of a figure 8, as described before in the treatment of simple fractures. Figs. 94, 95, 96, illustrate the Angle method applied to this class of cases. Occasionally the surgeon will be called upon to treat a fracture of the lower jaw in which all the known methods of retaining the frac- FRACTURES OF THE INFERIOR MAXILLA. 221 tured bones in their proper apposition will fail, or in which an appli- ance must be devised upon short notice which will be applicable to the peculiar conditions existing in an individual case. As an illustration, a case in point will be briefly described. Mr. G. G., a furnace man, em- ployed at the Iroquois Furnace Company, South Chicago, was blown, by the bursting of the furnace door, twenty-six yards, striking broad- side against a wall. His face and head especially seemed to receive the force of the concussion. The lower jaw was fractured upon the right side, just anterior to the angle, and between the cuspid and first bi- cuspid teeth. There was considerable displacement on account of the location of the fractures and the contraction of the muscles, the middle fragment overriding the others upon the outside. For several days Fig. 96. Angle's Appliance bor Fracture through Both Angles. (After Angle.) reduction was not attempted, as the man was suffering from a severe concussion of the brain, and gave little hope of recovery. Four days after his admission, the brain symptoms having somewhat improved, a careful examination, under ether, was instituted. Efforts were made to replace and secure the middle fragment in its normal position by the various methods of external splints, bandages, and wiring of the teeth, but without avail. An interdental splint could have been made for the case if the patient had been sufficiently recovered from the injury to the head to exercise self-control. This being out of the question, it there- fore became necessary to devise some other means of maintaining the fractured bone in normal position. This was accomplished by making two incisions in the soft tissues down to the bone, one just behind the angle of the jaw, about half an inch above the lower border, and the other between the roots of the cuspid and lateral incisor teeth, at about the same distance above the lower border of the jaw. Holes were then drilled in the bone at the points of incision, and long nickel-plated pic- 222 SURGERY OF THE FACE, MOUTH, AND JAWS. ture screws set into the holes. Extension was then made upon the an- terior fragment, aided by ligatures passed around the incisor teeth, until the middle fragment could be forced into place. Extension was main- tained by placing a wooden brace, made from the side of a cigar-box, between the screws. Ligatures were then passed from screw to screw, and under the ends of the brace, in the form of the figure 8, thus making a rigid appliance, which held the fractures immovably in their normal position. Dressings were applied to the external wounds, and the mouth kept as clean as the circumstances would permit. Four weeks later the screws were removed, and union was found to have taken place, while the perfect occlusion of the teeth proved that the fractured bones had been placed in normal apposition. Fractures of the alveolar process following the extraction of teeth need no other treatment, as a rule, than forcing the separated parts into position with the thumb and fingers. The after-treatment is comprehended in the term "surgical clean- liness." Abscess of the Jaws. — Abscess of the jaws frequently follows com- pound fractures. This is the result of local infection, generally from a filthy condition of the oral cavity or from necrosed bone. It is. often stated by the opponents of the germ theory of disease that pathogenic micro-organisms are constantly found in the blood and tissues of healthy individuals. This statement has not been substan- tiated, either by the most careful microscopic research or by clinical observation. There is no doubt whatever that such organisms do sometimes gain access to the tissues of the healthy living body, but they are at once, and almost invariably, destroyed by the action of the living cells and fluids of the body, or are eliminated by the excretory organs. A simple fracture will heal without suppuration in a healthy indi- vidual, even though it had been demonstrated that micro-organisms were already in the blood; but if a certain quantity of the pus- producing microbes were introduced, sufificient to overcome the resist- ance of the tissues and fluids of the body, suppuration was the result. Vital resistance, therefore, plays an important part in preventing suppuration. As soon as fluctuation can be detected, the abscess should be opened, preferably through the mouth, so as to avoid a scar; but some- times it is necessary to open it through the external tissues, especially where there is a tendency to phlegmonous inflammation in the sub- maxillary region and the neck. After the pus has been evacuated, search should be made for necrosed bone, and if found, it should be immediately removed, provided separation has taken place, and the wound irrigated and dressed antiseptically. If separation of the dead FRACTURES OF THE INFERIOR MAXILLA. 223 bone from the living has not taken place, it is better to wait for nature to complete the process, as surgical interference under such circum- stances is not indicated. Preceding- the discovery of an abscess, there will always be an elevation of the body temperature from 2° to 6° or 7° Fahrenheit, which is always indicative of the formation of pus, and the presence in the circulation of septic ptomaines. Such a condition should at once lead to a critical examination of the wound and the surrounding tissues. If septicemia should develop, treat the case as indicated in a previous chapter upon Septicemia. CHAPTER XXIII. FRACTURES OF THE SUPERIOR MAXILLA AND UPPER BONES OF THE FACE. Fractures of the superior maxillary bones are, from their pro- tected location, quite rarely met with except in the alveolar process. The causes of such injuries in this location are usually the extraction of teeth or blows or falls upon the chin, which separate and split open the walls of the alveoli. This is accomplished in the one case by the lateral force applied breaking up the attachments of the roots of the teeth, and in the other by driving the teeth upward and through their alveoli. Such injuries, however, are never very serious, and rarely require special apparatus to maintain the fractured bones in their normal posi- tion. Injuries of the upper bones of the face, which cause comminuted fractures and separation from the bones of the cranium, are always the result of great violence, — like the passage of the wheel of a car- riage over the face, falling from a great height, the kick of a horse, a blow in the face by some heavy missile thrown with great force, a gunshot wound, the overturning of a carriage upon the occupant, crushing of the head between a moving elevator and the floor, or other heavy, crushing force. Since the general introduction of passenger and freight elevators into hotels, ofHce buildings, and large manufacturing establishments, "elevator" accidents are much more likely to occur, and will doubtless be found more and more common. The experience of the writer, at least, leads to this conclusion, for during the last fifteen years about twenty-five per cent, of all the cases of fracture of the upper bones of the face which have come under his care have been caused by this class of accidents. The class of injuries which forms the subject of the present chap- ter is one which has received but little attention from either the gen- eral surgeon or the oral specialist. Several of the leading works on surgery make no mention whatever of them, which is due no doubt to the fact that the accidents which cause them have been in the past of rare occurrence. 224 FRACTUKi:S OF THE SUPERIOR MAXILL.E, ETC. 225 During the lust few \cars five cases have come under the personal care of the writer at St. Luke's Hospital. Tlie first led to a somewhat careful examination of the text-books and periodical literature bearing upon the subject. So far he has been able to gather together but nine- teen cases which can be fairly classed as similar to those which form the subject of this chapter. These injuries are always serious, and often prove fatal, either from shock, hemorrhage, direct injury to the l)rain, or from secondary- complication. In those cases which survive the shock of injury and escape im- mediately serious complications of the brain, a favorable termination may be looked for, and in many cases, if properly treated, with very little deformity. This, however, will depend very much upon the character and location of the particular injury, and the success ob- tained in readjusting the fractured and dislocated bones, and main- taining them in their proper positions. For the purpose of reference, the various published cases are here grouped together, only brief mention being made of the extent of the injury and the percentage of mortality. In speaking of this class of injuries, Erichsen says, "In some cases all the bones of the face appear to have been smashed and separated from the skull by the infliction of great violence." He mentions four cases of this form of injury,— one reported by South, one by Vidal^, and two which came under his own notice. The injury in South's case was caused by a man being "struck in the face by the handle of a rapidly revolving crank." All the bones of the face were "separated and loosened," and so comminuted as ta feel "like beans in a bag." Vidal's case, also a man, was injured by a "fall from a building: and striking upon the face, which fractured and separated all the facial bones." Erichsen's cases were both the result of falls from a considerable elevation, and striking upon the face. The two former recovered; the two latter died in a few hours. Packard mentions three cases, one by Cotting, in which the face was crushed by a cart-wheel passing over it; another, brought to the Pennsylvania Hospital, in which the injury was received by the head being caught between the platform of a steam hoisting machine and the floor; the third, a case reported by Heath in his "Injuries and Dis- eases of the Jaws," which was under the care of Dr. Fyfife. The first and last cases recovered; in the other, death resulted in a few hours. Heath describes two cases. The first came under his personal notice, and was "caused by the passage of a wagon-wheel over the face. The bones were completely crushed and separated one from 16 . 226 SURGERY OF THE FACE, MOUTH, AND JAWS. another, and death was instantaneous." The second one is that re- ported by Dr. F}ffe, the same before referred to as mentioned by Packard, and which will be described later. Tiffany mentions a single case, which was reported by Professor Christopher Johnston. The patient, a man, was struck in the face by the walking beam of a steamboat. All the bones of the face were crushed, and "seemed literally to consist of a bag of bones, moving freely with inspiration and expiration, so extensive was the comminu- tion." This case made a good recovery, and an excellent result was obtained by supporting the superior maxillae by means of a silver wire passed through the cheeks and under the teeth, and uniting the ends of the wire over tile head by a rubber band. Richard Wiseman published the report of the first case on record, and described the method of treatment. The patient was a little boy, eight years of age, who was kicked by a horse, the whole upper jaw being driven in so that the finger could not be passed behind the palate. A flattened hook was constructed which could be inserted be- hind the palate, and by extension, constantly maintained by the patient and assistants, the bones were held in place and a good recov- ery followed. In the case reported by Dr. Fyffe, of Vvestminster Hospital, Lon- don, the patient was thrown from a cab, the vehicle turning over upon him. The superior and inferior maxillae were fractured, and the bones of the face detached from the skull, so that the former "moved up and down in the act of swallowing," This patient also recovered. Holmes describes a single case, in which the bones of the face were crushed and dislocated by a carriage-wheel passing over the face, and in which, after recovery, there "was a disagreeable lengthen- ing of the face," as the result of the injury. It would seem more likely, however^ that this condition was the result of the treatment. Among the methods of treatment suggested by Holmes are gutta- percha molds, cork disks placed between the teeth, wiring of frag- ments, and carefully adjusted pressure by the Hanesby truss, Hamilton refers to one case which came under his own care, in which the upper bones of the face were fractured and torn from their attachments to the cranium, and had to be supported to keep them in place. The patient died on the twelfth day after the injury. Mason reports a case which was under the care of Mr. Bicker- steth, of Liverpool. A man, standing upon the deck of a steamer, was struck upon the side of the face by an iron hook attached to the hawser, which had parted under a heavy strain. On examination, "immediately after the accident, the mouth seemed to be filled by a piece of bloody meat; but upon a more thorough examination this proved to be the muscles attached to the upper jaw; the orbital plate FRACTURES OF THE SUPERIOR MAXILL.E, ETC. 22/ of the superior maxilla of the injured side was found beneath the cheek, while the palate process, with the alveolar ridge and teeth, were, for the time, situated in the upper part of the pharynx, looking to- ward the bodies of the upper cervical vertebrae. The facial surface of the bone took the place of the roof of the mouth, jamming the jaws open. The soft palate was not torn, but considerably injured. The superior maxilla of the injured side was turned completely upon its axis. The detached mass was replaced, the lower jaw firmly closed upon it for support, and the whole rapidly united with scarcely any de- formity." Salter reported a case in which the superior maxillse and malar bones were separated from their attachments with the skull, and so crushed as to feel like a mass of "loose bones." Harris, of New York, also reported a case of a little child, only two years of age, who fell a distance of fifty feet to the pavement, striking upon the face and sustaining fractures and separation upon the median lines of both superior maxillse and palate bones. "Union had not taken place six weeks after the injury." Houghton describes a case in which the "superior maxillse were i — around, dtrrer^ — bone, and c-ti — termination used to indicate inflammation). Inflamma- tion of the periosteum. The periosteum is a fibrous membrane which invests or covers the external surfaces of bones, except at the articular surfaces and at the points of insertion of tendons and ligaments. It is composed of two layers — an outer or fibrous, and an inner or osteogenetic. The perios- teum serves to give attachment to the surrounding tissues, and as a means of nourishment, growth, and regeneration of bone. Periostitis of the Jaws. — The jaws, like bones in other parts of the body, are subject to inflammatory conditions of their periosteal cover- ing, which may be made manifest in either an Acute or a Chronic form. Acute periostitis of the jaws may be either a simple local in- flammation, which may become suppurative, forming subperiosteal abscesses, or it may be diffuse and infective, depending upon the cause of the disease, the severity of the attack, and the diathesis of the patient. In an individual of good habit, the disease would in all proba- bility not progress beyond a simple local inflammation, with suppura- tion; while on the other hand, if the individual were possessed of a strumous or tubercular diathesis, or w-as anemic, or recovering from a protracted illness, etc., the inflammation would be more likely to take on a diffuse or infective character. The disease may terminate either in resolution, suppuration, or necrosis. Simple local periostitis is the most common form of the disease. It occurs more frequently in the inferior than in the superior maxilla, runs a more rapid course when located in the lower jaw, and almost invariably terminates in necrosis of the bone unless the inflammatory symptoms are promptly arrested. Occasionally the disease will attack opposite sides of the jaw at the same time, and gradually extend until the entire jaw is involved ; when beginning upon one side only, it may cross the median line and involve the jaw of the opposite side to a greater or less extent. Causes. — The exciting causes of acute local periostitis are the diffi- 264 PERIOSTITIS OF THE JAWS. 265 cult eruption of tlie deciduous or permanent teeth, irritation from de- vitalized teeth, traumatic injuries, the effects of the eruptive fevers, typhoid conditions, prolonged anemia in young children, syphilis, scor- butus, and long exposure to cold; chemical poisons, such as mercury, carried to salivation, and the vapor of phosphorus. In children of tubercular diathesis the disease may occur with no other evidence of the cause than the constitutional taint, as is frequently observed in periostitis of other portions of the body. The predisposing causes are the scrofulous, tubercular, and syphil- itic diatheses, and all other conditions which produce a lowered vitality. Symptoms. — The symptoms of the disease are elevation of tempera- ture, with general constitutional disturbance; swelling and congestion of the gum and of the affected side of the face; severe, tense, bursting pains, generally worse at night; the teeth become loose and raised from their alveoli; pressure or percussion upon the teeth causes ex- cruciating pain. The swelling often extends down the neck, and when pus forms it may point beneath the jaw, or burrow downward between the muscles, following the connective tissue, and point at various loca- tions above or even below the clavicle. Spasmodic closure of the jaws is not an infrequent accompaniment of the disease. In the milder cases of simple acute periostitis, the disease may be very insidious in its approach. The pain is intermittent, usually oc- curring at night; the swelling of the gum and side of the face is less marked, and may be overlooked altogether, while the teeth may not give evidence of being sore, unless sharply percussed. For these rea- sons advice may not be sought and the disease not recognized until considerable mischief has been done by the formation of periosteal abscesses and death of the bone. The general tendency of acute periostitis is to end in suppuration. When suppuration occurs the periosteum is dissected from the bone, and necrosis is induced. Acute Diffuse Periostitis. — This form of the disease occurs most frequently at the age of puberty, in children of strumous habit, and those sufifering from impoverished conditions of the blood. It runs a more rapid course than simple acute periostitis, the general and local symptoms are more aggravated, pus accumulates in greater quantity, and the disease invariably ends in necrosis of the bone. Causes. — The direct or exciting causes of the disease are external injuries, septic infection, eruptive fevers, exposure to cold and damp- ness, etc. Occasionally, in young children of tubercular or strumous ■diathesis, a considerable portion of the jaw may become necrosed without any previous history of injury, exposure, derangement of health, or other discoverable cause which seems adequate to account for the disease. 266 SURGERY OF THE FACE, MOUTH, AND JAWS. Treatment. — The treatment of acute simple, and of diffuse perios- titis, if recognized in their eadier stages, should consist of energetic measures: the extraction of devitalized teeth, local depletion by free scarification of the gum, cold applications,— or if these prove painful, hot fomentations, or hot water held in the mouth, — and opiates to re- lieve the pain. When the inflammatory process has reached the suppurative stage, the sooner the evacuation of the pus is secured the better. Free in- cisions down to the bone, made from within the mouth, ought to be insisted upon as soon as pus is discovered, v;ith the view of giving exit to the discharges and relieving the periosteal tension. Such a proced- ure affords great relief to the patient. When the abscess points toward the external surfaces beneath the jaw, as frequently happens, or burrows down the neck, external in- cisions become necessary, as evacuation and drainage are thus better accomplished. Irrigation with antiseptic solutions should be fre- quently employed, and if necrosis results the dead bone should not be removed until separation has taken place. The constitutional treat- ment must be sustaining throughout, viz: good foods, tonics, — iron, cod-liver oil, etc., — and stimulants if indicated. Mercurial Periostitis. — This form of the disease is due to the con- stitutional impression of mercury, and has been so common in the past as to come under the notice of almost every middle-aged practitioner of medicine. The effects which are produced by mercury upon the general sys- tem, and locally in the mouth, depend upon the quantity administered and the susceptibility of the individual to the action of the drug. Chil- dren from five to ten years of age are peculiarly susceptible. There is, however, a very great variety in the susceptibility of different in- dividuals; in one, an ordinary dose of blue pill or of calomel will pro- duce severe salivation and swollen tongue, while another seems to be almost proof against its action, even in large and repeated doses. Garretson mentions a case under his care, a child seven years of age, in whom necrosis of the left half of the body of the lower jaw was produced by the administration of three grains of calomel. Symptoms. — The symptoms of the disease, as presented in stages, are a coppery or metallic taste in the mouth, speedily followed by an increase in the flow of saliva and swelling of the tongue. The tongue in its swollen condition presses upon the teeth, causing indentations upon its edges. The gums next become swollen and puffy, commenc- ing generally in the neighborhood of the inferior incisor teeth. A con- gested condition of the oral mucous membrane also appears, extending- over the entire mouth, and sometimes associated with a sense of dry- ness or of burning. Tumefaction of the gums now becomes general; PERIOSTITIS OF THE JAWS. 267 they assume a livid color, and bleed easily. The salivary glands are swollen and tender, and the secretion of saliva is greatly augmented in amount; so much so, that the patient is obliged to constantly expector- ate. In some cases the secretion is so profuse that it runs from the mouth. The quantity in severe cases may reach several pints per day. The teeth frequently become loose, and can be picked out with the fingers; the breath and secretions have a very disagreeable fetid odor. The disease, if unchecked, may be complicated with necrosis of more or less extensive portions of the alveolar process, or of the entire jaw, or with sloughing of the gums and cheeks. Treatment. — The treatment of mercurial periostitis consists of eliminating the mercury from the system by the aid of the iodid of potassium in doses of from five to ten grains in solution, after meals, which forms soluble compounds with the mercury retained in the economy; or by the administration of chlorate of potassium in ten- to fifteen-grain doses every few hours, for its oxidizing effects in contam- inated conditions of the blood. Saline cathartics are also useful in promoting elimination. The general health should be built up by change of air, generous diet, and tonics. The local conditions are to be corrected by scarifying the gums and painting them with the tinc- tures of aconite and iodin, equal parts, or tincture of iodin and glycerin, equal parts. Solutions of chlorate of potassium, one drachm to an ounce of water, used as a mouth-wash, will be found very efficacious in relieving the local inflammatory con- ditions, and can be used ad libituni. Permanganate of potassium, two to ten grains in an ounce of water, or cinnamon water, are very useful in correcting the fetid odor of the breath. Solutions of boric acid and the Thiersch solution may be used freely as antiseptic washes. Chronic Periostitis of the Jaws. — This form of the disease is usually the result of syphilis. It is generally painless, causes but little swelling of the soft tissues, and manifests itself in the formation of nodes, as in syphilitic periostitis of other parts of the body. The palate and alveolar borders are particularly liable to those enlargements, which are due to exudations between the periosteum and the bone, and unless constitutional treatment is instituted for their removal, necrosis will sooner or later supervene. Fortunately, the disease will usually yield to large doses of the iodid of potassium, twenty grains three times per day, in the compound syrup of sarsaparilla, rapidly increased to drachm doses. Sy this treatment in a few weeks the swelling will dis- appear, and the periosteum be restored to its normal condition. Mer- cury is generally considered to be inadmissible in this form or stage of syphilitic disease. CHAPTER XXVIII. NECROSIS OF THE JAWS. Definition. — Necrosis (from the Greek •^^y.poi, dead). Death of the bone en masse. Necrosis is a condition, not a disease. It is rather a symptom, representing a local condition, which may be brought about by various causes. Necrosis of the Jaws. — Necrosis is much more common in the lower than in the upper jaw. This is no doubt due mainly to the greater vascularity of the tissues of the upper jaw, and the free anas- tomosis of its vessels, which augments its recuperative power; and, in comparison with the lower jaw, its better protected position, which renders it less liable to injury. The superior maxillae are supplied with numerous branches of the internal maxillary arteries, which freely inosculate with one an- other and with those from the opposite side, while the inferior maxilla is supplied with only one small branch upon each side, and these do not so fully anastomose one with the other. According to Stanley ("Diseases of the Bones"), the lower jaw stands fifth among the bones of the skeleton in its liability to necrosis, while the upper jaw occupies the twelfth place. Taking this state- ment as our authority, the lower jaw is therefore nearly two and a half times more liable to necrosis than the upper. Necrosis of the jaws may be complete or partial. It is complete when the entire thickness of the bone is involved, and partial when it is confined to the alveolar process. Causes. — The causes which produce necrosis are identical with those of periostitis, viz: traumatisms, the eruptive fevers, scorbutus, syphilis, inflammatory conditions of the periosteum and periodonteum, mercurial and phosphorus poisoning, local arsenical poisoning, gan- grgena oris, and other ulcerative affections of the soft tissues of the mouth, which establish inflammatory conditions, causing death of the bone by strangulation of its blood-vessels. Necrosis in this respect resembles gangrene of the soft tissues. Necrosis is therefore the result of unchecked periostitis, or sup- purative inflammation, induced by any of these conditions, and the 268 NECROSIS OF THE JAWS. 269 separation of the periosteum from the bone by the accumulation of the pus. In the upper jaw, which is composed of thin plates of bone, cov- ered upon both sides with periosteum, and the whole exceedingly vas- cular; and in the long bones, where there is medullary tissue abun- dantly supplied with blood-vessels, the resistance and recuperative powers are much greater than in the lower jaw, and it frequently occurs that after an extensive subperiosteal abscess has formed, and the bone has been denuded of its periosteum, recovery has taken place without death of the bone; but when the same conditions are associated with the lower jaw, it rarely happens that recovery takes place without more or less extensive necrosis, while death of the bone is not infrequently accomplished in a few hours after the formation of pus between the periosteum and the bone. The necrotic process does not, however, necessarily extend to the entire thickness of the bone, but may be confined to the outer surface only, — which it usually attacks first, — if proper treatment is instituted to remove the accumulated pus and con- trol the inflammation. In such cases the internal plate of the alveolar process remains intact, and gives support to the teeth, which other- wise would loosen and fall out, as generally occurs when the entire thickness of the jaws is necrosed. If, however, the disease involves the entire thickness of the bone, it may not extend beyond the alveolar process, the base of the jaw being left intact. Separation finally takes place between the living and the necrosed portions of the bone. The dead portion is termed the sequestrum. It frequentW happens in the lower jaw, but rarely in the upper, that new bone is formed from the periosteum over and around the seques- trum. This shell of new bone is termed the inxiolucrum. The new shell of bone often has openings in it, which are termed cloacce. In the more serious cases affecting the inferior maxilla, large sections of the entire thickness of the jaw, or even the entire jaw, from the articulation of one side to that of the other, may become necrosed. Similar conditions may prevail in the upper jaw, but it is exceedingly rare that the necrosis is so extensive as in the lower jaw. Several cases of an interesting character have come under the ob- servation of the writer, which will serve to illustrate the above state- ments, — one in which the trouble followed tropical fever in a man thirty years of age, and which began upon the right side of the jaw, in the region of the first molar tooth. Soon afterward it attacked the opposite side, and extended forward to the median line on both sides, and backward to the angles. The necrosis was principally confined to the external plate of the alveolar process, which came away in sec- tions and spiculge to the number of over fifty, and involved the loss of three anterior teeth. Another was the result of suppurative inflam- 270 SURGERY OF THE FACE, MOUTH, AND JAWS. mation of the left lower third molar in a man fifty years of age, suffer- ing from anemia. The necrosis extended rapidly until the entire alveolar process was involved from the left angle to the right second molar. All of the teeth, and the entire alveolar process, were lost be- tween these points. A third was the result of scarlet fever in a l)oy five vears of age, in whom the body of the jaw, from the right lower first deciduous molar backward, and the entire ramus, including the con- dyle and the coronoid process, were lost. A fourth (Fig 116) was the result of a suppurative inflammation of the left inferior third molar in a woman thirty-five years of age, suffering from general debility, the Fig. 116. Necrosis of Lower Jaw and Sloughing of Soft Tissues of Chin and Neck. result of frequent gestations, with short intervals, and overwork. The necrosis extended very rapidly until it involved the entire jaw, which was finally lost from the articulation of the left side to the upper third of the ascending ramus of the right side. This case terminated fatally from exhaustion complicated with la grippe, sixteen days after the re- moval of the necrosed maxillary bone. The illustration shows exten- sive loss of the soft tissues of the chin and neck by sloughing, which had occurred before the patient was admitted to the clinic at Mercy Hospital. Another was in a boy of seven years of age, the result of a severe attack of measles, in which the alveolar process and body of the right superior maxilla from the canine fossa backward to the tuber- ositv, and upward to the orbital plate, was lost, the palate process and NECROSIS OF THE JAWS. 271 the orbital plate remaining- intact. Others of an equally grave nature might be mentioned, but these are sufficient to illustrate the subject. Syinptoiiis. — The earl}- symptoms of necrosis are usually those of periostitis, which have already been mentioned under that head. After necrosis has been established the pus finds an outlet by the side of the loosened teeth, or burrows through the gums. Later the gums become loosened from the bone, and the pus oozes from between them. This is the usual course of necrosis in the upper jaw. When associated with the lower jaw it often burrows through the tissues cov- ering the body of the bone, and points upon the under side of the jaw, or follows the inter-muscular connective tissue of the neck downward, pointing at various locations, even as low down as the clavicle or mamniK. The discharges have the peculiar fetid odor which is char- acteristic of dead bone, and in those cases in which the pus is dis- charged into the mouth in considerable quantity, nausea and vomiting may ensue, digestion soon becomes deranged by reason of the en- trance into the stomach of the foul discharges, general emaciation fre- quently takes place, and septicemia is not an uncommon sequence. Necrosis of the jaws has been known to extend to adjacent bones of the face and head, and so involve the brain, causing a fatal termina- tion. Treatment. — The treatment of necrosis in general should be that of non-interference, except the opening of the subperiosteal abscesses, and disinfection, until such time as separation of the sequestrum has taken place. Nothing is to be gained by surgical operations for the removal of necrosed portions of bone before separation occurs, as it is usually impossible to previously determine to what extent the necrosis will involve the bone. Furthermore, such attempts at removing the dead bone would be worse than useless, as they would be likely to ag- gravate the inflammatory symptoms, and make a secondary operation necessary. The treatment must therefore be one of expectation and conservatism. The establishment of free openings for the discharge of the ac- cumulated pus, and frequent irrigation of the suppurating surfaces with antiseptic solutions, is about all that can be done until the sequestrum is loosened. The fetid odor of the breath and of the discharges may be corrected by the free use of solutions of the permanganate of potas- sium and cinnamon water. The peroxid of hydrogen and the medicinal pyrozone are also useful in the same direction, but they should not be used in those cases where there are not free openings for the escape of the liberated gas, since it may occur that the pressure of the gas will be so great as to dissect a considerable area of periosteum from the bone, beyond the original lesion, and by that much increase the extent of the necrosis. One such case occurred in the practice of the writer, 272 SURGERY OF THE FACE, MOUTH, AND JAWS. with the result of making him thereafter extremely cautious in the use of these remedies. The constitutional treatment should be supporting throughout, — good food, milk, and concentrated liquid foods are best in these cases, on account of the inability of the patient to use the jaws for mastication. Tonics are also indicated, — iron, quinin, inalt ex- tracts, cod-liver oil, etc., and change of air. CHAPTER XXIX. NECROSIS OF THE JAWS (Continued). Exanthematous Necrosis. — The eruptive fevers are productive of a large percentage of the cases of necrosis of the jaws in children. The age limit in which it is most likely to occur is between the third and eighth years. It is exceedingly rare that a case of necrosis is de- veloped as one of the sequelae of the exanthems outside of this limit. It is interesting to note the correspondence of the age limit with the period of the greatest activity in the developmental processes of the jaws and the teeth. The teeth are dermal appendages, developed from the layers of the mucous membrane; consequently these tissues are more or less susceptible during their development to the same in- fluences which affect other portions of the dermal skeleton. The pecu- liar toxic conditions of the system which exist during attacks of scarlet fever, measles, and smallpox would seem to be the exciting cause of necrosis, while the exceeding activity of the vascular system of the parts would predispose to congestion and inflammation. Necrosis is more liable to follow scarlet fever than measles or smallpox. Salter places the ratio as between scarlet fever and measles at about three of the former to one of the latter; between scarlet, fever and smallpox, as about four to one; and between measles and small- pox, six to four. The severity of the attack seems to bear no relation to the liability to cause necrosis. Mild cases develop necrosis as frequently as severe ones, and vice versa. Occasionally the necrosis is associated with other secondary symptoms, but in the majority of instances this is the only one, and it would seem that it had a predilection for otherwise healthy children. Symptoms. — This form of necrosis first shows itself a few weeks after the attack of the fever; the approach of the affection is marked by aching and soreness of the teeth, swelling, tenderness, and turges- cence of the gums, and fetid breath, quickly followed by suppuration and all the symptoms of necrosis. Treatment. — The treatment is substantially the same as that indi- cated for necrosis of the jaws in general. The condition of the gen- eral health, however, should be carefully watched, and every effort 19 273 274 SURGERY OF THE FACE, MOUTH, AND JAWS. made to improve it, by good foods, tonics, fresh air, and stimulants when required. Mercurial Necrosis. — Mercurial periostitis and necrosis of the jaws used to be quite common forty or fifty years ago, especially in the southern portions of our country, when mercury w^as used so ex- tensively and in such large doses. Happily, in these days the more intelligent use of the drug has made such cases much less common. The loss of osseous tissue from mercurial poisoning varies very greatly in its extent. It may be confined to the alveolar process sur- rounding one or two teeth, or extend throughout the entire alveolar process of one or both jaws, or an entire jaw may be lost. Sometimes the constitutional effects may be so overwhelming as to endanger the life of the sufferer, occasionally proving fatal. When the death of the bone is extensive there is often associated with it, as a complication, sloughing of the gums and of the cheeks, causing perforation of the buccal walls and consequent disfigurement of the face. In other cases the sloughing is confined to the mucous membrane, or it may invade the muscular tissue of the cheek or lips without perforating the integument. Under these circumstances large masses of cicatricial tissue are formed by the process of healing, which upon contraction may give rise to permanent closure of the jaws. The writer has seen but few cases of necrosis of the jaws that could be fairly attributed to mercurial poisoning, and two of these proved fatal. The first was a railroad engineer, forty years of age. Large doses of mercury were admiiiistered by his physician during an attack of malarial fever, with the result of producing severe ptyalism, with a profuse flow of saliva, three to four pints per day, and extensive stomatitis, periostitis, and necrosis of both the upper and lower jaws. All of the teeth in both jaws became so loose that most of them were removed with the fingers; the rest were extracted with the forceps. Suppuration was very extensive in both jaws, pus discharging into the mouth in large quantities, and through several sinuses under the lower jaw. The patient rapidly failed, and died before separation of the sequestra had taken place. This was an exceptionally severe case, and fortunately an uncommon one. The second fatal case was quite recently under observation. The patient was an Italian woman about thirty years of age, who was suf- fering from mercurial periostitis and necrosis of the superior and in- ferior maxillse, and gave a history of having taken only fifteen grains of calomel in three-grain doses "at bedtime." The necrosis was ac- companied with extensive sloughing of the gums of the inferior maxilla and the soft tissues covering the hard palate, swollen tongue, fetid breath, excessive salivary secretion, loosened teeth, and an uncontrol- lable diarrhea. Death was from exhaustion. NECROSIS OF THE JAWS. 275 Treatment. — The treatment has been already described under the head of mercurial periostitis. The rules governing the removal of the sequestra are the same as those for necrosis in general. Arsenical Necrosis. — Necrosis of the alveolar process is not an uncommon result of the careless application of arsenious acid for the devitalization of the tooth-pulp; or from accidental causes, like the penetration of the drug beyond the apical foramen; or through the minute canals which sometimes exist in the sides of the roots of the teeth, and which communicate with the root-canal and the pericemen- tum. Accidents more often occur in the treatment of the teeth of chil- dren, for the deciduous teeth have large apical foramina; consequently, the use of arsenic for pulp-devitalization in these cases is dangerous in the extreme. The same is true of all the permanent teeth during the development of their roots, which are not completed until some consid- erable time after the eruption of the crown. The first permanent molars most often require the devitalization of the pulp as a result of caries, but as they are not fully developed until about the end of the tenth year, it would be dangerous to apply arsenic for this purpose before that time. This rule should apply to all the teeth of young people during the development of these organs. Arsenious acid is a powerful escharotic, but at the same time a valuable remedy when carefully used. The faults in applying arsenic to the tooth-pulp for the purpose of devitalizing it, lie in two direc- tions : First, too large a quantity is generally used; and, Second, it is not properly sealed in the cavity. The one-hundredth of a grain of arsenic is just as effective in destroying a pulp as a larger quantity would be. This amount may be safely left in the adult tooth from two to three days, when properly sealed in the cavity; in fact, it will require about this length of time to effectually destroy the vital- ity. The only safe method of sealing a cavity in which arsenic has been placed is with the oxyphosphate cement. Gutta-percha, the tem- porary stoppings, and cotton and sandarac varnish cannot hermetically seal a cavity, and anything less than this is dangerous. In arsenical necrosis the disease rarely, if ever, extends beyond a fragment of the alveolar process involving one or two teeth, with the possible loss of the teeth involved in the death of this portion of the bone. It oftener occurs, however, that the necrosis does not extend beyond a portion of the alveolar process upon that side of the tooth on which the arsenic came in contact with the soft tissue. These acci- dents occur more frequently in applying the drug to teeth having cavities upon their approximal and buccal surfaces near the gingival "borders; consequently, the alveolar septi and the outer plate of the alveolar process are the most common locations of necrosis from this 276 SURGERY OF THE FACE, MOUTH, AND JAWS. cause. The soft tissue with which the drug comes in contact is always devitahzed and slouglis away. Treatment. — The treatment of necrosis from the effects of arseni- otis acid does not materially differ from that of necrosis from other causes. The application of the hydrated oxid of iron — sesquioxid — to the injured tissues is advocated very strongly by some authorities. To the writer the local application seems of little value, except to serve as an antidote for that which still remains in the tissues of the tooth. Phosphorus Necrosis. — ^Maxillary necrosis, the result of poisoning from the fumes of phosphorus, was at one time a very common aiTec- tion among the operatives in match factories. It was so terrible in its results that it became the subject several times of legislative inquiry in England and other European countries, with the desire of discover- ing some means of preventing or mitigating its ravages. Scientific in- vestigation was also instituted by medical men as to the cause of the disease, and to discover, if possible, some means of prevention, with the result of establishing beyond a reasonable doubt these facts: First, That the affection was caused by the fumes of phosphorus, but that it must gain access to the periosteum of the bone in order to establish the disease. Second, That in every case of necrosis of the jaws from this cause, the disease originated in connection with a carious tooth, and, on the other hand, operatives with sound teeth were entirely ex- empt from it. This seemed to indicate that the phosphorus gained access to the periosteum through the tooth-pulp, and thus established the affection. The disease appeared, therefore, to be one of local poisoning, and the fact that the other bones of the body escaped the disease added strength to the argument. Opposed to this view are Langenbeck and others, who maintain that the eft'ects of the poison were produced through the system, the same as with mercury. There seems to be no fact in pathology better established than that the disease is the result of local poisoning, pro- duced through some break in the continuity of the structures of the mouth, which permits the poisonous fumes to come in contact with the periosteum. Precautionary measures were therefore adopted by the manufac- turers, as a result of the scientific investigation, for the protection of their employes, which have proved so efficacious that now the disease is rarely seen. These means consisted of thorough ventilation of the dipping rooms, cleanliness of the factories, with a proper care and treatment of the teeth of the operators, and teaching them habits of personal cleanliness. The disease has occasionally been contracted by children from the chewing of the dipped ends of matches. Symptoms. — Phosphorus necrosis is very insidious in its first ap- proach, the symptoms being so mild as scarcely to be noticed, usually NECROSIS OF THE JAWS. 277 beginning- in a supposed toothache. As the disease progresses, the symptoms become marked and aggravated; the pain in the jaw is excruciating in the extreme, the swelHng very great, often extending over the entire side of the face and head. Abscesses form and open upon the external surfaces, and also into the mouth, forming sinuses through which the dead bone can be felt with a probe. The opening of the abscesses usually affords great rehef; the pus is very of=fensive, and usually profuse. The health of the patient often deteriorates very rapidly from inability to take food, and from the disturbance of the stomach induced by the unavoidable swallowing of considerable quan- tities of the fetid discharges. When the necrosis is extensive, the con- stitutional disturbance is correspondingly great. Death frequently occurs from exhaustion. A peculiar and characteristic feature of phos- phorus necrosis is the pumice-like deposit upon the sequestrum. Trcafmcnt.— The treatment consists of sustaining the vital powers of the patient by the administration of concentrated liquid food, tonics, and stimulants. The local treatment is that of necrosis in general.^ Syphilitic Necrosis.— The manifestations of syphilis in the jaws are generally associated with the tertiary stage of the disease, the earlier lesions being rarely met with in this region. The upper jaw is much oftener affected than the lower. When the disease attacks the lower maxilla, it is usually confined to the alveolar process, though it sometimes extends to the body of the bone. In the upper maxilla it attacks the alveolar and palatine processes and the palate bones most frequently; its most common site is the central part of the dome of the hard palate (Fig. 117), but it is not always confined to these locations. The writer recently saw a case in an old soldier in which the palate bones, the bones of the nose, and nearly the entire upper jaw, had been destroyed by the disease; the only portions of the jaw that remained were. the orbital plate and malar processes, and a portion of the outer walls of the antra. The soft palate was intact. The opening into the nose was bounded posteriorly by the soft palate, laterally and anteriorly by the cheeks and lips only, except that portion of the outer wall of the antra just referred to. The opening measured antero-posteriorly one and three-fourths inch, and from side to side one and one-half inch. The destruction of the osseous tissue of the nose and jaws is rarely so appalling as in this case. The tertiary symptoms of syphilis frequently present themselves long after the primary and secondary symptoms have disappeared, while the natural reticence of the patient to admit early indiscretion often makes the diagnosis extremely difficult, so that for lack of posi- tive evidence many cases are excluded from the category which no doubt properly belong there. The syphiHtic virus has a predilection for the compact tissue of 278 SURGERY OF THE FACE, MOUTH, AND JAWS. the bone, and most often attacks those portions of the bone which have soft, thin coverings, like the bones of the skull, the palate pro- cess, the palate bones, and the alveolar processes. A marked exception to this is the necrosis of the spongy bones of the nose, following syphil- itic ulceration of the nasal mucous membrane. Symptoms.- — Syphilitic periostitis of a marked type, or ulceration, always precedes death of the bone in the region of the mouth and nose. This form of the disease is, however, much less rapid in its work of de- struction than that form caused by the toxic influence of the eruptive fevers. In syphilitic necrosis, on account of the slower progress or chronic condition of the disease, and frequent exacerbations in the inflamma- tory process, death of the bone frequently occurs in such a way as to Fig. 117. Syphilitic Perforation of the Hard or Bony Palate. form numerous sequestra. Surgical interference before active inflam- mation has entirely subsided is often responsible for a renewal of the inflammatory symptoms, and extension of the necrotic process. It has been the fortune of the writer in his hospital service to en- counter a goodly number of cases of syphilitic necrosis of the jaws, the great majority of which have been associated with the vault of the mouth and the alveolar process of the upper jaw. Among these might be mentioned, by way of illustration, the case of a young lawyer, thirty years of age, who had contracted syphilis seven years before, and for whom was removed a sequestrum of bone involving the median half of the alveoli of the central incisor teeth, and the floor of the nasal fossa, to the extent of about half an inch in diameter, leaving an opening under the lip into the nasal fossa. This opening was successfully NECROSIS OF THE JAWS. 279 closed, and the teeth became reattached by the aid of sponge-g^rafts. This operation was made thirteen years ago, and the teeth are still firm and, to all appearances, in a normal condition. Another case, a man forty-five years of age, contracted syphilis at the age of twenty, had been married sixteen years, and had three healthy children. Necrosis of the right superior maxilla developed three months before his first visit. A sequestrum of bone was later removed for him, involving the alveolar process from the lateral incisor to the tuberosity, including the entire floor of the antrum. Another, a young man twenty-six years old, had contracted the disease about five years before. His present trouble had developed about four months previous to his admission to the hospital. In this case there was extensive necrosis of the palate process and palate bones. Several sequestra were removed at various times, which left an opening in the hard palate the size of a silver half-dollar. A very recent case is that of a little girl, nine years old, suffering from congenital syphilis, with extensive necrosis of the bones of the nose and palate process. Later the nasal septum, portions of the tur- binated bones and the hard palate were lost by the disease. The sequestra in syphilitic necrosis are frequently coated with a gray-black deposit, something like that found in phosphorus necrosis. Treatment. — Mercury in the form of the protiodid, biniodid, bi- chlorid, calomel, gray powder, blue mass, and other combinations of the metal are counted among the most efiicacious drugs in the treat- ment of syphilis in its earlier stages. The protiodid is the most popu- lar with the profession, and is administered in doses of one-fifth of a grain three times per day. In the tertiary stage of the disease, espe- cially in the bone-afifections, mercury in any of its forms is generally considered to be inadmissible. The iodid of potassium is more generally used in the tertiary stage of the disease than any other drug. It is administered in doses of from three grains to twenty, dissolved in distilled water, milk, cinnamon water, syrup of sarsaparilla, or any of the various syrups used as vehicles by the druggists. The iodid of potassium gives the happiest results in the treatment of syphilitic bone-diseases. The larger doses of the drug, viz : two drachms to one-half ounce, in twenty-four hours, are sometimes administered, but are not generally indicated in this form of the affection. In those cases in which the necrosis is very extensive and the vital powers are much depressed, it is better to withdraw the drug alto- gether, and substitute tonics. Especial attention should be given in all cases to the general build- ing up of the vital forces. The diet should be plentiful and nutritious. Alcohol should be administered in moderation, if at all, for its tonic, 28o SURGERY OF THE FACE, MOUTH, AND JAWS. not for its stimulating effects. Tobacco should be excluded in all its forms. The body should be kept scrupulously clean by daily sponge baths with tepid water, and covered with warm clothing. The mind and body should be kept employed with the customary duties, care being taken not to overtax the mental and physical powers. In the severer cases, change of climatCj such as a sea voyage or a few months' residence at the seashore in the summer season, or a trip South in the cold months, is to be advised. The tonics which may be administered with benefit are iron, cod- liver oil, quinin; the bitter tonics, coca wine, etc. Reproduction of Bone. — The bones in general have a very marked power of regeneration. The seat of this power lies in great measure in the periosteum, and in a less degree in the medullary tissue. In many cases the periosteum alone performs the office of reproducing the bone. The knowledge of these facts has brought about the most con- servative treatment upon the part of the surgeon in all operations upon the bones, that no more of the periosteum be sacrificed than is neces- sary to insure the success of the treatment for which the operative pro- cedure was instituted, Malgaigne was the first to recognize the importance of conserv- ing the periosteum for the purpose of establishing the process of re- generation of bone. Oilier demonstrated the possibility of transplanting the periosteum for the purpose of reproducing bone in locations where the original bone and periosteum had been lost. Reproduction of osseous tissue is a frequent occurrence follow- ing fractures, gunshot wounds, and amputations; more rarely after trephining and resections, after extirpation of bones and following necrosis. In all of these conditions there is a more or less incomplete or a complete reproduction of the bone. Regeneration of entire bones is rare. Wagner mentions the case of a woman in whom an entire new clavicle was formed following necrosis. Several cases of reproduc- tion of nearly the entire lower jaw have been recorded, and numerous cases of regeneration of considerable portions. The writer has reported two cases of regeneration of the ascend- ing ramus with perfect mobility of the temporo-maxillary joint. The first was in a girl sixteen years of age, suffering from dentigerous cyst of the lower jaw, the result of an inverted third molar tooth, and necrosis of the ramus, including the head of the condyle, which was removed (Fig. ii8). One year afterward the restoration was so com- plete in all respects as to make it seem impossible that so extensive a loss of tissue had occurred. The other was in a boy five years of age — • already referred to — who lost the ramus and body of the jaw behind NECROSIS OF THE JAWS. 281 the second deciduous molar from scarlet fever. In this case also there was a complete restoration of the lost bone and perfect mobility of the joint. The process of regeneration or repair after loss of the jaw from necrosis dififers greatly in the upper and the lower maxillae. In the upper jaw it is very rarely that true bone is reproduced, but instead there is developed a hard, fibrous tissue, which fills the gap and serves the purpose of bone. This often occurs in children who have suffered from exanthematous necrosis, but rarely in adults, except by the aid of sponge-grafting. In the lower jaw regeneration of bone after necrosis is the general result, but it is claimed by some authors that resorption of the new bone sometimes takes place — occasionally after a considerable period Fig. 118. Condyle of Inferior Maxilla with misplaced and inverted Third Molar. — in those cases where the entire body of the jaw has been reproduced, so that finally there is scarcely enough bone left to keep out the lower lip and the chin, and this feature of the face is completely obliterated. A case of this character, a young lady, recently under the care of the writer, for whom he has attempted the restoration of the contour •of the face by a plastic operation and the construction of an appliance to represent the body of the jaw, upon which are mounted artificial teeth. This appliance is being worn with considerable comfort; the effort has greatly improved the contour of the lower part of the face, and bids fair to be a tolerable success. The cause of this resorption does not seem to be understood. Salter suggests that the resorption of the new jaw might possibly be prevented by inserting a plate of artificial teeth, and thus supply it with a definite function. CHAPTER XXX. STOMATITIS. Definition. — Stomatitis (Gr. a-zoiw., mouth, and ;r;o, the ending used to designate inflammation). Stomatitis is an inflammation of the mucous membrane of the cavity of the mouth. All inflammatory conditions which involve the gums, the inner surface of the cheeks, the lips, and the tongue are in- cluded under the term stomatitis. The affections which are thus included are with few exceptions confined to infancy and childhood. Adults seldom suffer from these affections except as a manifestation of some other morbid condition. A clinical study of the inflammatory affections of the mucous membrane of the mouth will reveal a close resemblance in certain fea- tures to the inflammatory affections as they appear in the skin; while in other points they will present features which are comm.on to inflam- matory conditions of the mucous membrane in general. It is fre- quently noticed that "in measles a spotty or macular eruption appears upon the oral mucous membrane, and in scarlatina a punctate or diffuse scarlet eruption," while "in smallpox, chicken-pox, herpes, pemphigus, and in foot-and-mouth disease," — an infection from cattle, — "there are eruptions of vesicles and pustules, which pass through the same stages as those of the skin" (Ziegler). Erysipelas of the face not infrequently presents an inflamed condi- tion of the oral and nasal mucous membrane, while syphilis and scurvy are accompanied by characteristic mouth-affections. Diphtheria is not always confined to the tonsils, pharynx, uvula, and velum palati, but may likewise involve the mouth. Certain drugs, also, such as mercury and iodin, and the mineral acids, often produce inflammatory conditions of the oral mucous membrane. The forms of inflammation of the mouth which are most common are' stomatitis simplex, stomatitis catarrhalis, stomatitis aphthosa, stoma- titis parasitica, and stomatitis ulcerosa. From the time of Hippocrates to the present day, it has been the custom of some authorities to class all forms of inflammation of the mouth that are characterized by white patches, as aphthae; while others have included all those forms which present ulcerated patches not 282 STOMATITIS. 283 specific, and the more serious phagedenic conditions, as different de- grees of the same affection. , , , ^„a At the present time the distinctions are more sharply drawn, and the classification based upon the etiology and pathology of these affec- tions Stomatitis with white patches is now divided mto two distmct forms: stomatitis aphthosa and stomatitis parasitica, the former bemg due to a follicular inflammation with exudation or false membrane, and the latter to the action of a specific fungus which grows mto the squamous layer of the mucous membrane, ^hese, to the unaided eye are readily mistaken one for the other, the only observable difference being the smaller size of the patches in stomatitis parasitica and the tendencv of the patches in stomatitis aphthosa to spread, and m some Instanced to become confluent. The microscope and bactenologic cultures are necessary to arrive at a positive diagnosis Stomatitis Simplex.-This form of the disease is the mildest of the inflammatory affections of the mouth, and is generally expressed in a 'more or less intense redness of the surface" of the mucous mem- brane of the cheeks, the lips, and the gums, which is ^ue to localized hyperemia. It is usually found in infants and young children, and associated with some form of gastric or intestinal derangement. As a rule it is of short duration, and rapidly disappears, but occasionally it persists and gradually passes into a severe type of the disease known as stomatitis catarrhalis. t„„,*;ti. Sy,„m,us.-The disease is sometimes designated as stoma .t.s eryther^a from its resen.blance to erytl^ema of tlte skin The a£Eect.on s"cl!lracterized by tl,e appearance of rose-red, ^'^^'^^^tZ'^'Z the surfaee of the mucous membrane of the mouth, usually upon the cheeks and the lips, but occasionally also upon the gums, the palate, and the velum. Like erythema simplex of the skm .t appears sud- denly, lasts for a few hours or two or three days, and as rapidly sub- sides The bright color of the patches may be made to disappear by pressure upon them, but the color immediately returns upon removing the pressure. Hea and dryness of the mouth are often promment symptoms, while in other cases the salivary glands are sometimes very active and the saliva dribbles from the mouth. (Day.) There may be, and often is a rise in the body temperature and other febrile symptoms accompanying the appearance of the erythema but tWs in all probability is due to the constitutional disorder of wh h it is symptomatic. Restlessness, flatulency, and diarrhea are often ^™t:rrTr treatment of this affection is to be directed to the constitutional condition upon which it is dependent, and of which it sbuta local expression. The erythema usually subsides as soon as he constitutional disorder is corrected. This in many instances may 284 SURGERY OF THE FACE, MOUTH, AND JAWS. be accomplished by the administration of a mild cathartic and the regu- lation of the diet. Stomatitis Catarrhalis. — This affection is often a symptomatic ex- pression of a more grave constitutional malady, though it may be an entirely local disease induced by irritation from erupting teeth, or the taking into the mouth of irritating substances. The disease is often preceded by the simple erythematous condition just described, and it appears as a generally uniform diffuse inflammation, spreading over the cheeks, lips, and gums, and upon the hard palate as "streaks and patches." The papillae of the tongue are most affected (Ziegler), many of them appearing as prominent tubercles. The mucous glands be- come swollen and prominent, so that they can be readily felt by passing the finger over the surface of the membrane. As the inflammation progresses, the mucous follicles become enlarged, "giving rise to gray- ish or grayish-red elevations of the surface surrounded by a reddened areola" (Ziegler). Occasionally tiny cysts are developed as a result of the plugging of the excretory ducts of the follicles with mucoid cells and the retention of the secretions. Sometimes cracks and fissures will appear upon the lips and at the angles of the mouth, with exudation and the formation of crusts. The disease is most common among the children of the very poor, during the first year of infantile life, and is usually associated with bad food and unsanitary surroundings. It is rarely seen among the infants of the better classes of society, "unless the nipples of the nurse are sore or the milk is faulty" (Day), or in the bottle-fed children when the nurse allows the bottles and tubes to become foul. Causes. — The causes are gastro-intestinal disorders, unwholesome food, uncleanliness, and the nervous irritation induced by the eruption of the deciduous teeth. It is occasionally "the result of taking cold, the inflammation being an extension of the inflammatory conditions of the mucous membrane of the respiratory tract" (Swift). Symptoms. — The local symptoms are redness and capillary con- gestion of the mucous membrane of the mouth, accompanied by en- gorgement and swelling of the mucous follicles ; swelling of the tongue, lips, cheeks, and gums; fetor of the breath; heat and dryness of the mouth, followed in some cases by an excessive secretion of the saliva and mucus, especially in children who are teething. In the latter cases the gums are often soft and spongy, and bleed under the slightest pro- vocation. Vesicles and blebs are sometimes found upon the tongue, lipSj and cheeks, which when ruptured leave minute ulcers "having a yellowish patch of lymph in the center, with a red margin" (Day). Fis- sures form at the angles of the mouth, and upon the lips, with exuda- tion and the formation of crusts. Pain in this form of the disease is seldom very great, and the ulcerations are small and rarely trouble- some. STOMATITIS. 285 The constitutional symptoms are febrile disturbances, diarrhea^ thirst, loss of appetite, and sleeplessness. The prognosis is favorable. Treatment. — The treatment consists in correcting the gastro-intes- tinal derangement by appropriate remedies, such as a dose of castor oil, or a powder of rhubarb combined with carbonate of soda (Day). The milk should be inspected, and if found unwholesome changed for that which is good. The breasts of the nurse should be exam- ined, and if the nipples are found sore the child should be fed with the spoon or bottle. In the bottle-fed children the feeding utensils should be critically inspected, for many times the disease may be traced to unclean bottles, tubes, and nipples. The irritation to the gums from an advancing tooth is often relieved by lancing. The mouth should be cleansed after each feeding, by means of a piece of gauze or absorbent cotton wrapped about the finger or a probe, and dipped in a mild antiseptic solution, followed by washing the mouth with a chlorate of potassium solution, or "an astringent lotion in the form of a weak solution of the sulfate of zinc or of copper" (Swift). Lime-water should be added to the milk, and every effort made to keep the food and the surroundings of the child in a hygienic condition. Stomatitis Aphtliosa. — (Gr. acf^Oa, an eruption). This disease — known as Canker sore-mouth- — is considered by Ziegler to be a peculiar form of catarrhal stomatitis, for the reason that the aphthous patches occur upon the oral mucous membrane while in a catarrhal condition. Aphthous stomatitis may be considered as a severer form of catarrhal stomatitis. The disease is most common among sickly children during first dentition, but it is frequently seen during second dentition, and occasionally later in life in those who are debilitated from illness or debauchery, and "in women during men- struation, in pregnancy, and during the puerperal period." (Ziegler.) It is sometimes associated with pneumonia, gastric and intestinal ca- tarrh, bronchitis, diphtheria, exanthematous diseases, ague, whooping cough, and tonsillitis. Bohn has compared aphthous stomatitis with impetiginous eczema of the skin, which appears in the form of "an eruption consisting of pustules of the size of a pea, and drying into scabs without rupturing." Aphthous stomatitis is characterized by the appearance upon the mucous membrane of small whitish or slightly yellowish patches from the size of a hemp-seed to that of a split pea (Ziegler). These patches may appear singly or in groups, and are most abundant upon the edges of the tongue and at the gingivo-buccal fold of the lips and the cheeks. Each patch is surrounded by a more or less inflamed zone; they are inclined to spread and coalesce, forming liarger patches or streaks, though they never reach any considerable size. "The erup- tion occurs in successive crops, and may thus be kept up for weeks." 286 SURGERY OF THE FACE, MOUTH, AND JAWS. Bohn found the aphthous patches "to consist of a soHd fibrinous exudate lying between the fibrous tissue and the epitheHum." Some- times the inflammation does not extend beyond the formation of the exudate; resorption then takes place, and the aphthous patches disap- pear by resolution. The more common termination is for the epithelial covering to be lost, thus exposing the fibrinous exudate, which is grad- ually separated from its base and thrown off by the regeneration of the epithelium which advances from the margins and extends beneath the exudate. As a result of the simultaneous reproduction of the epithel- ium with the extension of the exudate there is rarely the formation of what might be termed a true ulcerated surface. The exudate is easily removed and comes away in the form of a thin, dirty-yellow slough, leaving behind a livid base. Occasionally the inflamed zone which sur- rounds the aphthous patch becomes infected with the pus-microbes, and suppuration results. Causes. — The causes of aphthous stomatitis are usually those which produce catarrhal stomatitis, viz: gastro-intestinal disorders, extension of inflammatory conditions of the respiratory tract to the mucous mem- brane of the mouth, unwholesome food, uncleanness of the feeding apparatus, and the nervous irritation induced by the eruption of the deciduous teeth; to which may be added mechanical irritation from the roughened surfaces and sharp edges of carious teeth, and the irritating effect of certain chemical substances which have been taken into the mouth. The acids of certain fruits, strawberries and tomatoes particu- larly, are not infrequently the cause of aphthous patches. Symptoms. — The local symptoms are the presence upon the lin- gual, buccal, and labial mucous membrane of numerous small white or yellowish-white patches, slightly elevated above the surrounding mem- brane, and which are exceedingly sensitive to the touch, to hot or highly seasoned food, and to acids. The most prominent symptoms are the pain and the soreness of the mouth which prevents the child from taking food. The eruption passes away under appropriate treat- ment, but it is prone to frequent recurrence, especially in debilitated children and adults who are suffering from indigestion and other de- rangements of the digestive functions. The constitutional symptoms rarely exceed a slight feverishness, loss of appetite, thirst, and irritability (Day). When the temperature rises more than one or two degrees above the normal, this is good evi- dence that the child is suffering from a more serious disorder of which the oral affection may be only a symptomatic expression. Treatment. — There is no special treatment for this affection other than that already indicated in the treatment of catarrhal stomatitis, ex- cept that the inflamed parts of the mucous membrane may be lightly brushed over with a camel's-hair pencil which has been dipped in a STOMATITIS. 287 solution of boric acid in glycerol. In the more obstinate cases the patches may be touched with a solution of silver nitrate (gr. v to fi.5j of water). Stomatitis Parasitica. — This disease is popularly known as thrush or white mouth, and is a parasitic or mycotic afifection, generally found in the mouths of infants and little children. The parasite is a confer- void plant or fungus (Fig. 119), the thrush fungus or o'idium albicans, which grows upon and between the layers of the epithelium, but de- velops most rapidly upon the squamous type of this tissue. The dis- ease is most commonly seen in the mouths of artificially-fed children, and is due to imperfect cleansing of the feeding apparatus. Being of Fig. no. OiDiuM Albicans (Thrush Fukgus) in Kidney of Mouse after Subcutaneous Inoculation. X 1000. mycotic origin, it is readily conveyed from the mouth of one child to another. It is most frequently seen in foundling and maternity hos- pitals. To prevent its spreading constant care should be exercised in the examination of the children's mouths, and under no circumstances should the promiscuous use of nursing bottles be allowed. When the disease occurs in adult life it is always associated with a debilitated condition of the system, and is considered as an unfavorable omen. The growth of the organism is favored by an abnormal acidity of the oral secretions, a debilitated condition of the system, and bad sanitary and hygienic surroundings. Symptoms. — ^The disease is characterized by a dry, feverish mouth, and scanty salivary secretion. Small, white, elevated patches are found 288 SURGERY OF THE FACE, MOUTH, AND JAWS. upon the inside of the hps, cheeks, angles of the mouth, and sides of the tongue (Day). These elevated patches, after two or three days, assume a curdy or soft cheesy appearance. This "thrush film" can be removed as a false membrane, leaving a denuded surface which bleeds easily, until it is again covered by another parasitic growth. The denuded or excori- ated surfaces are exceedingly sensitive, and render nursing and swal- lowing very painful. These patches sometimes extend to the pharynx, tonsils, and hard palate, and may even develop in the oesophagus and air-passages. The constitutional symptoms are disorders of the stomach and in- testines, with vomiting and diarrhea. The excreta from the bowels are greenish in color, mixed with curdy masses of milk, and are often acrid, causing excoriation of the anus, buttock, perineum, and in the male sex of the scrotum. Elevation of temperature and acceleration of the pulse are not uncommon symptoms. The disease sometimes terminates fatally in debilitated children from exhaustion and inanition. Treatment. — The treatment consists of clearing the alimentary tract with a dose of castor oil or calomel, and a proper regulation of the diet. Day recommends the use of chlorate of potash administered in small dose of a few grains, three times per diem, as he considers it a specific. The local treatment consists of washing the mouth after each meal with some bland antiseptic solution, and the application of boric acid in glycerol or honey. In the more severe cases the patches may be lightly touched with a solution of silver nitrate, gr. v to water fl^j. Occasionally it may be necessary when there is a tendency to ulcera- tion at the bottom of the patches to touch them with the stick nitrate. Sir Wilham Jenner recommended a solution of soda sulfite 3J to flgj of water. Stomatitis Ulcerosa. — Ulcerative stomatitis (cancrum oris) is a much more serious afifection than any of the forms previously described, although it is not considered to be a dangerous malady, like the other forms of the affection. It is in general a disease of childhood, and is most frequently observed between the fifth and tenth years. The disease is rarely seen outside of hospital wards and public clinics, as it seldom attacks the children of the better class of society. Individuals who are "badly nourished or debilitated from disease, such as scrofu- lous disorders, intestinal complaints accompanied by exhausting dis- charges, typhoid fever, diabetes or scurvy" (Ziegler), the exanthems, pneumonia, or irritation from diseased teeth, are most susceptible to the affection. Convalescence from exhausting acute disease predis- poses to an attack. There seems to be good evidence that the disease is sometimes epidemic, as several cases are usually seen at about the same period, while on the other hand, long periods may elapse without the STOMATITIS. 289 appearance of a single case (Swift). Unsanitary surroundings, like cold, damp, impure air, seem to favor its appearance and its dissemi- nation. The disease is generally acute in type, rarely chronic, and "always starts from the alveolar margin of the gums" (Bohn). Causes. — The causes are, principally, bad hygienic surroundings, unwholesome food, insufficient nourishment, debility from acute and exhausting diseases. Local injuries and irritations from diseased teeth, and the chronic poisoning by mercury, phosphorus, lead, and copper (Ziegler) may also be causative factors in the production of the disease. Symptoms. — The disease begins in the margins of the gums by redness, swelling, pain or sense of discomfort, tenderness and loosening of the gums from around the teeth. The loosened margins and festoons of the gums become swollen, congested, and partially cover the teeth, which now become loosened, and hemorrhage is easily provoked. Later the swollen and congested gum becomes discolored, softens, and sloughs away as a yellowish mass, leaving an irregular, ulcerating sur- face. The ulcers thus formed present an angry red surface and thick- ened borders, the center of the ulcer being sometimes partially covered with shreds of necrotic soft tissue. The progress of the ulceration is rapid, extending to the deeper tissues and to the surrounding parts of the cheeks and the lips. It occasionally involves the periosteum and the bone, causing necrosis and exfoliation of considerable portions of the alveolar process and the neighboring teeth. In the milder cases involving a limited area of ulceration, there is a slight rise in the temperature, accompanied by other mild febrile symptoms, which may last for a few days and subside upon the heal- ing of the ulcerations. In the more severe cases in which the ulcera- tion is extensive and involves the periosteum and the bone, the tem- perature may run high and not subside for several days, dependent upon the extent of the ulceration and the tissues involved. In those cases in which the ulcerations are deep, foul, and extensive (Swift), the breath is offensive, and the saliva, which is increased in quantity, is dis- colored with pus and blood, and emits a foul odor ; the salivary glands become enlarged and tender, and the jaws swollen and stiff. Some- times the disease resembles a gangrenous stomatitis, and there is al- ways danger that it may assume such form. (See Noma, chapter on Gangrene.) The prognosis of ulcerative stomatitis is good even in the severe form, provided it does not become gangrenous. Treatment. — ^This consists in the first place of correcting the bad condition of the health which may have been the cause of the affection. The regulation of the diet to the individual needs of the patient is a matter of prime importance, and should receive immediate attention. 290 SURGERY OF THE FACE, MOUTH, AND JAWS. If the surroundings are unhealthy the child should be removed as quickly as possible to a more healthful environment, preferably to the country or the seashore. Stimulants and tonics may also be neces- sary to assist the enfeebled system to regain its normal tone, but change of air and good food are the most valuable means at our dis- posal in the cure of this affection. In the local treatment the applica- tion of a solution of the chlorate of potassium every two or three hours is a valuable remedy. Swift recommends a solution of the sulfate of copper gr. v to fl § j of water, or boric acid in glycerol or honey. Day advocates the use of the silver nitrate solution gr. v to floj of water, used in conjunction with the chlorate of potassium solution; also the painting of the ulcers with the tincture of iron and glycerol. Stomatitis Ulcerosa Nocens. — This is an infectious ulcerative stomatitis which sometimes follows injuries to the gums from the ex- traction of teeth, abrasions from hard foods, too vigorous use of the tooth-brush and other traumatisms. The clinical characteristics of this form of the disease are the for- mation of ulcers at some point of injury, which at first appear in nowise different from the ordinary form of a localized ulcerative stoma- titis, but which after the lapse of twenty-four to forty-eight hours be- gins to spread rapidly along the margins of the gingivae in all direc- tions, involving both jaws and sometimes extending to the hard palate and the floor of the mouth. The margins of the gums assume a general ulcerative condition, accompanied by swelling, redness, and consider- able congestion of the parts, which bleed easily. Later they become covered with a dirty white or yellowish-white pellicle or membrane, — somewhat resembling the thrush film — which sloughs off after a day or two, destroying the festoons and leaving a ragged surface. The denuded surface is very red, and covered with coarse granulations which bleed upon the slightest provocation. The gums are loosened from the necks of the teeth, and the borders of the alveolar processes are exposed. Pus mixed with blood exudes from the inflamed tissue about the necks of the teeth. The breath and excretions are very fetid, and salivation is profuse. In these respects the symptoms resemble mercurial ptyalism. The ulcerated surfaces are exceedingly sensitive, and motions of the tongue and lips on this account are quite painful. Food is taken with difficulty. Accompanying the local manifestations, there is a general febrile condition, temperature rangmg from 100'^ to 101° F., thirst, loss of appetite and general malaise, sleeplessness, and irritability of temper. In illustration of the above clinical features of the disease, the fol- lowing cases are introduced. Case I. — Mr. A., American, aged twenty-four years, clerk, was referred to a dental specialist for treatment. STOMATITIS. 291 History: This gentleman had an abscessed lower molar of the right side extracted, which had caused considerable swelling of the jaw. The gum tissue had been somewhat lacerated upon the lingual side in the effort to remove the offending root. Two days later he returned with the injured gum ulcerated, the ulceration spreading to the adjoin- ing teeth. The festoons of the gums were detached from the alveolar process and the bone denuded. Antiseptics had been used to cleanse the mouth, the alveolus irrigated and dressed, and a listerine mouth- wash prescribed. The disease, however, spread so rapidly that in forty- eight hours the gums of the entire lower jaw were involved, and it had attacked the anterior portion of the upper jaw. This was the condition when the case first came under the notice of the writer. Diligent inquiry could not discover any constitutional conditions, like syphilis, mercurial or lead poisoning, etc., which would account for the presence of the disease. He had, however, recently been ill for a couple of weeks from a mild attack of la grippe. Treatment: The treatment consisted of first cleansing the mouth by irrigating it with a saturated solution of boric acid, followed by a 50 per cent, solution of 12-volume hydrogen peroxid in water, sprayed into the mouth and the approximal spaces between the teeth. The mouth was again irrigated with the boric acid solution to remove all debris and the foam caused by the use of the peroxid ; after which the gums were carefully dried and protected with rolls of bibulous paper, and the ulcerated surfaces swabbed with a 10 per cent, solution of zinc chlorid. The patient was furnished with a bulb atomizer, and instructed to spray the mouth every two hours with 25 per cent, listerine solution. This line of treatment was followed every day for a week, except the application of the zinc chlorid, which did not seem necessary after the third day, as marked improvement took place from this date. The case was discharged cured at the end of ten days. The only constitutional treatment was a saline cathartic, which seemed to be indicated to relieve a tendency to constipation. The fact that local treatment alone, except that just indicated, was sufficient to control the case, precludes the possibility of syphilitic infection being the cause of the affection. Case II. — This patient was a married man, aged thirty-four years, and of English birth,, formerly a practicing dentist, but now an expert accountant. History: Patient states that he has been overworked of late, and not well, that his gums had been congested and bled when the teeth were brushed; and thinking that perhaps he had not been vigorous enough in the use of the tooth-brush, he bought a new one which was quite hard and gave them a most thorough brushing before retiring. Next morning his mouth was so greatly inflamed that he could not use 292 SURGERY OF THE FACE, MOUTH, AND JAWS. the tooth-brush or masticate his food, or even take a cup of hot coffee. For the next two days he tried to allay the inflammation with various soothing preparations, with no benefit. At this stage of the case he presented for examination and treatment. Examination of the mouth revealed extensive ulceration of the margins of the gums of both jaws, with ulcerating streaks upon the roof of the mouth, extending from the region of the first molars on each side nearly to the median line, and looking as though they had been cauterized with silver nitrate. The ulcerations in all parts of the mouth were covered with the same dirty-white or yellowish-white film. The gums were separated from the borders of the alveolar process, leaving the bone exposed. All of the other symptoms correspond to those of Case I. In Case II, however, nearly every tooth in the mouth had a ring of salivary calculus encircling the cervix. This was no doubt the cause of the congestion of the gums which induced the bleeding on brushing. Treatment consisted of first cleansing the mouth, and then remov- ing the salivary calculus. In all other respects the treatment was the same as in Case I. He made a rapid recovery and was discharged at the end of two weeks. Case III.— Was almost identical with Case I. It originated from the same cause, viz, the extraction of an abscessed lower molar, fol- lowed by ulceration of the gingival wound and extension of the ulcera- tive process to the gingival borders of both jaws. In this case, which occurred in a young Jew, twenty-four years of age, there was a clear history of syphilis, infection having taken place two years before. He had visited Hot Springs and taken a course of treatment, but had taken no mercury or iodids since his return, four months before. The treatment prescribed in the other cases was followed in this, with the exception that after the third day of treatment, in consultation with his family physician, he was placed upon the usual course of treat- ment with the iodids. He rapidly improved under the local treatment from the first, and at the end of ten days all of the local symptoms had disappeared. From this we think the inference may be safely drawn that the local disease was not the result of his syphilitic condition, as it is hardly to be supposed that the constitutional effect of the iodids would be manifested in so short a period. It was evident, also, that the case was improving before the iodids were administered. Neither can the first or third cases be fairly attributed to infection from unclean instruments, as I am sure that the greatest care was observed in both cases to prevent such a contingency. The explanation would rather, it seems to me, be that of auto-infection from the pus micro-organisms of the alveolar abscess coming in contact with a freshly wounded surface of the gum, or from some of the other patho- STOMATITIS, 293 genie organisms which so constantly inhabit the mouths of even cleanly persons. The second case was also, without doubt, due to auto-infection from the last-named causes, through the brushing and lacerating of the already inflamed gums ; thus furnishing the only condition lacking be- fore to establish an infectious inflammation, which by reason of the debilitated condition of the system it was unable to successfully resist. The acute character of the symptoms and the rapid spreading of the ulceration from the initial point of injury seem to prove the infec- tious nature of the disease. CHAPTER XXXI. LEUCOPLAKIA. Definition. — Leucoplakia (from the Greek Xewo?, white, and TrXa^, a surface) literally "white surface" or "whitening of the surface." Leucoplakia is a chronic superficial inflammation affecting the mu- cous membrane of the tongue, the palate, the cheeks, and the gums, and is characterized by the presence of pearly-white or bluish-white plaques or patches ; in some cases small, in others covering the entire dorsum of the tongue, the cheeks from the angle of the mouth back to the fauces, the palate, or the entire buccal surface of the gums. Various terms, such as "leucoplakia linguae," "leucoplakia buccalis," and "leuco- plakia gingivae," have been introduced to designate the location of the disease. Nomenclature. — The disease is variously known as psoriasis linguae, zona (herpes zoster), smoker's patch, leucoma, leucoplakia, ichthyosis, leucokeratosis, leucoplasia, leucoplaques, plaques opalines^ and superficial glossitis. Varieties. — There are two forms of leucoplaques found in the human mouth; the milky opaline patches (plaques opalines), rep- resented by the mucous patches of condylomata of secondary syphilis, and the non-syphilitic, smooth white or pearly-white patches for which Schwimmer was the first to propose the term "leucoplakia," and Hutchinson "leucoma." The French writers generally refer to the dis- ease as "psoriasis linguae," or plaques opalines. Hulke has described a warty variety of the disease, and applied to it the term "ichthyosis linguae." The plaques opalines, or the mucous patches of secondary syphilis, are grayish-white and curdy in appearance, resembling the superficial corrosion caused by the application of the nitrate of silver to the mucous membrane; while the plaques of leucoplakia are usually thin, shiny, bluish-white, white or pearly in color, sometimes having a yellowish tinge, but this, according to Butlin, is almost always due to the stain of tobacco or some other extraneous substance. These two varieties of leucoplaques may be further differentiated by the slight elevation of the syphilitic mucous patches, the secretion of a thin watery fluid, which is the potent source of contagion, and their ten- 294 LEUCOPLAKIA. 295 dency to become painful and to ulceration; while in leucoplakia the patches are not elevated above the surrounding tissue, except in the warty form (ichthyosis) ; they are not painful except in the advanced stage of the disease, no secretion is present, and ulceration is not devel- oped until the disease has taken on a malignant form. To the latter variety of leucoplaques — the true leucoma or leuco- plakia — the writer desires to call especial attention, for the following reasons: i. It is an exceedingly dangerous afifection, often being a forerunner of carcinoma. 2. It is a disease which, from its innocent appearance and the painless character of its early stages, is seldom recognized until the disease has progressed to a stage which renders a favorable prognosis exceedingly doubtful. 3. The disease seems, from personal observation, to be on the increase. 4. The dental sur- geon, from the very nature of his specialty, is in a position to see and recognize the disease in its earliest stages, and to warn the patient of his condition before it has progressed so far as to prove a menace to life. The disease in its earlier stages is much more likely to come under the notice of the observing dentist, or stomatologist, than of the sur- geon or the laryngologist. As a rule, the patient does not consult a surgeon until the disease becomes troublesome ; it may then have pro- gressed so far as to give unmistakable evidences of degenerative changes of a malignant character. The dentist, therefore, should be so familiar w^ith the characteristic features of the disease that he could recognize it at a glance ; while it would be his duty to impress upon the patient the urgent necessity of consulting an oral specialist with the view of instituting measures calculated to arrest its further devel- opment, or for its complete extirpation. Etiology. — The etiology of leucoplakia is by no means a settled question in oral pathology. Marked differences of opinion still exist among the very best pathologists as to the causative factors in the pro- duction of the affection. The earlier writers looked upon the disease as a local manifestation of psoriasis ; others considered it due to certain other forms of skin disease, like zona (herpes zoster or hives) and lichen planus ; many have looked upon the disease as a circumscribed chronic inflammation of the oral mucous membrane, due to syphilis, and still others have thought it a distinct affection produced by the local irritation induced by smoking or chewing tobacco. The inflam- matory conditions of the oral mucous membrane and of the tongue resemble in certain respects the inflammatory conditions of the skin, while in others they present the characteristic features of mucous membrane in general. (Ziegler.) Various inflammations and eruptive diseases of the skin have their counterpart in the mucous membranes, as for instance in erysipelas, which is an infectious inflammation usually manifested in the skin, but 296 SURGERY OF THE FACE, MOUTH, AND JAWS. which often extends to the mucous membrane, especially of the mouth and nose, while upon the other hand it may originate in some wound or inflammation of the mucous membrane, and later extend to and involve the skin, as occurred in a case recently seen in consultation, in which the disease developed as a complication of acute septicemia caused by an alveolar abscess, and which terminated fatally. Zona is another example in the same line. Although zona is an eruptive dis- ease of the skin, it often attacks the mucous membrane of the lips and of the genital organs at the junction of the skin with the mucous mem- brane. Lichen planus, another skin affection, sometimes produces buccal lesions. These lesions have been described by Wilson, Hutchin- son, Kaposi, and Crocker as whitish, thickened and uniformly elevated plaques upon the mucous surface, sometimes grayish white or resem- bHng in color the places which have been cauterized with nitrate of silver. It is not strange, therefore, that the earlier writers should look upon leucoplakia as a manifestation of some of these forms of skin diseases, aind particularly of psoriasis, which it somewhat closely simulates in its earlier stages. Most modern writers look upon leucoplakia as an entirely distinct affection, having no association with psoriasis in any of its forms. Hyde says: "Psoriasis is not known to affect the mucous surfaces. The lesions of so-called psoriasis linguae are those of leucoplakia buc- calis, of smoker's patches, of syphilitic disease of the mouth, or of flat epithelioma." Nicholson, however, still holds to the old theory that leucoplakia is a local manifestation of a skin affection, and maintains that the disease is zona (herpes zoster) located in the mucous mem- brane. The peculiar burning sensation that accompanies the white patches located upon the lingual mucous membrane he considers as almost a pathognomonic sign, and calls attention to the fact that one or two herpetic vesicles may appear on the lower surface of the tongue during the course of the disease. Park is of the opinion that leu- coplakia is often due to syphilis, and says : "These late and recurring lesions (syphilitic mucous patches) lose their moist character, become quite smooth, shiny, of a bluish-white color, and may mark the be- ginning of the condition known as leucokeratosis." Butlin, than whom there is no greater authority upon such matters (Butlin's "Dis- eases of the Tongue"), considers smoker's patches, leucoplakia and ichthyosis as simply different manifestations of the same disease, namely, chronic superficial glossitis, which may have its origin in sev- eral forms of irritation, both chemic and mechanic, and which may act singly or combined. Predisposing causes. — Butlin agrees with Debove in the state- ment that there is in most patients some condition which predisposes to the disease. He says : "I suspect that the mucous membrane of the LEUCOPLAKIA. 297 tongue in leucomatous subjects is from the first less thick and stable, and more easily irritated than in the majority of persons. As some persons are known to have irritable and delicate skins, easily inflamed and prone to eruptions, and as some of those persons develop affections of the skin which are very chronic and difficult to heal, so I believe other people have tongues whose mucous membrane is abnormally delicate, prone to chronic inflammation, and difficult to cure when the disease has been excited." It has been suggested that chronic dyspepsia and the rheumatic and gouty diathesis might be a predisposing cause of the disease, but the evidence upon this point does not seem to be sufficiently strong to give any real weight to its consideration. Sajous says he has reason to think that gout is a cause of leucoplakia, for he has seen it in gouty women who did not smoke and were not syphilitic. Age and sex are both very important predisposing causes of the disease. Leucoplakia is rarely seen in persons under twenty years of age, even in boys addicted to smoking; while, on the other hand, it is rarely seen to commence in persons over sixty years of age. Women seem to be almost entirely exempt from the disease. Of the twelve cases seen by the writer all but one were in men, and occurred between the ages of forty and seventy-four years. Du Castel has reported a ■case in which the disease had existed since the age of twelve years in a man who had never used tobacco. In one of the writer's cases, an elderly female, the disease had existed since she was sixteen years of age. She had been addicted to smoking from fourteen or fifteen years of age. Exciting causes. — Among the most common exciting causes of leu- coplakia may be mentioned the irritation produced by the habitual use of tobacco, particularly smoking; the later recurring lesions of the mucous membrane due to the secondary manifestations of syphilis — the mucous plaques, acting locally upon the tongue or the buccal mucous membrane ; the frequent use of undiluted spirituous liquors ; the drink- ing of very hot fluids, or eating of very hot or highly spiced foods ; the mechanic irritation of teeth roughened by the process of caries, frac- tures, or the accumulation of salivary calculus; the irritation from dental plates which are rough, ill-fitting, or made of material which is irritating to the delicate mucous membrane of the mouth. Wallenberg is of the opinion that the use of tobacco is the most frequent source of leucoplakia, and believes the disease is produced by the irritation of the volatile and empyreumatic oils liberated in smoking it. The writer has no hesitation in expressing it as his opinion that the use of the pipe is on this account much more dangerous to a sensitive mouth than the smoking of cigars or cigarettes, as the pipe, from long use, is gen- erally saturated with these oils, which often come into direct contact with the mucous membrane of the tongue, causing smarting and bum- 298 SURGERY OF THE FACE, MOUTH, AND JAWS. ing sensations, with more or less irritation. In the habitual smoker the irritation becomes chronic, producing a thickening of the epidermal layer and infiltration of the papillary layer with round cells. Erb collected and analyzed 240 cases of leucoplakia, and states as his belief that the lesions are, as a rule, due to "epithelial thickenings resulting from syphilitic mucous patches." Of this number two only were women, and these were both syphilitic. In about 60 per cent, of the cases there was a clear history of syphilis, while in many others a very strong suspicion of such an infection existed. In four or five cases antisyphilitic treatment either cured or greatly improved the condi- tions, even when they had existed for a long time. Out of 148 cases who were interrogated as to their use of tobacco, 45 smoked little, or not at all; loi smoked moderately, and 2 excessively. Syphilis alone occurred in 36 of these cases, smoking alone in 37, syphilis and smok- ing occurred in 64, and neither in 1 1 cases. The following conclusions were reached: i, syphilis or smoking alone may be the cause of this affection in about the same proportion of cases ; 2, in a majority of cases it may be due to both ; 3, it rarely appears without being referable to one or the other of these causes ; 4, other forms of irritation seem to play only a minor part. He believes that a certain predisposition must be assumed, in view of the great number of syphilitics and smok- ers who never develop the disease. (Sajous' Annual.) Symptoms and Diagnosis. — Leucoplakia may be recognized by the presence of circumscribed or diffuse, smooth, white, bluish-white or pearly-white radiating patches appearing in varying numbers upon the mucous membrane of the cheeks, lips, gums, palate, or tongue,. These patches often coalesce to form larger ones. In their earliest stage they are not elevated above the surrounding membrane, are smooth and glistening in appearance, and range in size from tiny, irregularly- outlined spots, to large plaques the size of a silver half-dollar, or even larger. At first they are not sensitive, and on this account may exist for a long time without the knowledge of the patient. Many cases never progress beyond this stage. Others may slowly increase in size, thickness and intensity of color, the plaque being slightly raised, the surface hard — corniHed — and roughened. Accompanying this stage — especially when the disease is located upon the dorsum of the tongue — the patient will complain of a persistent dryness of the parts and in- ability to speak or use the tongue with comfort, except by frequent moistening of the mouth. Later, fissures appear in the tongue, and there is developed a smarting, burning sensation, as though the parts had been scalded. Alcoholic liquors, fermented beverages, acid fruits^ highly seasoned or very hot food or drinks, and chewing and smoking tobacco increase these sensations and sometimes render the partaking of food a very great discomfort. Associated with this condition there PLATE I\-. Cask 1. i.Euriii'L akia of tong^ AGED 40 YEARS. V ^^•4. / TONGUE. MALE. AGED 45 YEARS. LEUCOl'LAKIA. 299 is a tendency of some portion of the plaque to peel off or slough out from time to time, leaving a reddened or raw surface which is exceed- ingly sensitive, and sometimes quite painful. Ulceration may follow and degenerative changes develop, ending in the formation of a car- cinoma. When the disease is in the tongue, warty growths sometimes appear in the leucomatous patches, which show a marked tendency under the stimulation of an irritant to take on a rapid form of carci- nomatous degeneration. Authorities are not agreed, however, as to the earliest develop- ments of the leucomatous patch. Schwimmer and Barker described the earliest stage of the disease as appearing in the form of dark-red spots or reddish patches, which later are covered with the white or pearly-white surface. Butlin, Debove, Nedopil, and nearly all other writers upon the subject, describe the first stage as appearing in the form of radiating, non-sensitive white or pearly-white plaques, and the writer desires to state that the testimony of his own observation cor- responds with the latter conclusion. Another fact should also be borne in mind in diagnosing this affection, viz : The progress of the disease is in many instances very slow and may have the appearance of having reached the limits of its development, while occasionally it may disap- pear with advancing age. On the other hand, the disease, which has seemed for many years to remain in about the same condition, may suddenly assume a most rapid and malignant type of degeneration. Shield reported a case of leucoplakia linguae in a man seventy-five years old, for whom, two years before, one-half of the tongue had been re- moved for undoubted carcinoma, who gave a previous history of the presence of the disease — "bad tongue" — for more than twenty years. The following cases, arranged without reference to their chrono- logical order, are introduced to illustrate the various stages of the disease as found upon the tongue, gums and cheeks, and are takeii from the records of the private practice of the writer : Case i. — History: This was a case of leucoplakia linguae covering the entire dorsum of the tongue. (Plate IV, Fig. i.) Patient was a Hebrew merchant, forty years of age, of robust health, and an inveterate smoker of cigars, his daily indulgence being from ten to fifteen strong Havanas. The disease had never given him any inconvenience, and he had not known of its presence until the writer called his attention to it, when making an examina- tion of his mouth. He was advised to stop smoking, but refused point-blank under any circumstances. There was no history of skin diseases or of syphilis. He drank wine in moderation. Case 2. — History: This was a similar case of leucoplakia linguae, in which, however, the stage of degeneration of the papillary layer had begun. (Plate IV, Fig. 2.) The patient was of German birth, forty-five years old, of large physique and good health, and also an inveterate smoker, both of cigars and the pipe, and was addicted to the use of liquors, but rarely to excess. He had been cognizant for several years of the abnormal color of his tongue, but it 300 SURGERY OF THE FACE, MOUTH, AND JAWS. had given him no inconvenience until two years previous to the time when he appeared for consultation, and was referred to the writer by Dr. Gustav Fiit- terer, of Chicago. The patient complained of an abnormal dryness of the tongue, tenderness of the denuded point, and a smarting, burning sensation, as though the tongue had been scalded. This was increased by taking salty or peppery foods, acids, wines or spirits. There was no history of psoriasis, zona, or other skin disease, nor of syphilis. He was warned of the dangers of the disease assuming malignant characteristics under constant irritation, and was advised to leave off the use of tobacco and all irritating or stimulating foods or drinks. This he cheerfully consented to do, and has faithfully followed. The treatment consisted of: i, removing the salivary calculus and all sharp edges of the teeth and thoroughly polishing the surfaces. Carious teeth were treated by filling with gold, to remove all possibility of mechanic irritation; and 2, the application every other day of tinct. of aconite and tinct. of iodin, equal parts, to the denuded surface of the tongue. The applications caused slight smarting at first, but this subsided after a few minutes. After the first week a slight improvement in all the symptoms was noticed. Whether this was due to the local application or to the removal of all causes of irritation, was a question in the mind of the writer. The treatment, however, was continued, and at the end of two months the symptoms, with the exception of the abnormal dryness of the tongue, had entirely disappeared and the denuded part was covered with healthy-appearing papillae. Associated with the disease of the tongue were plaques upon both cheeks and the right superior gums. This case was seen two years afterward, and the patient reported having maintained his abstemious habits, with the result of having perfect comfort. The plaques, however, had not disappeared. Case 3. — History: This case illustrates the disease as seen upon the gums of both jaws in a gentleman of Canadian birth, fifty years of age, and in robust health. (Plate V, Fig. i.) This patient was also a great smoker of the pipe. The disease extended from the first bicuspid tooth backward to the maxillary tuberosity in the upper jaw, and from the second bicuspid tooth to the angle in the lower jaw. In this case the disease had not caused the least inconvenience, and the patient had not noticed any abnormal condition of the gums. There was no history of syphilis or of any skin disease, but he had gouty tendencies; he used spirits moderately, generally_ Scotch whisky. He was cautioned against the use of tobacco and spirits and stimulating or pungent foods or drinks, and advised to report frequently for examination, which he has done. This case has been under close observation for over eight years, and there has been a slight extension of the plaques, but as the disease does not trouble him. he will not give up his way of living. Case 4. — History: This case shows the disease in its early stage, located upon the alveolar ridge, in a Hebrew gentleman seventy-four years of age, who was in otherwise good health. (Plate V, Fig. 2.) He was not cognizant of the presence of the affection. There had been no sensation to arrest his attention other than a slight roughness to the tongue and the gums at the location of the disease, and which he had noticed for several months. No history of syphilitic infection could be obtained, and he has never been affected with any form of skin disease. He has been a moderate smoker since a lad, having rarely exceeded three cigars per diem. Case 5. — History: This was one of leucoplakia buccalis upon the right and left cheeks, opposite the line formed by the occluded teeth, in a retired gen- tleman of American birth, aged fifty-two years, and of fair health. (Plate Case TIL leucoplakia of gums, male, aged 50 years. Case IV. leucoplakia of gums, male, aged 74 years. PLATE VI. LEFT CHEEK LEUCOPLAKIA OF Clf ALE, AGED 52 YEARS. LKUCOPLAKIA. 3OI VI.) The disease was discovered while making an examination of his mouth. The patient had not been aware of any abnormal oral condition, and had not noticed the presence of the plaques. There had never been any pain or inconvenience associated with the affection. He is an habitual but not an excessive smoker of good cigars, and uses liquors and wine in moderation, but does not eat highly seasoned foods. There was no history of syphilis or of skin disease. The same advice was given as in the previous case, but he refused to give up the use of tobacco. This gentleman's case has now been under observation for over six years, with no appreciable change in the size or condition of the plaques. Case 6. — History: This was a case of leucoplakia linguse of eight years' standing, which first appeared upon the dorsum of the tongue in small white plaques; later two longitudinal fissures appeared, running nearly the whole length of the tongue, with several shorter ones radiating from these, which were very sensitive to acids, pungent condiments, acid fruits, or wines. On advice of his physician, he stopped smoking at this time. Tongue was dry and parched on waking in the morning. He was treated at this time for nasal catarrh and hypertrophied turbinated bones. This treatment gave great relief; the nasal obstruction being removed made it possible for him to breathe with the mouth closed, thus giving relief from the dryness of the tongue. Three years afterward a suspicious ulcer appeared upon the right side of the dorsum of the tongue near the median line; this was treated locally with silver nitrate, and iodids and mercury were administered constitutionally. At this time he was thin and emaciated, weighing only 130 pounds. The treatment im- proved his general condition; weight at present time 175 pounds, and general health good. Tongue presents fissures as above indicated, and the whole dorsum of the tongue is covered with a continuous white plaque, which is very sensitive to the irritation of acids, pungent condiments, spirits, ^tc. Treatment declined. Case 7. — History: This was a case of leucoplakia in an American gentle- man fifty years of age, and of robust health. Occupation stockbroker. The disease was discovered while examining his teeth for caries. The plaques, which were located upon the right and left sides of the superior gingivae, were of the size of a split pea, slightly raised above the surface, having a rough, curdy, yellowish-white appearance. They were not tender to the touch, and had never given any pain or uneasiness, and their presence had not been recognized by the patient. There was no history of syphilis or of any skin affection. He smoked from three to five cigars each day. Was advised to give up tobacco, but declined. There were no other evidences of the disease in his mouth. Case 8. — History: This case was one of leucoplakia linguae buccalis, etc., in a Greek woman, married twenty-six years and aged sixty years. Has had no children. Claims to have always enjoyed good health, and disclaims ever having any skin eruptions, mucous patches of the mouth, or any general or local disease requiring the attendance of a physician. The disease first ap- peared when sixteen years of age; it followed a meal in which she ate green peppers, and was located at that time upon the dorsum of the tongue. It now covers the roof of the mouth, the cheeks, the dorsum and under side of the tongue, and the floor of the mouth; in fact, the whole oral cavity looks as though it were lined with a layer of curdled milk, or as though the whole mouth had been cauterized with nitrate of silver or carbolic acid. The power to taste 302 SURGERY OF THE FACE, MOUTH, AND JAWS. foods had been lost, except for salt, acids, peppers, and pungent sauces. These substances caused a burning sensation, which was very painful. Exfoli- ation of the thickened membrane upon the tongue frequently takes place in patches, the uncovered surface at such times being very sore and painful. At the time of the examination there was no uncovered surface presented. She has smoked cigarettes, three to four each day, since she was a girl of fourteen or fifteen years of age. This case presented the most extensive involvement of the mucous sur- faces of the mouth that has ever come under the observation of the writer. The opinion expressed at that time, in reference to the cause of the disease, was the use of tobacco. Case 9. — History: This was a case of leucoplakia linguae and buccalis in a Hebrew gentleman fifty-six years of age, who had retired from business. His health was good, and had always been so. The extent of the disease was very similar to Case 4. He was a moderate smoker of cigars, but never used the pipe. There was no history of syphilis. He was advised to give up the use of tobacco, but declined to do so, as he had never experienced any inconvenience from his indulgence. Case id. — History: This was a case of leucoplakia linguae, the plaque being situated upon the dorsum of the tongue, and the size of a quarter dollar. This gentleman was forty years old, and an inveterate smoker of cigars. Case ii. — This case was one of leucoplakia gingivae and buccalis in a man past fifty 3'^ears of age, which proved fatal three years after from malignant degeneration. Case 12. — This was a similar case in a physician forty-five years of age. The disease, however, was in its early stage, and had not been recognized by the patient. Immediate operation was demanded, and the diseased tissue removed down to the bone. Eleven years afterward there had been no recur- rence. Differential Diagnosis. — The affections which may be confounded with leucoplakia buccalis are the muco-plaques of syphilis and epi- thelioma. In the earlier stages of the disease such a mistake could hardly be made, but in the later period of the affection it might quite easily be confounded with syphilis or epithelioma. A three or four weeks' course of treatment with the iodid of mercury or potassium would clear up the diagnosis of the former, while in the latter it would be necessary to resort to the aid of the microscope for a positive diag- nosis, even though there was present the clinical evidence of enlarged lymphatic glands. Pathology. — In examining the histologic structure of the leu- comatous patches, whether ''thick or thin," a marked change will be noticed in the character of the papillary layer of the tongue, the mucosa of the lips and the cheeks, and in the cells of the epidermis. The papillae of the tongue are often very much atrophied, and occasionally have almost entirely disappeared; while the epidermal layer has taken on a horny character more like that of the skin. This is true also of the epidermal layer in leucoplakia of the mucous membrane of the lips and the cheeks. It is also noticed that the epithelial processes, both of LEUCOPLAKIA. 3O3 the tongue and of those portions of the oral mucous membrane affected by leucoplakia, are much shorter than is natural, and that the corium is infiltrated with leucocytes. In advanced stages of the disease true ccll-nests are discovered, which establishes the fact of carcinomatous degeneration. How these cell-nests are formed in carcinoma is still a disputed question, but it would seem more than probable that in carci- noma of the tongue and oral mucous membrane following leucoplakia, the cell-nests were developed from traumatic inclusions of epithelial cells following the repeated ulceration and healing of the leucomatous patches. Prognosis. — The interest in the prognosis of leucoplakia centers around the tendency or the predisposition of the disease to be followed by malignant degenerative changes, ending in the formation of car- cinoma. That such a predisposition exists there is not a shadow of doubt. In the "American Text-Book of Surgery" we find this statement: "Many cases of cancer of the tongue are preceded by leucoma, the so- called psoriasis of the tongue." Garretson was of the opinion that the disease occupied the border-line between the non-malignant and the malignant growths. Le Dentu says it is not at all unusual for leu- coplakia to become epitheliomatous. He does not, however, consider this to be a general predisposition of the disease, but that it is sometimes induced by a tendency of leucoplakia to degeneration. Sutton says : "In a fair proportion of cases (20 per cent.) epithelioma of the tongue is preceded by changes known as leucoplakia and ichthyosis ; and they are frequently referred to as pre-cancerous conditions. In the case of the cheek, epithelioma is sometimes preceded by a patch of leucoplakia. The disease often starts close to the angle of the mouth and extends backward into the cheek ; or it begins in the fold of mucous membrane between the gum and the cheek, and occasionally it starts in the center of the cheek, often on a level with the meeting-place of the crowns of the upper and lower molar teeth." Senn, in speaking of carcinoma of the mouth, says : "Carcinoma of the mucous membrane of the cheek is sometimes preceded by a patch of leucoplakia. The influence of chronic irritation in producing carci- noma is well shown in carcinoma in this locality, as the tumor very often corresponds in its location with the crowns of prominent upper and lower molar teeth." Butlin states that out of eighty cases of cancer of the tongue, sixteen were preceded by leucoma. Park believes leucokeratosis may become the seat of an epithelioma, and its surgical interest depends upon the frequency with which it is followed by this malignant growth. Warren says he "has seen but few cases of leu- coma ; one of these in a lady on whose tongue it first appeared in youth, and remained in the shape of several large, brilliant white patches, until 304 SURGERY OF THE FACE, MOUTH, AND JAWS. old age, when it disappeared ; in another case, a man forty-three years of age, the tongue had been troublesome from childhood ; the mucous membrane was sensitive and easily irritated, and it was prone to inflam- matory conditions, during which small ulcers appeared. At the age of thirty-four years typical leucoma appeared, situated for the most part on the right side of the tongue. Three years later the patches enlarged, and a warty growth formed in the center. Three years after this he (Warren) removed with the knife the largest patch, which was about the size of a silver half-dollar. This operation was performed in June, 1891. In October, 1891, a small epithelial growth of an apparently malignant nature appeared on the opposite side of the tongue. This growth was removed and found to be typical cancer. In December a similar growth was removed from the tip of the tongue. In April, 1892, both growths having reappeared, a large portion of the left side and the tip of the tongue were removed by a wedge-shaped incision. The disease never returned on the tongue, but six months afterward a glandular enlargement was observed under the left jaw, and the patient died two months later. The growth was found to be typical carcinoma." Treatment. — Leucoplakia of the oral mucous membrane is gen- erally exceedingly rebellious to treatment, and quite often shows a marked tendency to carcinomatous degeneration ; therefore the meas- ures employed are, perforce, largely those of palliation and heroic operations. Those cases, however, which give a clear history of syphilitic infection may be benefited by a course of antisyphilitic treat- ment ; but it may be stated as a fact, that up to the present time no drug has been discovered which, acting constitutionally, has any beneficial effect whatever upon the progress of leucoplakia. The preventive measures which may be instituted in the treatment of leucoplakia are the removal or discontinuance of all forms of chemic and mechanic irritation. Persons who suffer from an irritable and sen- sitive oral mucous membrane should avoid chemic irritants of all kinds, particularly alcohol in any of its forms, acids, pungent condiments, very hot foods or drinks, and tobacco. In persons already afflicted with the disease such irritants stimulate the progress of the affection, and should, therefore, be strictly interdicted. It is much easier, however, to advise a patient as to what he should do and what he should not do than it is to get him to follow your advice. In the early stage of the disease — before it has caused any real inconvenience — it is very difficult to get a man who is in the habit of using spirituous liquors or tobacco to consent to give them up. He feels that you may be mistaken, or that you are magnifying the danger, and hence decides not to change his habit of living, at any rate for the present, or until he is convinced that your advice is correct. Perhaps he will consult some other professional LEUCOPLAKIA. 305 gentleman wlio disagrees with your diagnosis and laughs at your fears. This reassures the patient, and he goes on with his old hahit of life for months, perhaps for years — in some cases with im]nniity ; in others witli most disastrous effects to his comfort and his life. The mechanic irritants which are most common in the mouth are usually associated with the teeth or with artificial dentures, such as carious cavities, jagged roots, fractured teeth, salivary calculus, rough or ill-fitting plates, or plates made of a material which is irritating to a sensitive mucous membrane. All such forms of irritation should be at once removed, by filling the cavities, extracting the roots, giving appropriate treatment to the fractured teeth, removing the salivary calculus and carefully polishing the surfaces of the teeth, while the irritating artificial dentures should be replaced by others free from these objections, or discarded altogether. Too much stress cannot be laid upon these points as a safeguard to the patient against the devel- opment of the malignant form of the disease. Local Treatment. — Nicholson, who believes leucoplakia to be zona of the oral mucous membrane, considers local applications of only tem- porary service, while the constitutional treatment for zona is often entirely fruitless. He recommends, however, a trial of the tincture ferri perchlorid, 25 to 30 minims (1.3 to 2 grams), three times per dietn, as in one of his cases it seemed to give relief from the burning pain, and improved the condition of the lingual epithelium in a remarkable man- ner, when all else had failed. Rosenberger recommends the local appli- cation of pure balsam of Peru painted upon the patches with a briish, allowing it to remain in contact for from three to five minutes. The immediate effect is a slight burning sensation with an abundant saliva- tion. These applications he advises to be made three times per diem. In thirteen cases so treated great relief was obtained. The patches, however, heal slowly, a year in some cases being required to produce a cure. Leistikow advises the local application of the following paste : Terras siliceje gr. xxiv 1 15 Resorcini gr. xlviii 3I Adipis gr. viii |5 This he applies to the afifected parts with a swab. From eight to fourteen days afterward a contraction or shriveling is observed, and a slightly inflamed condition of the mucous membrane, which by the application of balsam of Peru is brought to a normal condition. Rosen- berg reports a case of leucoplakia which had lasted for over seven years, and had resisted all the usual methods of treatment, in which the plaques disappeared in a few days after being painted with a 20 per cent, solution of potassium iodid. 21 306 SURGERY OF THE FACE, MOUTH, AND JAWS. In Case 2, the local application to the plaques and the denuded surface of the tongue of tinct. aconite and tinct. iodin, equal parts, every other day for two months, relieved all the symptoms except the abnormal dryness of the tongue, while the denuded part healed and was covered with healthy-appearing papillse. In six of the cases treatment was declined because of the apparently trivial nature of the disease to the minds of the patients, while all but two of the others declined from fear of an operation. Palliative Treatment. — This consists of the use of alkaline lotions or mouth-washes. Butlin recommends for this purpose in the milder cases, potassium bicarbonate, 15 to 20 grains in one ounce of water, and in the syphilitic cases, chromic acid, i to 2 grains to the ounce of water, or a 5- to lo-grain solution may be painted upon the plaques. Mercury bicyanid is also recommended in solution of i to 2 grains to an ounce of water, and painted upon the plaques. In the severer cases, he recommends solutions of bicarbonate of soda or of boric- acid. He thinks mel boracis (honey and borax) is better suited to some cases than alkaline solutions, but as a general rule, the alkaline solu- tions give greater relief in cases of leucoplakia of long standing. A trial of these various remedies is necessary in order to find the one best suited to the individual case. Surgical Treatment. — In the severer forms of the disease, radical operation is the only safe method to follow. The tendency of the dis- ease to assume a malignant character should cause it to be treated as a malignant growth, and thorough extirpation practiced at the earliest moment. Temporizing by the use of caustics is worse than useless, and most authors deprecate their use for the reason that the irritation seems to increase the dangers from malignant degeneration. Garretson was very emphatic in his denunciation of the use of caustics, of every form, in the treatment of this disease. Butlin says : ''One general rule holds good for all cases of leucoma, namely: not to use caustics. Whatever danger there may be of the development of carcinoma is certainly increased by the employment of nitrate of silver and other caustics." In the fatal case of leucoplakia buccalis and gingivae reported by the writer, the physician who had charge of the case treated it with nitrate of silver, and later with chromic acid, with the result of stimulat- ing the more rapid spread of the disease. On the other hand, we may contrast the results obtained by a radical operation in an almost identical case, also referred to on a previous page, in which a permanent cure resulted, as proved by the fact that there has been no recurrence after a period of over eleven years. The consensus of opinion obtained from the perusal of the most eminent authorities is, that thorough and complete extirpation of the diseased tissue is the only reliable method LEUCOPLAKIA. 307 of treatment, and this, to be effective, must be practiced before malig- nant symptoms have developed. Perrin, who reports a case of leucoplakia linguae and labialis with papillomatous epithelial degeneration, secured a permanent recovery by the thorough extirpation of the plaques by surgical means. He urges early and complete extirpation as the only way by which to avoid a final transformation of the disease into true epithelial carcinoma. Dubois-Havenith exhibited a case of leucoplakia linguae upon the left border of the tongue, which was successfully treated by curetting and the galvano-cautery. Butlin does not recommend the early ex- cision of the plaques when the disease is located in the tongue, unless it "is very obstinate, and scarcely at all relieved by treatment" ; but he has no doubt of the wisdom of such an operation in "indurations, warty growths, and very obstinate ulcers, particularly when they pre- sent the slightest increase of induration about their bases. Such con- ditions must be considered as young cancers, and must be dealt with as if they were in truth cancers." Hulke urges early excision of all hard and warty patches (ichthyosis) upon the tongue before they attain a large size as the only means of cure. CHAPTER XXXII. SURGICAL TUBERCULOSIS. Definition. — Tuberculosis (Lat. from tuherculum, dim. of tuber, a little swelling. An infectious disease caused by the Bacillus tuberculosis. Tuberculosis has a widespread, almost universal distribution among the human race, and it has been estimated that more than one- seventh of the entire population of the civilized world die from its effects. Warren places the mortality as about one to every five deaths, and when the fact is taken into consideration that a considerable por- tion of those who contract the disease finally recover their health, it will need no other demonstration to prove that the disease is one of the most serious and widespread of all the afflictions of mankind. The active etiologic factor in the disease is the Bacillus tuberculosis, which was discovered by Koch in 1882. The discovery of this bacillus, and the demonstration, also by Koch, that by it only could the various phe- nomena of the disease be produced, have wrought great changes in the views held as to the pathology of the disease, revolutionizing a large and interesting department of surgery. Senn says, "Tubercular lesions furnish a most excellent illustra- tion of the origin, force, termination, and tissue-changes of what is known as chronic inflammation, and a description of the histology of a tubercular nodule is a description of the pathology of chronic inflam- mation. "Of all the diseases which are produced by micro-organisms, next to that of suppuration, tuberculosis is of the greatest interest to the surgeon; of greatest interest, because it is better understood, from the bacteriologic standpoint, than are most other surgical diseases which come under his care, and of no less great importance on account of its frequency." "The discovery of Koch has also done away with that vague and indefinite term scrofula, which has been used so long to indicate a large and ill-defined class of diseases, for later experiments have proved conclusively that they were identical in all respects with recog- nized forms of tuberculosis." Avenues of infection. — The virus of tuberculosis gains an entrance 308 SURGICAL TUBERCULOSIS. 309 into the body by various channels, — through the inspired air, with the food, and by direct inoculation. It has been recognized since 1826 that the disease was transmissible by inoculation through the case of Laennec, who injured his finger with a saw while making an autopsy upon a subject affected with tubercular disease of the vertebrae, and thus contracted the affection. He finally died, some years afterward, of tubercular disease of the lungs. Through experimentation, it was found that tubercular peritonitis could be produced by the injection of infected sputa into the peri- toneum of guinea-pigs; infected food produced tubercular ulceration of the mesenteric glands; and the dried sputum when inhaled pro- duced tubercular inflammation of the lungs. Senn. in speaking of the frequency of the disease and the dangers of infection, says, "At least one person out of every seven dies of some form of tuberculosis. IMost of our large hospitals contain from twenty-five to fifty per cent, of patients afflicted with the disease. Health resorts frequented for years by tubercular patients have be- come infected to such an extent that there is great danger of the whole population becoming exterminated by this disease. The sources of infection in such places have become so numerous that it is unsafe to breathe the air, to drink the water, or to eat the food prepared in houses which for years have been hot-beds for the Bacillus tubercu- losis, and by persons carrying the microbes upon every square inch of their surface. That whole communities and nations where this disease has been prevalent for centuries have not been completely depopulated long ago is owing to the fact that many persons possess, from the time of their birth, such a degree of resistance to infection that €ven direct infection by inoculation would prove harmless." Heredity. — It has been assumed by certain writers that infection might take place through the spermatozoa. Jani found bacilli in the testes in five out of eight phthisical patients with urogenital tuber- culosis ; in some cases the bacilli were found in the seminal tubes and in others in the prostate gland. Semb, Spano, and Bugge have each found like conditions. Walther, on the other hand, was unable to obtain like results in an examination of nine cases. Gartner produced genital tuberculosis in male guinea-pigs by in- jecting the bacilli into the testicles, but of the seventy-four young pigs born of healthy females impregnated by the tuberculous males all re- mained free from the disease. The mother pigs, however, in some cases became infected. Further proof is therefore necessary in order to settle the question of the hereditary transmission of the disease through the seminal fluid. The question of hereditary transmission of the disease from the mother to the child through the placenta is one which has been ear- 310 SURGERY OF THE FACE, MOUTH, AND JAWS. nestly discussed, Baumgarten and others maintaining that the virus may be implanted during fetal life, and yet not show itself until per- haps many years later. Experiments, however, upon pregnant guinea-pigs by inoculation failed to produce the disease in their offspring. According to Warren, tuberculosis in new-born children is exceedingly rare, and in those cases reported with early manifestations of the disease it is an open question as to whether the disease may not have been contracted from the milk of the mother, or in various other ways. Most authorities, however, maintain that a predisposition may be inherited through a peculiar weakened condition of the tissues and fluids of the body, which makes them a favorable soil for the growth and propagation of the bacillus. In substantiation of this statement, it is generally found that tubercular subjects have a family history of tuberculosis. The pulmonary tissues are probably the most common avenue through which the tubercular virus enters the system. The Bacillus tuberculosis is very tenacious of life, and retains its vitality for a con- siderable period even in the dried state. These attributes make it a constant menace to the health of those persons who come in contact with tubercular subjects, unless the greatest care is exercised to destroy the sputa and discharges while in a moist state. The bacillus when in a dried state is capable of being floated in the atmosphere and introduced into the lungs by inspiration, and therefore becomes a source of great danger, as has been frequently proved by experiments upon animals. It has also been shown by Cornil that the dust of rooms occupied by such patients contains large numbers of bacilli; while Prudden and others have found it in the dust of the streets. The linen, carpets, and dishes used by tubercular subjects are also a source of danger, as is also the communion cup; while the habit of expectorating upon floors of public halls, street and railroad cars, indulged in by so many consumptives, is an added danger to the public health which should be prohibited. Fliigge claims that tuberculosis contracted from this source, — namely, the dust from dried sputum, — has never been satisfactorily proven. He believes the germs under such conditions are not suffi- ciently virulent to inoculate animals, and that it is more than probable that the same is true of man. The greatest danger in his opinion is from the moist germs which may be readily disseminated in the atmosphere from the air expelled from the lungs of tuberculous subjects in the acts of speaking, coughing, sneezing, etc., the bacilli floating in the tiny drops of moisture contained in the expired breath. Experiments conducted by Fliigge upon susceptible animals by means of a fine spray charged with the bacilli and blown into their SURGICAL TUBERCULOSIS. 3 II faces, similar to the spray expelled by a consumptive in the act of coughing- with open month, were successful in inoculating such ani- mals. A most convincing proof, however, was afforded by the inocu- lation and death of a laboratory attendant in charge of the spray inocu- lation experiments who neglected to use the preventive precautions imposed upon him. Dogs which were kept in an opposite end of the laboratory for another purpose were also infected from the spray float- ing in the atmospliere. Certain cases of pulmonary tuberculosis, according to Bollinger, are not due to the inhalation of the bacilli, but to metastasis from dis- ease in other parts of the body. Tuberculosis of the upper extremities is most liable to produce secondary infection of the lungs. Tubercular disease of the wrist is a well-known cause of pulmonary consumption. The alimentary tract is also a channel through which tubercular infection may take place. It has been frequently demonstrated that the intestinal tract of animals can readily be infected by feeding them with tuberculous food. In the human subject primary tuberculosis of the intestines produced from infected food is not an uncommon occur- rence. Milk from tuberculous cows, and water infected with the virus, have long been recognized as sources of danger. The viability of the bacillus is somewhat remarkable, Cornil having demonstrated that it could live in sterilized water at the ordinary temperature for seventy days. Roasted meat, if infected with tubercle, may be a source of consid- erable danger on account of the central portions not being subjected to the same high degree of temperature during the process of cooking. The Bacillus tuberculosis is destroyed if subjected to a temperature of 212° F. for four minutes, but the spores will resist a much higher temperature, and for a longer time. Secondary tuberculosis of the intestines is due to auto-infection, as the infected sputum is frequently swallowed. The investing mem- brane or capsule of the bacillus is not readily acted upon by the gastric juice, consequently it arrives in the intestinal tract in an uninjured con- dition, where it attacks the Peyer's patches, or the solitary glands. Later, the mesenteric glands become infected, and also the peri- toneum. In women, the infection frequently takes place through the genital tract. The mucous membranes of the mouth, nose, and pharynx are also channels through which infection may take place. The disease may be transmitted from one individual to another by kissing, or by the drinking-vessel or spoon used by a person suffering frorn pulmonary tuberculosis. The tongue spatula, or the instruments and hands of the dentist, may become a source of considerable danger, unless they are carefully washed and sterilized after being used upon such a 312 SURGERY OF THE FACE, MOUTH, AND JAWS. patient. As much care should be taken in this direction with instru- ments, etc., as would be given to them after having been used upon a syphilitic subject. The skin is sometimes the avenue for the introduction of the tubercular virus. Bollinger thinks this channel of infection is under- estimated. Direct inoculation, however, through the skin does not play a very important role in the causation of the disease. All cases of primary tuberculosis of the skin, however, are the result of inocu- lation. The bacillus does not seem to have the power to enter the skin like the pus-producing cocci. Infection, how-ever, may occur through superficial wounds and slight abrasions of the cutis. A con- siderable number of cases have been reported during the last few years, — enough, it would seem, to establish the fact that tubercular infection may take place in man by absorption of the virus through slight abrasions and superficial wounds of the skin. Tubercular infection occasionally takes place in those whose duty it is to perform autopsies upon bodies of persons who have died of tuberculosis, as in the case of Laennec, just mentioned. Watson Cheyne also reports such a case in a student who injured the finger at the base of the nail. A wart formed, which remained as an ulcer after three years of treatment. Later an abscess formed upon the back of the hand, and finally the finger was amputated. Six years after the injury he died of tubercular meningitis. All portions of the body do not appear to be equally open to infection. Certain tissues and organs seem to have a predisposition for the disease, viz: the lungs, the lymphatic glands, and the bones. The face and head are peculiarly liable to infection. There is, how- ever, hardly a tissue of the body which under favorable conditions may not become the seat of primary tubercular infection, or escape secondary infection w^hen the virus is disseminated through the general infection. The lymphatic system is often the avenue through which remote parts of the body may become infected. The lymphatic glands, how- ever, on the other hand, exert a protective influence against the dis- semination of the disease, by retarding the progress of the bacilli or indirectly accomplishing their destruction. The bacilli may gain an entrance to the general circulation either through the thoracic duct, after having traversed the last chain of glands of the lymphatic system, or by the breaking down of tubercles in the immediate vicinity of blood-vessels, the contents being dis- charged directly into the blood-current. Eventually the bacilli are conveyed to some arteriole or capillary where they become lodged, and the conditions are established w^hich favor the development of miliar}' tubercle. SURGICAL TUBERCULOSIS. 313 Pathology. — The lesion which is produced by the growth of the Bacillus tuberculosis in the tissues is known as tubercle. It is variously designated as the miliary or gray tubercle or nodule. In appearance it is a grayish, translucent mass from i-io to 2 mm. in diameter, and firmly imbedded in the surrounding tissues. It is made up of an aggregation of cells which are microscopic in size, and is the product of a minute point of inllanimation established by the Fig. 120. Tuberculosis— Reticular Form— Lung, showing Fibrous Reticulum, Lymphoid and Giant Cells. X 50. presence of the tubercular bacillus. Larger masses are formed by the ■coalescence of neighboring tubercles, producing the so-called tuber- €ulous infiltratious. The histologic elements which make up a typical primary tubercle are three groups of cells, — the round or lymphoid cells, the epithelioid cells, and the giant cells, and a delicate reticulum of connective tissue which is more dense at the outer surface of the tubercle than toward the center. (Fig. 120.) Senn classes the lymphoid cells as leucocytes, and accounts for their 314 SURGERY OF THE FACE, MOUTH, AND JAWS. presence in the tubercle by the inflammatory action of the specific microbe upon the walls of the capillary vessels. These cells are found most abundantly at the periphery of the tubercle, but are scattered about through all the cellular elements, and they are most numerous when the inflammatory process is acute. These facts, he claims, are convincing proofs of the inflammatory nature of tuberculosis. Fig. 121. fe^l ■>- 4IJ ■■.- .^ ' ".-^ — ~r — ^T- ■"..-I'i..--- ■ r* ' Lymphoid cells. ."!,•-■.■'." -'"■--'•■A'- Giant cells. Giant cells. mm '^<^^^^^^i!t:^^^^'' • ■ ■ '~> ' ' "' r ■ V' ■i^n ■:-.f^^-m^- Giant celL Giant cell. Acute Tuberculosis— Small Nodule, showing many Giant Cells. Lung. X 50. The epithelioid cells are so designated by their resemblance to epi- thelial cells. These cells were first described by Rindfleisch. Klebs calls them platycytes. Cheyne is authority for the statement that the epithelioid cells are the most characteristic cellular elements of tubercle, and are more constant than the giant cells. They are prob- ably derived from the epithelial tissue (epithelium and endothelium)^ and are about two or three times as large as the white blood- corpuscles; in shape they are round or elongated; in structure finely granular, and they contain one large or several smaller nuclei. They SURGICAL TUr.ERCULOSIS. 315 are scattered all through the tubercles, but are found in the greatest numbers grouped around the giant cells and at the periphery of the nodule. The giant cells, according to Senn, are hyperplastic epithelial cells, and consequently are derived from the same kind of tissue. They are a characteristic feature of tubercular nodules, one or more being found in the center of each. (Fig. 121.) This feature enables the micro- scopist to make an almost positive diagnosis, even though the tubercle bacilli cannot be found in a nodule. The giant cell in structure is finely granular, and contains mul- tiple nuclei. These nuclei occupy chiefly a position at the periphery of the cell, and are arranged with their long diameters radiating from the center. Occasionally they are arranged in the form of a crescent at one end. During the progress of the disease the giant cells become progressively fibrous at their periphery, which gradually encroaches upon the protoplasmic central portion. The bacilli are found in the giant cells; also between and in the epithelioid cells, and in the later stages in the round cells. Degeneration of the nodule begins first in the center of the giant cells, and as this central degeneration progresses the bacilli disappear in this portion of the cell, though they may still be found at the periphery. The giant cells of tubercular tissue are similar to the cells found in normal tissue (particularly in bone and the medullary tissue). They are also found in the tissues surrounding foreign bodies which are undergoing the process of encystment. Giant cells have the power of ameboid movement, which enables them to take up into their proto- plasm small bodies, such as micro-organisms, disintegrated blood- corpuscles, etc. The reticulum, according to Warren, is not usually a new forma- tion, but is composed of the pre-existing intercellular connective tissue. Cell-growth being most active in the center, a certain amount of pressure is exerted from within outward, causing a thickening of the fibrous elements, which sometimes amounts almost to the formation of a capsule. Sometimes the reticulum seems to be formed, to a large extent, by the processes of the epithelial cells. As the vascular supply is generally very slight, the smaller vessels soon disappear altogether. In consequence of this, the vitality of the nodule is soon greatly low- ered, resulting in the death of the cellular elements, or coagulation necrosis, followed by granular disintegration and fatty degeneration of the cells, producing the condition known as caseous degeneration. The tubercular bacillus, by its specific action, or through its ptomaines, also appears to exert an influence which brings about a chemical change in the cells. 3i6 SURGERY OF THE FACE, MOUTH, AND JAWS. The process of caseation (Fig. 122) begins in the center of the nodule, and may gradually extend so as to affect the entire mass. When caseous degeneration is extensive, ulceration may take place, or abscesses may form. Sometimes calcareous materials are deposited in the mass, resulting in what is known as calcification. Arrest of the disease frequently takes place in the lungs, and occa- sionally in the lymphatic glands, by the processes of caseation and calcification. Fig. 122. Tubercle. Tuberculosis— Caseous Tubercle. Lung. X 5°- Calcification is nature's method of preventing the local extension of the disease, and guarding against the infection of surrounding tissues or of the general system. Liquefaction of the caseous material, and the formation of ab- scesses, is the more common termination of the cheesy degeneration. The material thus formed has always heretofore been regarded as pus; recent investigations, however, have established beyond a doubt that it is the product of a retrograde metamorphosis of tissue, and not true pus. SURGICAL TUBERCULOSIS. 317 The tubercular or so-called cold abscess contains a fluid which to the unaided eye resembles pus, but when subjected to examination by the microscope it presents none of the characteristic histologic ele- ments of pus. The effects produced by the presence of the tubercular bacillus in the tissues are always those of chronic inflammation, and this in- variably results in the production of granulation-tissue. The embry- onal cells of which the granulation-tissue is composed seem under certain conditions to act as a wall of protection against the encroach- ment of the disease upon the surrounding tissues. The secondary infection of tubercular abscesses with the pus-mi- crobes causes a breaking down of this wall of protection, and the patient incurs the dangers of local septic infection and a general dissemination of the tubercular condition. Garre is of the opinion that many cases of tubercular ulcerations and abscesses are the result of a mixed infection. The examination of the contents of cold abscesses, and of the liquefied caseous material of tuberculous cavities in bone, revealed no pus-microbes, not even in those which pursue a rapid course. He therefore believes it is possible in many cases of suppuration following the tubercular process, that the pus-microbes had ceased to exist before examination for their presence was instituted. AVhen the specific bacillus meets with a sufficient resistance from the tissues surrounding the nodule, it eventually exhausts the nutrient material found in the granulation, and either dies or assumes a latent condition. The granulation-tissue is then converted into cicatricial tissue, and the local manifestations of the disease disappear. If, on the other hand, the bacilli are present in sufficient numbers to cause destruction of the embryonal cells wdth coagulation, caseation, and liquefaction of the infected tissue, a spontaneous cure may still be possible, by absorption of the fluid portion and the encystment of the solid debris. If bacilli or spores remain behind, there will always be great danger of a relapse in this disease. CHAPTER XXXIII. SURGICAL TUBERCULOSIS (Continued). Tuberculosis of Bone. With the definite statement of the proposition that tuberculosis is an infectious disease caused by the Bacillus tuberculosis; that it is characterized by the production of a pecuHar tissue designated as tuberculous, and of certain inflammatory products which appear in the form of nodules or miliary tubercles, and as a diffuse infiltration, and which rapidly undergo caseous degeneration, we may now turn to the consideration of those tubercular conditions which are found affecting the bones, the skin, and the mucous membrane, as of greatest interest from the standpoint of the oral surgeon and the dentist. Tuberculosis of the bone is one of the most common of tubercu- lar affections, those of the lungs and lymphatic glands only being more frequent. Tubercular disease of the bones occurs very often in chil- dren and youth, — in fact, the great majority of cases occur before adult life. Dollinger reported, as a result of investigation into the family history of two hundred and fifty cases of tubercular disease of the bones, that in more than one-third of them, one or more of the imme- diate ancestors had suffered from pulmonary tuberculosis, usually the grandparents. He therefore comes to the conclusion that the influ- ence of the tubercular virus must be exerted through several genera- tions before the normal resistance of osseous structures is so far weak- ened that they become a suitable field for the lodgment and develop- ment of the tubercular bacillus, and that in the inherited (?) form, or predisposition to tuberculosis, the lungs are attacked in the first gener- ation, and the bones in the second. The most common location of the disease is in the epiphyseal ends of the long bones, but it is, however, frequently found in the short bones of the hand and the foot, and occasionally in the flat and irreg- ular bones, as the vertebrae, the ribs, the scapula, the ilium, the bones of the cranium, of the nose, and of the face. The disease is most fre- quently found in the cancellated structure of the bone, but it may occur in the compact tissue, and in any portion of the bone. The disease may be primary or secondary in its origin. 318 SURGICAL TUBERCULOSIS. 3^9 It is probable, however, that only a very small portion of the cases • of tubercular nodules of the bones are primary in their origin; the great majority of them are secondary to disease of the lymphatic glands, of the bronchial or mesenteric group, infection having taken place through the mucous membrane of the respiratory or alimentary tract, the bacilli being transported through the circulation, and deposited in the bone. Landerer, according to Warren, examined post mortem one hundred and fifty cases of tubercular and bone diseases, and with one or two exceptions found tubercular disease of the bronchial glands that evi- dently antedated the bone-affection. Primary tuberculosis of bone when it does occur is doubtless the •result of inoculation, through wounds and abrasions,— in other words, -of traumatic origin. Authorities differ as to the influence of traumatic injuries in pro- -ducing tubercular disease of the bones. Senn quotes Volkmann as saying that traumatisms which produce tubercular disease of the bones are afways slight, and often insignificant. Senn himself believes that •only in a small per cent, of tubercular disease of bones can the disease be traced to a traumatic origin. Warren says the great majority follow slight contusions and sprains. Experience teaches that tuberculosis of bone rarely if ever, even in tubercular subjects, follows a severe injury or fracture of the bone, doubtless on account, as Senn expresses it, of the active cell-proliferation going on about such an injury that neutral- izes the pathogenic action of the bacilli which might reach the seat •of the injury with the extravasated blood. But in injuries less severe, the same cell-activity does not exist, the tissues are disabled for a brief period by the damage which they have sustained, and during this time they are in a less resistant state through the deleterious action of the bacterial ptomaines. They then become a favorable soil for the development of the bacillus, and, as already shown, in individ- uals predisposed to tuberculosis the seeds of the disease may already be present in the lymphatic glands, and only waiting for favorable con- ditions to begin their active growth. Such a point of injury might therefore establish a focus for the development of the bacilli, the forma- tion of nodules, and later a more or less extensive tubercular osteitis. It very rarely happens that tuberculosis of bone occurs during the progress of tubercular disease of the lungs, but pulmonary tubercu- losis and diffuse miliary tuberculosis can frequently be traced to tuber- cular disease of the bone. The frequency with which this occurs is explained by the intimate relationship existing between the tubercular nodule in bone and the blood-vessels, thus rendering systemic infection almost certain. The tendency of tubercular disease of the glands, if allowed to take its course, is toward bone tuberculosis, and later, to pulmonary or diffuse miliary tuberculosis. 320 SURGERY OF THE FACE, MOUTH, AND JAWS. Volkmann says that a child suffering from glandular tuberculosis- has a good chance of becoming the subject of osseous tuberculosis dur- ing adolescence, and to die of pulmonary tuberculosis before reaching the age of thirty. A peculiarity of tubercular disease of the bone is, that it generally begins at that point where the growth is the most rapid and greatest in amount. In the long bones this is at the epiphyseal ends; in the flat and irregular bones at the outer borders. When infection takes place it is practically never direct, and when the disease makes its appearance it is only an evidence that the germs of the disease were already present in some other organ. When the bacilli are present in the blood-cur- rent they sometimes become localized in the terminal branches of an artery, particularly in partially developed bone, by being arrested in their progress, and the lumen of the vessel is obliterated by the pres- ence of a minute embolus of granulation-tissue containing bacilli, or the caliber of the vessel may be gradually decreased until it is finally obliterated by the formation of a mural thrombus around bacilli which have found a lodgment upon the inner walls of the vessel. In young persons the new vessels which are forming in partially developed bone are, by their imperfect structure, and the irregularity of their contour, the most favorable in location and conditions for the arrest of floating granular particles and bacilli. These conditions would therefore seem to be a strong predisposing cause, and an explanation of the frequency with which tuberculosis of bone occurs at the point of greatest growth. The relative frequency with wdiich tuberculosis occurs in the bones of the head and face, as compared with other bones of the body, is one of considerable interest. Quoting from the tables of Schmallfuss, in Senn's "Principles of Surgery," we find Billroth places the bones of the cranium and the face third in the list, with a percentage of thirteen. Jafife gives the bones of the cranium the eighth place, with a per- centage of three; but no reference is made to cases affecting the bones of the face. Schmallfuss also places the bones of the cranium in the eighth place, with a percentage of four, but also mentions no cases affecting the bones of the face. If Billroth's cases of tubercular disease of the bones of the cranium did not average higher than those of the other authorities named, it would be fair to say that the ratio of cases of the disease in the bones of the face would be nine per cent. Tuberculosis of the bones of the cranium is found most frequently in the bones of the ear and the mastoid process. After these, it is found chiefly in the frontal and temporal bones. The bones of the face which are most often the seat of the disease are those of the nose, the superior maxillae, the malar, and the palate. The inferior maxilla is rarely affected by the disease. Tttbercidosis of Bone, or Caries of Bone, is an ulcerative process; a SURGICAL TUBERCULOSIS. 321 molecular death of bone, due, as wc have already learned, to the pres- ence of tubercular nodules formed by the action of the specific bacillus upon the bone-tissue in which it has been deposited. The disease always begins as an intercellular osteitis, of low, chronic type, and Volkmann says these chronic tuberculous inflamma- tions of bone have a tendency to form in the ends of the long bones near the joints, just as pulmonary tuberculosis does in the apex of the lung. The clinical history of tuberculosis of bone, as well as the appear- ance of the tissues, with the unaided power of the eye, and also micro- scopically, is the same as that found in typical cases in other tissues of the body. Warren describes these appearances as follows: "On making a section of the bone the tubercular nodule appears as a well- defined mass of reddish gray, yellowish white, or pure yellow color. The surrounding bony tissue is usually red and hyperemic, and the trabeculse may be somewhat thickened. The cancellous spaces are devoid of fat-cells, and they contain a swollen semi-fibrous material. With a microscope the miliary tubercles are seen at the periphery of the nodule, its center being composed of broken-down cheesy material. The size of these nodules varies greatly. As they grow, the tubercular virus attacks the trabeculge, leading to their absorption, the bone becomes softened, and breaks up into a mass of greasy, cheesy mate- rial, containing crumbling fragments of bone-tissue. When complete softening has taken place, the material of which the nodule is composed becomes puriform, and it may be washed away, leaving a cavity lined with granulation-tissue. In case the trabeculas are not completely de- stroyed in the infected part, the cancelli between them become filled with cheesy debris ; as the vitality of the part is destroyed, granulation- tissue is formed around the diseased mass, and absorption of the con- necting trabeculse occurs ; the spongy sequestrum which is thus formed separating from the living bone. These sequestra are quite small, and are more or less globular in form. The surrounding bone becomes somewhat thickened, and the interstices are filled with gray fibrous tissue, or eburnation of the bone may in some cases take place. When the nodule has softened completely into pus — liquefied — the surround- ing bone is covered by a tubercular membrane, or its surface is infil- trated with granulation-tissue, which usually contains miliary tubercles on its inner aspect, affording, nevertheless, protection to the adjacent bone. These small sequestra — spiculse — lie firmly imbedded in a thick layer of blue-gray, transparent granulation-tissue, dotted with yellow spots. Large amounts of pus rarely accumulate around these nodules." The crucial test, however, of the tubercular character of all chronic inflammatory bone affections, is the presence of the specific bacillus. 322 SURGERY OF THE FACE, MOUTH, AND JAWS. In many cases there is great difficulty in finding the bacillus, but Cheyne attributes this to the fact that they are more numerous in the first stage of the disease, and that their numbers decrease in the later stages, or rapidly pass into the spore formation. There are also diffi- culties in staining them, which are not understood, for sometimes in double staining some will take red and others blue, which he thinks is probably due to the dififerent stages of their development. Tubercular abscesses are formed by the breaking down into caseous material of confluent masses of tubercle in the center of a nodule. This material becomes infiltrated with fluids and leucocytes. A cavity is thus formed which contains fluid, fatty material, fragments of disorganized cells, and leucocytes, surrounded by granulation-tissue filled with tubercles. Cold abscess is the result of the burrowing of pus, forming large ca"" .ies, into which tuberculous cavities at neighboring points may have d.jcharged after liquefaction has taken place. The pus which these abscesses contain is so characteristic that it would never be mistaken after it had once been seen. It is of a pale white color, much thinner than the pus of acute abscesses; it frequently contains masses of cheesy material resembling coagulated casein, and for this reason is termed grumous. Sometimes it is mingled with blood, when it will be a dirtv brown color. Small particles of bone are not infrequently present, which feel to the fingers like grains of sand. The presence of bacilli can rarely be demonstrated with the microscope in such pus. Cultures, however, yield the characteristic microbe. The tubercular membrane, as it is termed, was first described by Volkmann. It is an opaque membrane, several millimeters in thick- ness, of violet gray or yellowish brown color, scantily supplied with blood-vessels on its inner aspect, containing innumerable clusters of miliary tubercles, which are supported by a matrix of coagulated fibrin. It is easily scraped off with the finger, or removed by washing with a stream of water from the irrigator, or peels o& during an operation. This membrane is considered by Volkmann as an absolutely certain diagnostic sign of the tuberculous character of the abscess. Burrowing of the pus is a much more rare condition in tubercular disease of the bones of the cranium and of the face than it is in the long bones and in the vertebra, as the former are not so deeply covered by soft tissues. Symptoms and Diagnosis. — In this disease the general symptoms are often of little value as an indication of the presence or the extent of the local afifection, as it frequently occurs that patients with quite extensive tuberculosis of the bones may give every indication of robust health. Konig, who is authority on all matters relating to tuberculosis, has called attention to the fact that in nearlv all cases of SURGICAL TUBERCULOSIS. 323 even limited local tuberculosis there will be found a slight evening rise of temperature. Senn says that an evening rise, if not more than one-half of a degree F., if continued for weeks, should indicate a care- ful search for a local tubercular focus. Aiic7iiia, if progressive, is always an unfavorable symptom, and is the result either of the extension of the disease to other important organs, or of exhausting discharges, growing out of secondary infec- tion with the pus-producing micro-organisms. Such infection is always announced by a sudden and high temperature, with the accom- panying signs of septic infection. Paiiij of a more or less mild character, is an almost constant symp- tom. It is rarely, however, so intense as in acute suppurative osteo- myelitis, where the tension from the accumulated pus is sometimes very great. In tubercular inflammation, the primary exudation is always scanty, and the product of the inflammation is principally granulation- tissue formed from the pre-existing cells, — fixed tissue-cells; the bone in the immediate neighborhood becomes porous, thus allowing the pus to penetrate the bone, and relieving the tension that would otherwise exist, and mitigating the pain to a greater or less extent. When the pain is severe, it indicates an acute inflammatory condition. The pain is also intermittent, and ahvays more severe at night. Another peculi- arity of the pain is, that it is often referred to some remote part, as, for instance, in hip-joint disease, the pain is referred to the knee, and in tuberculosis of the vertebrse the suftering is usually experienced in the pit of the stomach, or some part of the abdomen supplied by nerves having their exit from the spinal canal near the diseased vertebrae. Tenderness is usually present over a tubercular focus in the inte- rior of the bone, which can be readily located by palpation. Swelling is usually absent in the early stage of the disease, or until the external compact tissue yields to the pressure from within or is perforated and forms a soft, boggy, circumscribed swelling beneath the periosteum. This condition is not always indicative of the presence of pus. The swelling may seem to fluctuate, but is misleading on account of the character of the granulation-tissue beneath, which gives it a pseudo- fluctuation. Such granulating foci have many times been incised under the belief that they w^ere abscesses. When caseation takes place in the tubercular focus before perforation of the periosteum occurs, the surrounding tissues become rapidly infected, and a tubercular abscess is the result. The color of the skin is not changed over a tubercular focus in bone, or over a tubercular abscess, until the granulations have perme- ated the deeper portions of the skin, or until the liquefied caseous mate- rial has so far reached the surface as to have only the skin for a cover- ing, when it presents a dusky red hue. This is due to an impaired 324 SURGERY OF THE FACE, MOUTH, AND JAWS, circulation; the skin becomes thinner and thinner from atrophic changes induced by pressure, destruction occurring in the deeper por- tions, until finally it ruptures spontaneously, and the contents are discharged. Diiferential Diagnosis. — As a means of differential diagnosis, a doubtful swelling may be explored (antiseptically) by a strong, spear- pointed steel needle, — or, if such an instrument is not at hand, a heavy hypodermic needle will serve the purpose. Such an instrument will usually enter the bone, which has been reduced in density by the action of the chronic inflammation, provided osteo-sclerosis has not taken place. In the active stage of tuberculosis of bone, the osseous tissue becomes softened and porous, so that sometimes the needle readily penetrates it. If the needle meets with any considerable resistance, it may be rotated as it advances; when it reaches the granulating focus or caseous mass, resistance is suddenly lost, and the needle may be passed through to the opposite side. The size of the cavity may be approxi- mately determined by this method. In tubercular disease of the bones of the face, it is also necessary to differentiate between syphilis, sarcoma, cysts, and chronic indurations located in the alveolar processes. The great majority of chronic inflammations of bones are due to tuberculosis. Senn claims that 95 out of every 100 cases are due to this cause. This, as a general state- ment, is quite correct, but it would need to be somewhat modified in applying it to the bones of the face. A bacteriologic examination is necessary to establish a positive diagnosis. Prognosis. — The prognosis in cases of tuberculosis of bone is more favorable than if it were located in a joint, or in the skin, the lym- phatic glands, or any of the internal organs. Tuberculosis of bone is sometimes spontaneously arrested, and a complete cure takes place, just as occurs in certain cases of pulmonary tuberculosis. This is brought about by the establishment of favorable conditions of the health, which give the system control of the disease, and limitations are defined, sometimes before caseation has taken place. If, however, caseous material has been formed, and it can be removed surgically, the prognosis is still favorable. As already stated in preceding pages, an individual who has suffered from osteo-tuberculosis in childhood or youth is always liable, under favoring conditions, to reinfection with the disease from the spores of the bacilli which may remain indefinitely in the tissues where they have been deposited. In osteo-tuberculosis of the face, the part most liable to be affected is the infraorbital ridge. Tubercular inflammation occurring in this region is most common in children. Warren has seen it in adults. The disease progresses very slowly, being marked by swelling or full- ness of the region; suppuration finally occurs, the skin may rupture SURGICAL TUDERCULOSIS. S^S Spontaneously, one or more sinuses are formed, the discharge becomes chronic, and may continue for months, terminating in unsightly scars and ectropion of the lower eyelid. A case of this character in a boy of seven years came under the care of the writer about ten years ago, in which the entire orbital plate of the maxillary bone and a portion of the bodv of the bone were destroyed, producing ectropion and closure of the nasal duct. The malar bone is occasionally the seat of the disease. Warren mentions a case in which the disease in this location caused an exten- sive suppuration, and finally terminated in ankylosis of the jaw. Oste- otomy was performed a year after the old sinuses had closed. The bones of the nose are not infrequently the location of the dis- ease. The infection may be primary, or it may be secondary to tuber- culosis of the skin (lupus), or to the disease in the mucous membrane. In this way, also, the floor of the nasal fossa may become involved, and tubercular caries of the hard palate, with perforation, occur; or the disease may have its origin in the hard palate, and upon perforating the floor of' the nares, extend to the bones of the nose, resulting in loss of tissue, and sometimes considerable deformity, by reason of the removal of the support to the soft tissues. Du Castel has reported a case of tuberculosis affecting the bony palate in a man who consulted him for a perforation of the hard palate, which was at first thought to be due to svphilis. A more careful examination revealed an ulcera- tion upon the roof of the mouth near the palatal root of the second superior right molar tooth, covered by a soft coat and surrounded by miliarv granulations. There was no history of syphilis and no scars or other manifestations that could be attributed to this disease. Ex- amination of the chest showed the man to be suffering from pulmonary tuberculosis in an advanced stage. The margins of the perforation m the hard palate were covered with granulations which upon examma- tion were found to contain numerous tubercles with Koch bacilli. In this form of the disease there is danger, therefore, of confounding it with syphilitic manifestations in the same locality. It is better where doubt exists as to the diagnosis to place the patient upon anti-syphilitic treatment for two or three weeks, when the diagnosis will most likely be made clear. The alveolar process is also occasionally the seat of the affection, the disease generallv being located through the chronic inflammatory process established bv devitalized teeth. Garretson mentions a case of this character having its origin at the seat of a chronic abscess caused bv a pulpless superior lateral incisor, which resulted in caries of nearly the entire upper jaw, and required an extensive operation for the removal of the diseased bone. The writer recently operated upon a little boy, five years of age, 326 SURGERY OF THE FACE, MOUTH, AND JAWS. for extensive caries of the alveolar process of the right upper jaw caused by the irritation of two badly decayed and devitalized deciduous molars. The bone was so soft as to be easily scraped away with the curette, while the pus was filled with cheesy masses. Fig. 123 showS a giant cell, etc., from tubercular disease of the angle of the lower jaw. Treatment. — Patients who are suffering from tubercular disease of the bones need, first of all, tonic and supporting treatment, nourish- FiG. 123. Giant cell. Tuberculosis of Angle of Inferior Maxilla, showing Giant Cell. )< 800. ing food, out-door air, and moderate exercise; change of climate, sea- bathing, or a sea-voyage are often of more real value than drugs. The local treatment of tuberculosis of the bones of the face com- prehends mainly a radical operation. This consists of removing, under antiseptic precautions, the entire focus of infected tissue, and the measure of success will depend largely upon the stage of the disease when the operation is made. Success is more likely to be assured in the granulating form of the disease if caseation has not taken place. Operations should not be delayed after a positive diagnosis has been SURGICAL TUBERCULOSIS. 327 established, that adjacent tissues may not become involved, and that general infection may be prevented. Ftg. 124. The Cryer Surgical Engine in its Latest Form. In operations upon the bones of the face and jaws, the writer has found the surgical engine and round burs the most satisfactory instru- ments for the removal of carious bone. Figs. 124, 125, 126, 127 illus- 328 SURGERY OF THE FACE, MOUTH, AND JAWS. Fig. 125. M Trephine and Typical Burs for Surgical Engine Fig. 126. Two forms of Cryer's spiral osteotome, one (a) with dentate, and one {/>) with plain cutting-edges, c shows the osteotome mounted, with its button-like guard for cuttingfenestra,etc.,in thebrain-case without injury to the subjacent membranes, a and d are twice the size of cutting-tool ; c is full size. SURGICAL TUBERCULOSIS. 329 trate the improved surgical engine, trephine, burs, osteotome, etc. The curette and chisel, however, answer a good purpose, if the engine is not to be obtained. The delicacy and speed with which the bone can be removed with the engine and burs places these instruments in the front rank of this kind of bone surgery. The softened or osteoporotic bone must be thoroughly removed, and the surface carefully examined, to see that healthy tissue has been reached; as an added precaution, the surface may be punctured at sus- picious places with a sharp-pointed steel probe, as occasionally this Fig. 127. Cryer's Circular Saw with Adjustable Guard for Cutting the Brain-case to any Pre- determined Depth. instrument will reveal a concealed focus of infection that can then be removed. Senn recommends that the surface be punctured with a sharp-pointed Paquelin cautery to the depth of a few lines, as this pro- cedure will destroy some of the bacilli that might remain, and also incite a plastic inflammation that would effectually resist the patho- genic action of such bacilli as w^ere still present. Too much stress cannot be laid upon this part of the operation. The cavity is then to be dried, dusted with iodoform, packed with iodoform gauze ; the edges of the wound sutured, except at the lower angle, where space is left for the removal of the packing and for drainage. Senn fills the cavity with antiseptic, decalcified bone-chips, suturing the periosteum sepa- rately in operations upon the long bones, and claims excellent results. Such a procedure ought to be available in the treatment of certain cases of tuberculosis of the superior maxillary and malar bones having external openings, and where loss of bone-tissue would cause a serious deformity. Tubercular abscesses are treated by incision, and the removal of the tubercular membrane and granulation, and irrigation with an aqueous solution of iodin. The primary lesion must also be found and 330 SURGERY OF THE FACE, MOUTH, AND JAWS. removed. Aspiration and injections of solutions of iodoform and gly- cerol are rarely practiced in connection with tubercular abscesses in the region of the face, for the very good reason that abscesses requir- ing such treatment are exceedingly rare in connection with the bones of this region. Most cases of tubercular abscess associated with the face can be treated more successfully by radical operation. CHAPTER XXXIV. SURGICAL TUBERCULOSIS (Continued). TUEERCULOSIS OF THE SkIN AND MuCOUS MeMBRANE. Tuberculosis of the Skin, or Lupus Vulgaris. — Until the pos- itive demonstration by Koch that lupus was a form of tuberculosis of the skin, there was a very wide difiference of opinion among the various authorities as to the real nature and origin of the disease. The French and English authors were quite generally agreed that it was one of the manifestations of scrofula, and that it was composed of granulation- tissue. The German authorities differed very greatly as to the causa- tion of the affection. Virchow did not believe it to be a manifestation of scrofula, and classed it with the granulomata. Heuter considered it to be a fungous inflammation, and that the specific cause was capable of producing miliary tuberculosis when introduced into the tissues. Volkmann classed it with those diseases which are characterized by the production of granulation-tissue. Baumgarten afifirmed that the ab- sence of caseous material in lupus was an evidence of its non-tuber- culous character, while Friedlander stoutly maintained that lupus was a tubercular disease of the skin, identical in its histologic structure with other forms of the affection, and presenting the same characteristic miliary tubercles. At the present time there seems to be no doubt that lupus, and many other forms of skin-disease, are tubercular in their nature, and directly caused by the presence in the tissues of the Bacillus tubercu- losis. Koch not only demonstrated the presence of the bacillus in lupus nodules, but he succeeded in producing a pure culture of the microbe from lupus tissue, which in every respect resembled that produced from recognized tubercular tissue, while with the fifteenth generation of the bacillus from this culture he successfully inoculated five guinea-pigs by subcutaneous injection, producing typical tuberculosis in each of them. Before this time, however, clinical observation and the accumu- lation of anatomical proofs had demonstrated that in all probability lupoid affections were of tubercular origin, or that there was a very close relation between them and tuberculosis, but the positive proofs 331 332 SURGERY OF THE FACE, MOUTH, AND JAWS. were lacking until the discovery of Koch. The experiments of Koch have since been repeated many times by other scientists to prove the identity of the bacillus found in lupus tissue and tuberculosis, with al- most uniformly positive results. Tuberculosis of the skin is often associated with other forms of tuberculosis. Brock found 79 per cent, of the cases examined by him were complicated with other forms of tuberculosis. Rassdnitz found that 30 per cent, out of two hundred and nine cases were associated with other manifestations of tubercular disease. Besnier reported that 21 per cent, of the cases of lupus that came under his observation eventually died of phthisis. Pontoppidan said that 50 to 75 per cent, of his patients suffering from lupus gave additional evidence of other forms of tuberculosis. Tuberculosis of the skin may be primary or secondary in its origin. All forms of primary tubercular disease of the skin are doubtless the result of inoculation with the Bacillus tuberculosis. It is some- what remarkable, however, that taking into account the frequency with which abrasions and slight wounds occur upon the exposed portions of the skin, and the many ways in which the dangers of infection with the tubercular virus are presented, the primary form of the disease does not occur with much greater frequency. It is a well-known fact that lupus occurs most frequently upon those parts of the body which are most constantly exposed to injury and infection. Lupus is found most frequently in the skin of the nose, face, eyelids, ears, and hands, locations which are not afforded protec- tion by either the hair or clothing, and which are constantly exposed to slight injuries, to the lodgment of bacilli floating in the atmosphere, and to direct inoculation with the virus from almost innumerable sources. The secondary form of the disease is usually found in pa- tients suffering from advanced tuberculosis, and is a manifestation of a general diffusion of the affection to the skin and mucous membrane, or of auto-infection in persons suffering from primary tuberculosis of the lungs. Pathology. — As primary tuberculosis of the skin is always the di- rect result of inoculation, the pathologic changes are therefore always first made manifest at the point of infection. These manifestations consist of the formation of nodules which contain all of the histologic elements of true tubercular nodules, viz: giant cells, epithelioid cells, leucocytes, and the Bacillus tuberculosis ; caseous material is, however, rarely found. This is accounted for, in all probability, as suggested by Senn, from the location of the tubercular product so near to the surface of the skin, and also because the granulation-tissue soon be- comes the seat of suppuration, due to secondary infection from the pus-microbes. By the aggregation of these nodules, and the infiltration SURGICAL TUBERCULOSIS. 333 of the surrounding cellular tissues, the lesion gradually spreads, and by the coalescence of the infiltrated portions there is established a more or less extensive area of tubercular tissue. In those cases where the break in the continuity of the tissue at the point of the infection has been restored, the cell proliferation may be so abundant as to cause a swelling resembling a papillomatous growth and covered with a scaly epidermis, the result of excessive formation and exfoliation of epidermal tissue. Whenever the underlying granu- lation-tissue becomes exposed, septic infection immediately takes place from the introduction of the pus-microbes, and the process of destruc- tion of the granulation-tissues is hastened by the action of the septic organisms and their ptomaines. Ulceration immediately takes place, the break in the continuity of the skin increases in size and rapidity, commensurate with the formation of granulation-tissue by the action of the Bacillus ttiberculosis and the development of new nodules in the immediate vicinity of the ulceration. In some forms of lupus the infection remains superficial, and only the outer layers of the skin become involved; in others the destructive process strikes deeper and deeper, involving the muscles, fascia, peri- osteum, and bone, simulating very closely the clinical features of ma- lignant neoplasms. This form of the disease not infrequently attacks the face, destroying the nose, eyelids, lips, and a greater portion of the cheeks, leaving the face much like that of a skeleton. Symptoms and Diagnosis. — ^Tuberculosis of the skin is found most frequently in middle life; no age, however, is exempt from it. It is occasionally found in little children and persons of advanced age. The disease is usually described as a neoplastic affection of the skin, or of the contiguous mucous membrane, of highly chronic char- acter and type, manifested in the form of slowly developing small red- dish-brown or yellowish-red nodules, or centers of infiltration. These nodules, when further developed, tend to rise above the surface, and form papules or tubercles. The spread of the disease is by peripheral extension and the formation of new centers, while the older ones disap- pear by gradual resorption, or ulceration takes place, resulting in the formation of disfiguring scars. The varying degree to which the corium and the papillary layers of the skin are involved gives rise to the differences in the clinical appearances of the disease, and the terms applied to them. The ordi- nary classification is as follows: Lupus Maculosus. Lupus Exfoliativus. Lupus Exulcerans. Lupus Serpiginosus. Lupus Hypertrophicus. 334 SURGERY OF THE FACE, MOUTH, AND JAWS. Another classification of the various forms of the disease, also based upon the clinical appearances, is as follows: Non-ulcerative, or lupus non-exedens; Ulcerative, or hipus exedens; Exfoliative, or liipiLs exfoliativus; Hypertrophic, or lupus hypertrophicus-(W3Lgner). Lupus Maculosus is characterized by the formation in the skin of minute yellow-brown nodules or patches, usually of pin-head size, more or less transparent, and covered with epidermis. The color is changed to a lighter shade under pressure. The nodules appear to lie just beneath the surface, their outline being well defined. The epi- dermis covering the patch is usually smooth, but it is occasionally scaly or shiny. The papules commonly appear in clusters, and as they grow they approach one another, finally becoming confluent and forming nodules of considerable size. The most characteristic feature of the lupus patch is its soft con- sistence. It is much less firm than the surrounding skin, and offers little resistance to the end of a blunt probe when pressed upon it. The normal skin will entirely resist such pressure, while the lupus patch gives way and the probe is buried in the mass. Lupus maculosus is the simple form of the affection, and is always the first stage of the dis- ease. It also appears at the periphery of old patches, and is often the first indication of a relapse in old cicatrices. This constitutes lupus non-excedens, or the non-ulcerative variety. When ulceration does not take place, the nodules may rem.ain stationary for an indefinite period, or a spontaneous cure may take place by cicatrization. Lupus Exfoliativus is a later stage in the progress of the disease, characterized by central degeneration of the matured nodule, caseous change, and cicatrization. The skin becomes rough, scaly, and fis- sured; exfoliation takes place, leaving the skin considerably thinned or atrophied, which thus easily becomes folded or wrinkled. Lupus Exulcerans. Occasionally the lupus process terminates by a sort of subcutaneous cicatrization. Usually, however, the disease progresses to ulceration. Before ulceration takes place the surface is usually covered with thickened epidermis, which can be scraped off in white scales. Ulceration begins over the center of the nodule, and extends toward the periphery, attacking the new nodules almost as rapidly as they are formed. The ulcerative process is hastened by the secondary infection with the pus-producing micro-organisms, which enter the granulation-tissue at the border of the ulcer. Repair by cica- trization and the ulcerative process often go on at the same time in a lupus patch. Repair is more likely to occur if the tubercular process has been confined to the skin, than when it has progressed beyond this tissue. This constitutes the ulcerative variety, or lupits exedens. SURGICAL TUBERCULOSIS. 335 Lupus Serpiginosus is but another form of hipus exedens, in which the process of repair by cicatrization and epidermization pro- gresses in an irregular form. Healing may take place in the center of a lupus patch, or in a segment of the periphery, while at other points the morbid process continues, and the disease creeps on, followed by the scar, and giving rise to irregular gyrate forms. When the ulcerative process accomplishes its work of destruction with greatest rapidity, penetrating to muscle and bone, and destroying them, it is termed lupus vorax. Lupus Hypertrophicus is a form of the disease in which there is an exuberant formation of tissue which produces a papillary growth. These papillary growths are probably derived from the granulation- tissue which has been covered by epithelium in the process of healing, and may remain as permanent warty growths, or at other times become soft and fungous, with a tendency to bleed. When this form of the disease is located in the lower extremities, the formation of hypertro- phied tissue is sometimes so excessive as to cause a very considerable enlargement of the limbs, producing a species of elephantiasis. This latter form never remains as a permanent condition, but sooner or later, sometimes after years, the hypertrophied tissue breaks down, followed by ulceration and cicatrization. Tuberculosis of the Skin of the Face. — The first manifestations of lupus in the face are the so-called primary efflorescences found upon one or both cheeks, upon the nose, or upon the cheek and nose, in the form of a dull-colored maculation upon the skin, often unnoticed for a long time; or it may appear in the form of a minute nodule; or a thick- ened purplish patch, the size of the finger-nail. The disease spreads, as already described, by extension from a single patch, or by multiple lesions. The contraction of the cicatrices formed by the process of healing often results in great disfigurement of the face, in some cases causing ectropion of the eyelid or lip. The nose often becomes very much reduced in size after the ravages of the disease have subsided, the point being markedly sharpened, though occasionally, according to Hyde, the point becomes bulbous, flattened, livid, and knobbed, with a thickened septum and distorted alse. The upper lip is frequently involved when the disease is situated upon the nose, marked at first by considerable swelling, followed by fissures which are prone to bleed and the formation of crusts on the granulating surface. Considerable deformity usually follows the heal- ing of tubercular ulceration of the upper lip, the mouth being some- times reduced to a mere slit or hole in the face, with little power to open or close it. Tuberculosis of the Mucous Membrane of the Mouth. — Tubercular disease of the mucous membrane of the mouth is generally 336 SURGERY OF THE FACE, MOUTH, AND JAWS. found as an extension of the affection from the neighboring infected integument. In the great majority of cases it is secondary to tuber- culosis of the skin, proceeding from this tissue to the mouth, extending to the mucous hning of the hp, the gum, the hard palate and the velum palati, or the pharynx, or the conjunctiva. Primary tuberculosis of the mucous membrane is comparatively of rare occurrence. When it is remembered that the oral cavity is often the seat of superficial injur- ies and pathologic changes which form excellent points for infection with the bacillus, it seems a wonder that the primary form of the dis- ease is not much more prevalent in this locality than it is. The changes which take place in the mucous membrane are the same as when the disease is located in the skin. The lupus nodules, as found in the mucous membrane, are minute white points, set in the livid red and slightly thickened membrane; they may assume the form of a papillary outgrowth or a granulating patch, which may ulcerate and cicatrize. Ulceration is an earlier and more frequent symptom in tuberculosis of the oral cavity than in other locations, on account of the constant maceration of the newly-formed abnormal tissue by the fluids of the mouth. The ulcerating patch has well-defined borders, and is usually covered by a whitish film or false membrane, produced by the death of the superficial layers of the mu- cous membrane. On removal of this pseudo-membrane the character- istic granulating surface is exposed. Caseation is seldom seen. Ul- ceration and cicatrization sometimes cause serious deformities which interfere with the proper function of the parts. The most characteristic feature of tubercular ulcer of the mucous membrane of the mouth and the tongue is the presence of minute tubercular nodules in the margins and underneath the layer of granula- tions, and if the infection has extended to some distance, in the sur- rounding mucous membrane also. (Senn.) The disease is most often seen in persons from forty to fifty years of age, and rarely attacks the very young. Tuberculosis of the Tongue and Pharynx may be seen inde- pendently of the disease in the skin, and may be primary or secondary in its origin. Tubercular ulcers of the tongue are exceedingly rare. Butlin says the disease is so uncommon that at intervals it excites an entirely new interest, and is described almost as if it were a new disorder. These ulcers are most often situated upon or near the tip of the tongue, though they are found in all locations, especially upon the dorsum. Men are more prone to the disease than women, and adults more than children. The ulcer (or ulcers, for there may be more than one) is at first indolent, not painful or very tender, but later, as the disease takes on a more active progression, it becomes more and more painful, ex- SURGICAL TUBERCULOSIS. 337 cceding-ly sensitive, and salivation becomes a marked symptom. Fig. 128 represents a typical tubercular ulceration of the tongue. In some cases the tongue is rapidly destroyed, the lymphatic glands be- coming infected, and as the sore extends the strength of the patient fails, death resulting in a few months, or at the end of a year or two. Fig. 129 shows a tubercular nodule from the same case with giant cells and beginning caseation. Fig. 128. Giant cell. Giant cell. Round-celled infiltration. Tuberculous Ulcer of the Tongue. X 50- Tubercular disease of the pharynx may extend to the tonsils and velum palati, destroying these organs, or if cicatrization takes place the posterior nares may become more or less contracted, and the exer- cise of function become greatly hindered, speech also being rendered imperfect. The larynx may also become involved from extension of the disease, and aphonia result from implication of the epiglottis and the vocal cords. Differential Diagnosis. — In the diagnosis of lupus of the face and mucous membrane, it must be borne in mind that the clinical features 23 338 SURGERY OF THE FACE, MOUTH, AND JAWS. of certain forms of tertiary syphilis and epithelioma closely simulate those of tuberculosis of the skin and mucous membrane, and to dififer- -entiate them is sometimes very difficult or well-nigh impossible. Even the microscope in the hands of an expert cannot always be relied upon as an exclusive means of diagnosis, on account of the great similarity in the histologic elements of a tubercular nodule and a gumma. Fig. 129. Early tubercle beginning caseation. Giant cell. Tuberculosis of Tongue, showing Giant Cells and Caseation. X 50. A careful examination into the history of the case is of the greatest importance when trying to differentiate between tuberculosis and syph- ilis, for even though the patient may be sure that syphilis has not been acquired, still it is possible that the disease may have been inherited; while on the other hand, although a positive history of primary and secondary syphilis may have been established, it is not improbable that the manifestations may be those of tuberculosis. When doubt exists as to the true nature of the disease, the matter may be cleared up in the course of a month or six weeks by prescrib- SURGICAL TUBERCULOSIS. 339 ing antisyphilitic treatment, and at the same time inoculating several guinea-pigs or rabbits, after the method of Koch, by implanting sub- cutaneously small fragments from the diseased area, as these animals are very susceptible to tuberculosis. The doubt is removed either by the improvement manifest in the ulceration, after two or three weeks, as a result of the antisyphilitic treatment, or by the production of tuberculosis in the inoculated ani- mals, and their death at the end of five or six weeks. If the fragments which have been implanted are from syphilitic ulcers, it will have no efifect upon these animals, as they cannot be inoculated with syphilis. In differentiating between tuberculosis and epithelioma, the micro- scope is the only reliable means of diagnosis. A section of a tubercular nodule shows a fine, delicate reticulum, the meshes of which are occu- pied by granulation-cells; in epithelioma there is a well-marked retic- ulum, the areolar spaces of which are filled with embryonal epithelial cells, arranged concentrically. Blood-vessels are also abundant in epithelioma, and absent in the tubercle nodule. Glandular infection is an early manifestation in epithelioma, while in tubercular ulcerations of the mucous membrane it is a late manifes- tation or may not occur at all. Simple ulcers of the cheek and tongue sometimes occur from the mechanical irritation of a sharp or jagged tooth, resulting from a cari- ous cavity, or from masses of salivary calculus, or from a misplaced tooth. Such ulcerations are easily recognized from their location and appearance, and only a careless observer would be misled. It should be borne in mind, however, that they may become the focus of infec- tion of tuberculosis, or the starting-point of a carcinomatous growth. Prognosis. — Although lupus is usually confined to the skin, it may attack deeper parts, involving the muscles and periosteum, caus- ing necrosis of the bone. Primary tuberculosis of the skin may lead to infection of the lymphatic glands nearest to the seat of the disease, and eventually to general miliary tuberculosis. Pulmonary tuberculosis often develops as a secondary complication. It occasionally happens that a lupus patch is the cause which locates the formation of a carci- noma. The tendency to local extension varies greatly. In some cases the disease may begin in early life, remain stationary for a number of years, then suddenly become very active and not confined to the skin, but attacking the deeper tissues and destroying them with the greatest rapidity, regardless of their structure. In tuberculosis of the face, the tendency is toward rapid extension; in some cases the soft tissues and the superficial bones may be completely destroyed in a few months. On the other hand, the process of repair by cicatrization follows closely upon the destruction of tissue, and extensive scars are formed, causing frightful deformitv- 340 SURGERY OF THE FACE, MOUTH, AND JAWS. The prognosis, so far as the hfe of the patient is concerned, is fav- orable so long as the disease remains local, or does not progress more rapidly than the process of repair. Regional infection of the lym- phatic glands is always considered as a menace to life, as sooner or later important internal organs are affected, or miliary tuberculosis be- comes general. A spontaneoris cure is sometimes effected. The dis- ease, however, is prone to recurrence in the scar tissue. The prognosis of tubercular ulceration of the mucous membrane of the mouth is usually favorable, except when located in the tongue. When associated with generalized tuberculosis, or cachexia, as occas- ionally happens, the prognosis is exceedingly unfavorable. The de- struction of the membrane is sometimes very extensive, and the result- ing cicatrix, by its contraction and adhesions, causes unsightly de- formity, often greatly interfering with the function of the parts. The prognosis of tubercular ulcer of the tongue is almost as bad as in carcinoma. The disease is not only fatal, but the lease of life is usually short, the end coming in a few months, or in a year or two at the longest. The pain and distress which accompany the downward course of the disease is very great, while the patient is considered as fortunate if the end is hastened by the presence of a rapidly-progressive tuberculosis of some important internal organ, which produces a fatal termination before the ulcer of the tongue becomes large and painful. Occasionally tubercular ulcers of the tongue heal, but the cure is usu- ally only a temporary affair, for sooner or later the disease returns, the second outbreak being more rapid in its course, and all efforts for its cure are unavailing. (Butlin.) Treatment.— The internal treatment of tubercular disease of the skin and the mucous membrane should be governed by the indications of the patient. There is no known remedy that has any specific action in curing the disease, or, according to Hyde, that is capable of reliev- ing the victim of his local ailment. Recent authors think the only remedy that deserves any confidence is arsenic, in the form of Fowler's solution. It is administered in doses of from three to ten drops after meals, diluted with water, beginning with the smallest dose and grad- ually increasing until the maxinnmi dose is reached or the physiologic effect is produced, and then gradually diminishing. To be of any real value its use must be continued for several weeks or months. Cod-liver oil, the tincture of chlorid of iron, the bitter tonics, com- bined with nutritious diet, out-door exercise and sea-bathing, are the most useful agents in sustaining the general health, assisting nature to limit the spread of the disease and favor the process of repair. The local treatment consists of the removal of the diseased tissue by surgical operation, under anesthetics; to be efficient it must be thorough; half-way measures are of no more real value here than they SURGICAL ti'1!i-:rculosis. 341 would be in the treatment of malignant neoplasms, for the disease is almost sure to recur unless every particle of infected tissue is removed. The use of caustics is generally of no real value, often positively harmful. Since the nature of the disease has been recognized, antiseptic agents have been recommended for local treatment. White uses the bichlorid of mercury, one to two grains to an ounce of water, applied for half an hour morning and evening on compresses kept wet with this solution, or an ointment made from the same drug, two grains to the ounce, applied continuously, and changed morning and evening. Care must be taken that salivation is not produced by absorption of the drug. He also obtained satisfactory results by the application of a 2 to 4 per cent, solution of salicylic acid in castor oil. Iodoform in the form of the powder, ointment, or emulsion in glycerol is recom- mended as one of the very best antiseptics in all forms of tubercular disease. Balsam of Peru is also of benefit as a local application. Dr. Thomas S. K. Morton, of Philadelphia, recommends ace- tanilid as an antiseptic dressing in all surgical wounds, tuberculous ulcerations, and bone-disease, either in substance or as gauze, or oint- ment (i in 8), or dissolved in alcohol or oil (as an injection). A 10 per cent, solution in water seems to answer every purpose in preventing suppuration in all surgical cases, while it seems to act better than iodo- form in the treatment of tuberculous lesions. Care must be exercised in the use of the drug in substance to prevent toxic symptoms. Antiseptic agents, however, can never become efficient means of treatment in this aflfection, for the reason that they cannot be brought into direct contact — except at the surface and for a little distance be- neath — with the bacilli and those parts in an active state of disease. In those cases in which a radical operation is declined by the patient or friends, the above treatment is the next best means at the disposal of the surgeon. Treatment by repeated exposure of the affected tissue to the in- fluence of the "Roentgen-ray" has been advocated during the last three years by certain German and Austrian physicians as a cure for this disease. Most of the work in this line has been done by Schiff and Freund, of Vienna, and by Kummell, of Hamburg. A few cases have been reported by various surgeons of Europe, and three in the United States, one by Jones, of San Francisco, one by Knox, of Cincinnati, and one by Pusey, of Chicago. The technique of the treatment ad- vocated by Schiff and Freund is that of repeated exposures to a weak light of definite strength. The light is produced by a secondary cur- rent generated in an induction coil of 30 cm. spark-length, which in turn is energized by a weak primary current of 12 volts and i^ amperes, 342 SURGERY OF THE FACE, MOUTH, AND JAWS. interrupted from 800 to looo times per minute. The exposures are continued from five to fifteen minutes, and the distance of the tube from the surface being treated, varies from 15 to 5 cm. The surround- ing surfaces should be protected by a lead mask. Care must be exer- cised not to overstep the bounds of safety either as to the strength of the current, the length of time of the exposure, or of the distance at which the tube is held from the surface. The object is to obtain by the exposure the required effects of the ray without producing injury to the tissues. Excision is the most eft'ectual form of radical treatment, but un- fortunately it cannot be performed in all cases. This operation is not admissible when the disease is upon the nose or some other prominent part of the face where the resultant deformity would be nearl}^ as unwelcome to the sufferer as the disease, nor where the disease is very extensive. When excision is practiced, the lines of incision should be made at some distance from the margins of the visible diseased area, in order that all infected tissue may be included; while great care should be ex- ercised in removing the deeper portions of the infiltration, as this may send out projections at various points, which must be extirpated in order to insure non-recurrence. If it becomes necessary to remove extensive portions of the skin, the gap may be filled by the Thiersch method of skin-grafting. Another method of radical operation is by curetting. This opera- tion consists of scraping out the diseased tissue by means of sharp spoons or curettes. Lupus tissue is much softer than the healthy skin, consequently the curette easily penetrates the former, while the latter offers sufiicient resistance to guide the operator in removing the diseased tissue. Besnier recommends the use of the galvano-cautery for removing the diseased tissue, and he has devised special cautery points for this purpose. The writer believes the most effectual plan of treatment is a com- bination of the last two methods, the bulk of the diseased tissue being first removed by the curette and then followed by the galvano-cautery. The storage battery makes it possible for every surgeon to use Bes- nier's cautery point and knives. No more successful method can be used to follow up and remove the more minute points of the disease which have been left behind by the other operations of excision and curetting. Antiseptic after-treatment is very desirable, and the patient should be kept under observation for some time after the healing of the wound. The site of the operation should be protected from injury for several months, as a precaution against the pathogenic action of re- maining latent bacilli or reinfection from the outside. SURGICAL TUBERCULOSIS. 343 The treatment of the disease located in the mucous membrane of the mouth should be upon the same general principles as when located in the integument. The curette and galvano-cautery are most appli- cable for radical treatment. Excision, if practiced early, is the most effectual treatment in tubercular ulceration of the tongue. This may be accomplished by removing a wedge-shaped piece with the knife, and stitching the sur- face together, or it may be removed with the ecraseur or the galvano- cautery. Methods of operating will be found described in the chapter which deals with carcinoma of the tongue. Recurrence, however, is the rule after operations for this disease when located in the tongue. CHAPTER XXXV. ACTINOMYCOSIS HOMINIS. Definition. — Actinomycosis (from the Greek uktIv^ a ray; iJ.vK-q<;^ a fungus). A specific, infectious, inoculable disease affecting both man and the lower animals. The disease was first observed in cattle and has been variously known as "^clyers," "lumpy jaw," and "holdfast." It is caused by a parasitic organism known as the streptothrix actino- mycotica, actinocladothrix, actinomycosis hovis, or the ray fungus, more correctly the ray bacterium. This organism causes lesions that are somewhat similar to those produced by the bacillus tuberculosis and it has therefore been classed with the infective granulomata. History. — Until a comparatively recent date very little of a definite nature has been known in reference to the cause or the pathology of the disease. The disease was undoubtedly seen by many early writers and described either as tuberculosis or cancerous growths. The first reference to the disease to be found in medical literature occurred in the Journal de Medecine Veterinaire in an article written by Leblanc (1826). This article described the disease as appearing in cattle, the most prominent symptoms being swelling and suppuration of the jaw. Prof. Dick (1833) described the disease as an affection of cattle manifested in swelling of the jaw and known as "clyers." In 1841, he called attention to the fact that the disease was known to affect human beings, the seat of the affection being in the jaw. Prof. Simmonds (1845) referred to the disease as found in the tongue, as "scirrhus tongue." Langenbeck (1845) described a case of the disease occurring in the vertebra of a young man the discharges from which contained yellow granules, as "vertebral caries with yellow grains in the pus." Duvaine (1850) mentions a case of tumor occurring in the jaw of an ox, in which there were discovered yellow grains in the pus, "which, under the microscope, had neither the characteristics of tuber- cle nor of pus." Lebert (1858) published a case of the disease occurring in man, which he had seen in the practice of Louis in 1848. In this case the patient was suffering from an abscess in the thoracic region accom- 344 ACTINOMYCOSIS IIOMINIS. 345 panied with great swellini^. Later he described very minutely the actinomvcotic granules, and speaks of special bodies found in the pus. Robin and Laboulbene ( 1853 ) called attention to the disease in a memoire upon the peculiar character of the disease, presented to the French Societe de Biologic. Rivolta (1863) spent many years in studying the disease as found in the jaws of oxen. These tumors are known in Italy as the "mal de rospo.'' In 1868 he published the results of his researches into the ac- tive causes of the disease, and announced the discovery of certain rod- shaped bodies in the pus, which he compared to the rods of the retina. These after several failures he succeeded in inoculating into other animals, and in later communications he established the identity of the disease as it appears in the horse, the dog, and several of the domes- ticated animals. Perroncito (1875) discovered sulfur-like granules in a case of osteosarcoma (supposedly) in the jaw of an ox. Bollinger (1877) published an elaborate article upon the disease as found in cattle. This was the first article published which gave a minute description of the pathology of the disease as it appeared macroscopically and microscopically. He says, in describing the dis- ease and its location: "On the lower jaw of cattle tumor-like neoplasms sometimes occur, which proceed from the alveoli of the molars or from the spongiosa of the bone, inflate the latter, corrode it, and finally, after having loosened the molars and destroyed the normal tissues which impeded their growth, break through the skin externally or into the oral or pharyngeal cavities. "The inflated bones have a pumice-stone-like appearance, caused by central osteoporosis and external hyperostosis. Most of the bulbous and conglomerated growths, which, after some length of time, often become puriform or entirely break down and lead to the formation of ulcers, abscesses, and fistulous canals, usually attain the size of a child's bead or even larger. ''Such tumors are composed of a conglomeration of soft con- sistence, pale yellowish color, and juicy luster, united by tense connec- tive tissue. On the surface of the cut we find scattered, usually cloudy, yellowish-white, abscess-like centers, or the hard cores are of spongious structure, showing numerous hempseed-sized spaces and caverns in the fibrous stroma, which contain murky, yellow, thick, often cheesy pap. The mass of the tumor is infiltrated with a puriform or cheesy substance which often shows a reticular arrangement, and may be readily obtained by scraping the surface of the cut with a knife. "The microscopical examination reveals, among other things, numerous opaque, slightly yellow, coarsely granulated or gland-like bodies of dififerent sizes, often resembling mulberries. These are here 346 SURGERY OF THE FACE, MOUTH, AND JAWS. and there incrusted with Hme, and on closer examination are found to be of a fungous nature. This mycosis occurs not only in the jaw- bones, but also in the tongue of cattle, where it leads to the formation of erosions, ulcers, and scars, or to secondary interstitial glossitis."* Bollinger submitted these yellow granules to the botanist Harz, of Munich, who discovered their parasitic nature and gave them their name Actinomycosis. Israel (1878) published the results of his observations and inves- tigations concerning two cases of the disease occurring in human beings which presented the symptoms of chronic pyemia. Abscesses appeared in great numbers upon all parts of the body, and when opened dis- charged a profuse malodorous pus, strewn with yellowish millet-seed- like granules. These granules when crushed revealed certain mor- phologic elements which were afterward recognized and proved to be the elements of the ray-fungus. Israel reported a third case in 1879. Ponfick (1879) found the same fungus in a prevertebral abscess in man, and was the first (1882) to suggest the identity of the disease as found in man and the lower animals. Johne was really the first to establish the inoculability of the dis- ease by introducing the yellow granules into an ox. Previous to this Bollinger and Rivolta had failed to reproduce the disease by inoculation. Harley (1884), of St. Thomas Hospital, London, reported the first case of actinomycosis in man that had been recognized in England. Bristow reported a case in the same year. Several specimens of "scrof- ulous disease" to be seen in St. Thomas Hospital Museum, which have been there for many years, were in 1884 studied microscopically, with the view of ascertaining their real nature, and were found to be cases of actinomycosis. James Israel (1885) in his classic article t gathered and classified all the cases on record at this time in reference to the point of entrance of the infection, which he was able to group under four general heads : I. Cases which gained an entrance through the oral and pharyn- geal cavities. (a) Central formation of foci in the mandibula. {h) Localization on the margin of the lower jaw in the sub- maxillary and sublingual regions. {c) Localization on the neck. {d) Localization on the periosteum of the upper jaw. {e) Localization in the region of the cheek. II. Cases of primary actinomycosis of the respiratory tract. III. Cases of primary actinomycosis of the intestinal tract. IV. Cases with uncertain point of entrance. *Miller's "Micro-organisms of the Mouth," 1890. tKlinische Beitrage ziir Aktinomykose des Menschen. ACTINOMYCOSIS IIOMINIS. 347 Belfield (1883) published the first paper upon the disease in America, as observed in cattle. This article briefly reviews certain cases found in cattle at the Chicago Stock-yards. In three of the cases the tumors were located in the upper jaw, a fourth was located in the lower jaw, and the fifth below the orbit. The microscopic examination showed radiating fungi. The disease, however, seems to have been recognized before this time by Osier and Clement as occurring in Canadian cattle. Law also demonstrated the nature of the disease to his classes in Cornell University, and Taylor of the Agricultural Department in Washington demonstrated it in dogs. Murphy (1885), however, was the first to demonstrate the disease as occurring in man in the United States. In a paper read before the Cook County Medical Society, Chicago, be describes the case as oc- curring in a female servant, aged twenty-eight years. The disease be- gan in a left lower tooth in the form of "toothache" accompanied with swelling of the throat and great pain in swallowing (dento-alveolar abscess in all probability). After using poultices for several days the swelling disappeared, to return a few days later. An abscess formed and was lanced, discharging a large quantity of pus. From this she rapidly recovered, but in a week another swelling formed below the angle of the jaw, in the tissues of the neck. This was the size of a walnut, and the tissues about it were indurated. There was fluctuation, but only a little pus. A drainage-tube was inserted, through which pus containing sulfur granules escaped. The mass was removed, the tooth extracted, and the site of the tumor and the cavity curetted. Primary union resulted. Ochsner and Schirmer (1886) each reported a case occurring in man. Many cases have since this time been reported in medical litera- ture, both home and foreign. Ruhrah (1899) in an elaborate article* has gathered all of the cases published in American medical literature and several unpublished cases the notes of which were furnished him by the operators, making 65 in all. The writings upon actinomycosis (as found in man and the lower animals) are now very voluminous in both European and American medical literature. Etiology. — Actinomycosis is caused by the entrance into the tis- sues of the Streptothrix actinomycotica, a cryptogam which is found upon grain, grass, straw, or seeds. The Ray-fungus or actinomyces microscopically is composed of three distinguishing morphologic ele- ments, viz : club-shaped formations ; a centrally-placed network of fungous filaments of varying shape and size, and fine coccus-like bodies. The fungous threads or filaments radiate from the center. The *Annals of Surgery, 1899. 348 SURGERY OF THE FACE, MOUTH, AND JAWS. threads are sometimes club-shaped at their extremities, but more often this feature is absent in man. The most constant and characteristic morphologic elements are the. coccus-like bodies. Sometimes one of these filaments having club-shaped extremities will extend far beyond the others, as shown in Fig. 130. The ray-fungus as it appears in man is a small globular mass, usually described as about the size of a millet-seed, commonly of a pale yellow color, though sometimes brown or green. The presence Fig. 130. The Ray-Fungus. (Actinomyces.) (After Ponfick.) of these bodies in the discharges of chronic inflammatory swellings is pathognomonic of this disease. It may gain access to any part of the body, through a wound or an abrasion. The usual locations of the in- fection are the skin, the mucous membrane of the mouth, the alimentary tract, and the respiratory apparatus. A carious tooth, an alveolar ab- scess, the open alveolus of a recently extracted tooth, an inflamed and ulcerating gum, or an abrasion of the mucous membrane, furnish the most inviting avenues of infection, for the reason that they present an open ACTINOMYCOSIS HOMINIS. 349 atrium; and are the tissues with which the organism comes most often in contact. The organism may also gain an entrance to the body through the inspired air and the drinking-water. Farmers, liostlers, threshers, and millers should therefore be cau- tioned against chewing straws or eating raw grain, as the organism is found in its primitive state growing upon these substances. Sex. — In the first fifty-six cases reported as occurring in America, 38 were males, 15 were females, and in 3 the sex was not stated. Out of 357 cases reported by Poncet and Berard 248 were males and 109 females. Leith found 295 males and 1 10 females in a total of 405 cases. Age. — There seems to be no period in life when the individual is not liable to contract the disease. In the American cases the youngest was six years of age and the eldest sixty-five. The earliest age at which the disease has been seen was in a child of one year, and the oldest in an individual of seventy-seven years of age. According to Hutyra's table, which was arranged by decades, it would seem that the disease was most prevalent in early adult life. This, however, may be ac- counted for by the fact that the exposure to the disease is greater at this period than at any other. Hutyra's figures are as follows : From five to nine, 7; ten to nineteen, 44; twenty to twenty-nine, 118; thirty to thirty-nine, 78 ; forty to forty-nine, 54 ; over fifty, 56. Race. — The liability to the disease seems to be about the same in all races. The negro presents no especial predisposition to the disease over the white race. Geographical Distribution. — The disease seems to be more prev- alent in the north and south temperate zones than in tropical climates. The disease has been found in man and among cattle in America, in nearly all of the European countries, in Australia and some of the islands, and in Algeria and Egypt. The disease is more prevalent among those living in the country, and especially more frequent in persons who are in contact with cattle and horses and who handle hay, straw, and grains. It has been stated that it was most frequent among cattle which grazed upon salt marshes that were from time to time flooded by the sea. Sources of Infection. — Authorities do not agree as to the pos- sibility of the disease being directly communicated from cattle by con- tagion. Leith denies this possibility, and Liebman has shown that the organism loses its virulence in passing through animals. The character of the organism is such that it would not be likely to be readily com- municated from one animal to another. Ochsner, however, reports two cases which point very strongly to direct infection from animals to man. The first case refers to a man who had driven for the six months previous to his illness a horse afifected with "lumpy jaw" ; while in the second case the patient was a cattle-dealer who had fre- 350 SURGERY OF THE FACE, MOUTH, AND JAWS. quently handled cattle affected with this disease, and was in the habit of treating the diseased animals by curetting the swelling and cauter- izing the cavity with arsenical paste. Murphy reports a case which was presumably acquired from a dog, and Ponfick one following the bite of a louse. Baracz has reported a case of the transmission of the disease from a man to a woman by kissing; Two other similar cases have since been reported, but these appear to be the only cases on rec- ord in which the disease has been conveyed directly from one human being to another. It has been stated that the infection might occur from flesh and milk used as food. There are, however, no authentic cases on record of the disease occurring in this manner. It is possible for the infection to result from breathing dust laden with the micro-organisms during the threshing of grain, provided an open atrium exists in some part of the respiratory tract. The disease is, however, most often transmitted by direct infection from the plant or grain, by the introduction of the sharp barbs or beards of the grain or leaves of the plant. In numerous cases the barbs of the grain have been found in the infected tissue. Johne first observed this fact when he found a barb of grain in the tonsil of a pig which died from the disease. Bostrom, however, established the relationship between the fragments of the grain and the plant, as he found the barbs of the grain imbedded in the infected tissues of eleven cases. Several other cases are on record in which the presumptive evidence is strong that the disease was contracted in this manner, as some were habitual users of straws as toothpicks or were accustomed to chewing raw grains. Location of the Disease. — The location of the disease as found in cattle, according to Poncet and Berard, who gathered the statistics of various observers, is as follows: Claus, of Bavaria; Jaw, 51 per cent.; tongue, 29 per cent. ; lung, 2 per cent. ; skin, o per cent. Mari, of Rus- sia; Jaw, 32.8 per cent.; tongue, i per cent,; lung, 5.6 per cent.; skin, 51 per cent.; submaxillary and bronchial glands, 11 per cent. Leclerc, of France; Jaw, 72 per cent.; tongue, 18 per cent.; lung, 9 per cent.; skin, o per cent. Moosbrugger (1887) published a collection of statistics, for man, of the disease in Germany which covered the reports of 73 observers, giving: Head, neck, lower jaw, mouth, and throat, 29; upper jaw and cheek, 9; tongue, i; digestive tract, esophagus, 2; intestines, ii; bronchi and lungs, 14; doubtful, 7. Leith's statistics give the anatomical distribution of 393 cases as follows: Head and neck, 207; tongue, 13; pulmonary, 52; abdomen, 88; skin, 10; doubtful, 23. Illich's figures place the number of cases in which the disease was ACTINOMYCOSIS IIOMINIS. 351 found in the head and neck as 234 in a total number of 421 cases, or 55 per cent. Sokolow found in a total number of 62 cases that the disease was located in the head and neck 33 times, or 53 per cent. Guder out of 20 cases in man found it located in the face and neck II times, or 50.5 per cent. Poncet and Berard collected the histories of 67 cases in man, and found it present in the face and neck 54 times, or 82 per cent. Rutimeyer states the disease occurs in the jaw in 50 per cent, of the cases. In 58 of the cases reported as occurring in America it was located in the lower jaw, mouth, and throat 19 times, and in the upper jaw and cheek 8 times ; total for the head and neck, 27, or 46.5 per cent. Ruhrah, who had gathered the histories of 1094 cases, reported from various sources, found that it occurred in the head and neck 604 times, or in 56 per cent, of the cases. After eliminating the cases that might have been counted twice, be found that it occurred in the head and neck 359 times, or 55 per cent. Secondary Infection. — Extension of the disease to remote parts of the body is always by the blood-current and never by the lymphatics and glands. Murphy says: Extension of the disease takes place in two ways : "First, by diffusion in loco, and second, by the entrance of the actinomyces into the blood-stream. This extension is greatest in the direction opposite to the course of the lymphatics." The organisms which gain access to the blood-stream are floated along in the current until they meet some obstruction, where they become lodged, multiply, and form secondary foci of the disease. Secondary infection of internal organs may also take place from ' primary foci of infection located in the mouth and jaws, through swallowing or inspiring the germs of the disease. An interesting case of this character has been published by Israel. The patient was a driver, twenty-three years of age, who was in the habit of sleeping upon the straw or in the haymow, and often drank out of the same trough with His horses. Israel found the ray-fungus in the secretions of the abscesses and ulcers which covered the left side of the man's breast, but was not able to discover the primary seat of the infection until after the patient's death. The autopsy revealed an actinomycotic cavern in the anterior portion of the superior lobe of the left lung ; from here it extended upon the peripheral tissue and had broken through the wall of the chest in various places. In this cavern Israel found an irregular calcareous body about the size of a No. 6 shot, which upon examination was found to consist of a small fragment of dentin, surrounded by a chalky mass composed of phosphate and carbonate of lime. Microscopic preparations from this revealed, besides the dentin, numerous threads of ray-fungus, and 352 SURGERY OF THE FACE, MOUTH, AND JAWS. there was no doubt that the fragment of dentin was the carrier of the infection. Another case of primary infection of the lung from the inspiration of the fungus has been reported by Baumgarten. In this case the infection was caused by the inspiration of the specific fungal elements which had accumulated in the left tonsil. Miller found that out of 113 cases of actinomycosis hominis, the histories of which he had carefully examined, 33 were produced by invasion of the ray-fungus through the oral and pharyngeal cavities. Incubation Period. — The disease has no definite period of incuba- tion, as the cases in which the histories were definitely known vary considerably in the periods at which the disease was developed after infection. These periods range from a few weeks to several months. The progress of the disease after infection has been established is also very slow, giving a chronic character to the disease. Pathology. — The general characteristics of the disease are those of chronic inflammation, the lesions produced by the organism being somewhat similar to those caused by the action of the bacillus tuber- culosis, and it is therefore classed with the infective granulomata. The pathogenic action of actinomyces upon the tissues is to transform mature connective tissue into embryonal or granulation tissue. The organism does not possess pyogenic functions, consequently the pres- ence of pus in actinomycosis is the result of infection with the p3^ogenic organisms. According to Ruhrah the action of the actinomyces upon the tis- sues is as follows : "The organism, having found a lodgment, grows in colonies. At first there is a poisoning of the cells in the immediate neighborhood. This leads to hyaline degeneration of the cells, then to necrosis. This area is invaded by small round mononuclear cells simi- lar to those found in tuberculosis ; later it contains epithelioid, and occasionally giant cells. This excites the growth of the fixed con- nective tissue cells, and new connective tissue forms about the place of infection ; these become indurated, and a tissue, made of bands of connective tissue, soon passes in various directions ; the intervals are filled with masses of the streptothrix, with zones of small, round, mononuclear, epithelioid and giant cells, etc. Sometimes a discharge of pus occurs near the surface, and abscesses frequently form in the deeper tissues. These processes may be found in connection with ex- tensive formations of connective tissue or not. In all cases in which the blood was examined slight leucocytosis was found." The product of inflammation formed around each fungus is shown by the microscope to be composed in the early stage of the disease of round cells ; at a later stage the cells are epithelioid in character, and often giant cells are found in the infiltration, associated with extensive connective-tissue proliferation, and but for the presence of the specific organism the growth might be mistaken for sarcoma. ACTINOMYCOSIS IIOMINIS. 353 Water or weak solutions of sodium chlorid cause the fungus to swell enormously and lose their shape ; ether and chloroform have no effect upon them. (Sarjou.) Syiiiptoiiis and Diagnosis. — Actinomycosis is an affection of an intiammatory nature, with a marked tendency to chronicity; it is, how- ever, occasionally very rapid in its progress. The affection first ap- pears as an induration or swelling with marked absence of pain or tenderness and no elevation of temperature. "The specific product, composed of granulation tissue, is abundant, and the swelling, often Fig. 131. Actinomycosis of the Neck. (lUich.) of considerable size, resembles more a tumor than an inflammatory swelling. The extension of the morbid process takes place by eft'usion of the actinomyces in loco, in preference along the loose connective- tissue spaces, each fungus constituting a nucleus for a nodule of granu- lation tissue. By confluence of many such nodules the inflammatory sw^elling often attains a very large size, and when suppuration occurs in the interior the further history is that of chronic abscess." (Senn.) Induration of the lymphatic glands in the immediate neighborhood of the diseased area indicates secondary infection, but rarely general dis- 24 354 SURGERY OF THE FACE, MOUTH, AND JAWS. semination of the affection. (Fig. 131.) Exceptionally the disease pursues a rapid course, and under such circumstances the affection may be mistaken for "an acute phlegmonous inflammation, osteomyelitis, or, when diffused over a large surface of the body, for syphilis." (Senn.) Clinically, actinomycosis closely resembles the malignant tumors, as it invades all tissues with which it conTes in contact, regardless of their anatomical structure. It spreads most rapidly in the loose con- nective tissue, but all the tissues of the body are destroyed by the action of the fungus as soon as they are invaded. Fig. 132. ACTINO.MYCOSIS OF THE ChEEK. (Illich.) In actinomycosis of the jaws, extensive destruction of bone takes place and large abscesses are formed which communicate with the primary lesion. The formation of the abscesses is due to secondary infection of the tumor with the pyogenic micro-organisms. This infec- tion with the pyogenic organisms produces an elevation of temperature ranging from 100° to 102° F. Redness of the tumor indicates the extension of the disease to the skin. Infection with the pyogenic organ- isms is usually the result of a break — perhaps of minute size — in the ACTINOMYCOSIS HOMINIS. 355 continuity of the surface of the sweHing. When suppuration is estab- lished the gn)\\th increases in size very rapidly; diffusion is hastened by the breaking" down of the granulation tissue, which permits a more rapid migration of the fungus. The diagnostic signs of actinomycosis are not well marked until the suppurative stage has been established. The discovery of the characteristic yellowish, millet-seed-like, calcareous granules is the only positive diagnostic sign of the disease. Upon the establishment of the suppurative process numerous sinuses are formed from which pus escapes in considerable quantity, and when located in the lower jaw the tissues of the floor of the mouth, of the cheek, and of the neck are often involved. (Fig. 132.) Trismus and swelling of the masseter and temporal muscles is an early symptom when the disease is located in the lower jaw. The disease in its earlier stages may be mistaken for sarcoma, carcinoma, tuberculosis, or syphilis. In the more acute form it may be mistaken for acute phlegmonous inflammation or osteomyelitis. The lesions produced by the ray-fungus are so similar in histologic structure to those of sarcoma, tuberculosis, and syphilis, that it w'ould be difficult to differentiate the disease from these affections except by the discovery of the actinomyces imbedded in the granulation tissue. Occasionally the organism cannot be detected in the granulation tissue of the tumor ; it then becomes necessary in the absence of this proof to resort to therapeutic measures to clear up the diagnosis be- tween actinomycosis and syphilis. Pi'ogjiosis. — Actinomycosis is an exceedingly grave disease and in its nature and serious character may be classed with the malignant tumors. The gravity of the disease will be in proportion to the rapidity of the suppurative process. Actinomycosis of the upper jaw is more serious than when the disease is in the lower jaw by reason of the fact that in the former there is a greater tendency to penetrate the deeper structures. Primary actinomycosis of the external tissues and other portions of the body that may be reached by the surgeon's knife are susceptible to cure. The disease, however, has no tendency to a spontaneous cure, while, when the primary affection is located in the internal organs, it almost without exception terminates fatally. In those cases which are inaccessible to surgical treatment, numerous fistulous openings are formed, from which pus is discharged in profuse quantities, and the patient dies from pyemia, sepsis, amyloid degeneration of vital organs, or exhaustion, in from one to three years. The prognosis is usually favorable in those cases which are accessible to surgical treatment and in which operative measures are instituted early in the history of the disease, and complete removal of all infected tissue is secured. Murphy gives the following statistics in reference to the prognosis 356 SURGERY OF THE FACE, MOUTH, AND JAWS. of actinomycosis. Recoveries in the external forms of the disease, 70 per cent.; recoveries in the internal forms, 18 per cent., — the average mortality of the disease being 60 per cent. Treatment. — The treatment of actinomycosis of the jaw consists of a thorough surgical removal of all infected tissue, the employment of suitable antiseptics, and drainage. As soon as the diagnosis of actin- omycosis has been established, immediate operation should be advised. The operation consists of an incision carried at least half an inch beyond the granulation tissue, the excision of the mass and thorough curetting of the surface, careful search being made in all directions for hidden foci of the disease. All suspicious tissue should be removed with the curette, the knife, and the scissors, and then cauterized with the actual cautery or chromic acid. After thorough irrigation with strong solutions of carbolic acid or mercuric chlorid, the wound should be packed with iodoform gauze and free drainage provided for. The wound should be kept open for some time, and its surface carefully inspected at each dressing for any appearance of local recurrence. Such evidences, if they appear, should be immediately removed and the surface again cauterized. On account of the difficulty often experi- enced in removing all of the infected tissue, especially in the deeper por- tions of the tumor where the bone has been involved, great care should be exercised to follow every indication of an extension of the disease in the cancellated structure of the bone. Under no circumstances should the wound be closed until the entire surface is covered with healthy-appearing granulation tissue. If the wound is too extensive to be closed by suturing, it may be permitted to fill up by granulation tissue, and the defect in the skin remedied by skin-grafting after the method of Thiersch. Billroth and Illich claim to have observed a reaction from the in- jection of Koch's tuberculin. Ponfick was unable to confirm these ob- servations. Ponfick (1898) recommended the injection of mercuric chlorid i to 500, repeated several times in those cases in which the disease is not well marked. Thomassen (1885-6) recommended the administration of potas- sium iodid to animals and found it always sufficient. Rydygier (1895) treated two cases successfully by parenchym- atous injection of a one per cent, solution of potassium iodid. Vallas (1897) insisted that the injection of potassium iodid in man had but little effect, and that mercuric chlorid showed the best results. Camus (1899) says: "The iodin treatment alone often succeeds with animals ; in man it should be supplemented by surgical interven- tion (incisions, curetting, and cauterization)." Ochsner (1899) says: "In all cases where the infected tissue was ACTINOMYCOSIS HOMINIS. 357 not in large masses, the patients recovered 1)y exactly the same treat- ment as that given to animals, viz, potassium iodid." He prescribed a dram of the drug three times per day for as many days as the pa- tient could endure it ; then withdrew the drug and repeated it again until the patient was well. Sawyers (1901) strongly recommends the administration inter- nally of potassium iodid and of parenchymatous injections of one per cent, solution of the drug, 15 minims to each dose. In the administration of potassium iodid the consensus of opinion is that the drug should be given in large doses, and for a sufficient period to produce decided iodism. CHAPTER XXXVI. DISEASES OF THE MAXILLARY SINUS. The Maxillary Sinus, or Antntvi of Highmore, is a cavity in the body of the superior maxillary bone, somewhat pyramidal in form, hav- ing its base at the nasal fossa, and its apex directed toward the maxil- FiG. 133. Left Superior Maxillary Bone, exhibiting the Communications between Antrum and Nasal Cavity. (After Zuckerkandl.) . O, orbital cavity ; H, maxillary cavity of antrum of Highmore; M , slit-like opening ostium max- illare ; A, accessory opening between antrum and nasal cavity. lary tuberosity. (Fig. 133.) It communicates with the nasal cavity by an irregular opening in the external wall of the middle meatus. Through this opening the mucous membrane of the nasal cavity, the Schneiderian membrane, passes to line the sinus. 358 DISEASES OF THE MAXILLARY SINUS. 359 The maxillary sinus has five walls; an internal, which is the lateral wall of the nasal cavity and forms the base of the pyramid (Fio^. 134) ; an antero-external, which is the antero-external portion of the body of the superior maxillary bone; a superior, which is the floor of the orbit; a posterior, which is that portion of the superior maxillary bone that articulates with the pterygoid process of the sphenoid bone; and an inferior, which is that part of the superior maxillary bone from which arises the alveolar process. The thinnest and most inferior, or de- pendent portion of this wall, is opposite the alveoli of the second molar tooth. The floor of the antrum has generally an uneven surface, the eminences corresponding to the roots of the teeth. Occasionally the roots of the first and second molars penetrate the floor of the sinus. Fig. 134. Inferior Surface of the Right Superior Maxillary Bone. P, palate process ; S, anterior nasal spine ; M, lower meatus of nasal cavity ; L, lachrymal groove ; A, antrum of Highmore. Bony septa are frequently found crossing the floor from side to side. The septa rarely extend higher than one-fourth to one-third of the dis- tance from the floor to the roof of the sinus. The sinus has a capacity of from two drachms to one ounce, or even more. The other accessory cavities which open into the nasal passages are the frontal and sphenoidal sinuses. The frontal sinuses are two irregular cavities situated between the plates of the frontal bone, on either side of the median line. They are not present in childhood, but are fully developed in adult life. They communicate with the nares by a rounded canal, which opens into the middle meatus, and is called the infundibulum. The accompanying Roentgen-ray picture (Fig. 135), female head, shows the outlines of the frontal and maxillary sinuses and 36o SURGERY OF THE FACE, MOUTH, AND JAWS. the orbits. Cryer has shown, in a paper read before the American Dental Association in 1895, illustrated by the stereopticon and pub- lished in the Dental Cosmos for January, 1896, that the infundibulum often discharges directly into the antrum, and in others so near to the ostium maxillare that it might discharge into it. This was a new dis- covery, and goes far toward an explanation of the difficulties often Fig. 135. Female Head, showing Sinuses. encountered in the treatment of antral inflammation. In describing this newly-discovered relationship and in explanation of Figs. 136 and 137, he says this ''is a sagittal section made near the inner wall of the orbit. The frontal sinus is seen at the top, and below this is the inner wall of the orbit, os planum of the ethmoid, including the edge of the inner portion of the floor, below which is the internal wall of the max- illary sinus. ... To locate the opening and the direction in which DISEASES OF THE MAXILLARY SINUS. 361 the excess of fluid would pass from the sinus, a wire has been passed backward into the hiatus semikmaris. A perpendicular probe passes through the upper portion of the opening of the sinus, which in this case is partly in its roof or at the angle of the internal wall and the roof; as the straight probe passes out of the antrum, it passes through the infundibulum into the frontal sinus, showing- that fluids could pass directly downward from the frontal into the maxillary sinus." These specimens also show "where the anterior ethmoidal cells open just at Fig. 136. Probe passing: frontal sinii<;. Superior maxilla. Probe passing irontal sinus. (After Cryer.) the maxillary sinus. If the hiatus semilunaris should be closed by pressure of the septum or inflammation of the mucous membrane, the fluids from the frontal and ethmoidal cells would pass into the antrum." Fillebrown, in a paper read before the American Dental Association in 1896, and published in the Dental Cosmos for November, 1896, states it as his opinion that in certain obstinate chronic cases of empyema of the antrum, the frontal sinuses are also affected, and that the inflamma- tory secretions from these sinuses drain into the antra, and thus keep up the inflammator}' conditions of the latter sinuses. But inasmuch 362 SURGERY OF THE FACE, MOUTH, AND JAWS, as such a supposition was contrary to the accepted opinion upon the subject, and also not in accord with the generally accepted teaching as to the anatomical relations of the parts, he instituted a line of investi- gation in order to demonstrate the correctness or the possible error as to the relations of the infundibulum and the point at which it discharged its secretion. The text-books 'on anatomy state that the Fig. 137. 4 ,'■■■ i..1^"\^ Infundibulum t Opening max- illary sinus. Superior Maxilla. (After Cryer.) infundibulum terminates in the middle meatus of the nose, but Fille- brown's investigations do not bear out the correctness of this state- ment, for he has found in eight subjects, taken at random, that in every one the frontal sinuses communicated directly with the antra, thus cor- roborating the investigations of Cryer. He says, "The infundibulum, instead of terminating directly in the middle meatus, continues as a half-tube, this half-tube terminating directly in the foramen of the maxillary sinus. In seven of the specimens there was a fold of mucous DLSKASKS OF TllK MAXILLARY SINUS. 363 membrane which served as a continuation of the unciform process and reached upward, covering the foramen and forming a pocket which ef- fectually prevented any secretion from the frontal sinus getting into the meatus until the antrum and pocket were full to overflowing." Dr. Fillebrown further thinks that this pocket cannot be an an- omaly, as thought by some other observers, it being found in seven out of eight subjects, but that its absence might be considered anomalous, Fig. 138. Middle turbinate cut away. Infundibulum. (After Fillebrown.) rather than the usual type. Figs. 138, 139, and 140 illustrate the points made by the author of the paper. The sphenoidal sinuses are tw^o cavities hollowed out in the body of the sphenoid bone, and are separated from each other upon the median line by a thin lamella of bone. These sinuses are also lined with mucous membrane. Diseases of the maxillary sinus are quite common, much more so than is generally supposed. These diseases are more common among the lower classes of society, especially those who give no attention to 364 SURGERY OF THE FACE, MOUTH, AND JAWS. the care of their teeth. Abundant proof of this statement can be found in any of the surgical cHnics in the free dispensaries and hospitals of our large cities. Climatic influences are important factors also in the production of certain forms of antral disease. Mucous engorgements, and empyema, are much more prevalent in damp and changeable climates, where catarrhal conditions abound, than in dry or equable climates. Fig. 139. Frontal sinus Infundibulum Antrum. (After Fillebrown.) The diseased conditions most commonly found afifecting the max- illary sinus are : I St. Suppurative inflammation, or purulent empyema. 2d. Mucous engorgements. 3d. Syphilitic ulceration. 4th. Necrosis of the bony walls. 5th. Tumors. Suppurative Inflammation of the Maxillary Sinus. — Suppura- tive inflammation of the antrum is the most common of all diseases DISEASES OF THE MAXILLARY SIXUS. 365 affecting- this sinus. It is not an idiopathic affection. It may be acute, subacute, or chronic. In the acute form there is rarely any difficulty in making a correct diagnosis, but in the chronic very great difficulty is sometimes encountered, owing to the fact that the symp- toms are rarely well marked, and so closely simulate chronic nasal catarrh as to be easily mistaken for that affection. The disease may be unilateral or bilateral. It is extremely rare that both antra are Fig. 140. Frontal sinus. Superior turbinate. Pocket. Middle turbinate. Inferior turbinate. After Fillebrown.) found affected at the same time. Two cases only of bilateral disease have ever come under the personal observation of the writer. The first was a German woman about forty years of age, who presented herself at the clinic of the Post-Graduate Medical School of Chicago. Both antra were engorged with purulent secretions, the face much swollen in the infraorbital region, the left somewhat more than the right; parchment-like crepitation was present over both antra, and bulging of the palate process upon both sides. There was consider- 366 SURGERY OF THE FACE, MOUTH, AND JAWS. able protrusion of the left eye, but this condition was not so marked in the right; she complained of impaired vision. The superior teeth were all decayed to the gums. This case was due to the infection of the antra with pus from several alveolar abscesses upon both sides of the jaw. The second was a recent case, in the person of a professional friend, in which the disease followed an attack of la grippe, producing a mucous engorgement of both antra, and loss of the voice as a compli- cation. This at least was the opinion of the patient, and it proved to be correct, for immediately after draining the antra the laryngeal symp- toms began to improve. This case made a quick recovery. Etiology. — The causes of suppurative inflammation of the maxil- lary sinus generally arise from one of the following local conditions: Diseases of the teeth, Presence of foreign bodies in the sinus, Traumatic injuries. Catarrhal affections. The diseases of the teeth which may give rise to suppurative in- flammation of the antrum are often of a more or less obscure nature, frequently requiring considerable skill in special diagnosis to arrive at a correct solution of the difficulties presented in certain cases. It is therefore no wonder that the general practitioner of medicine or of dentistry should sometimes fail to make a correct diagnosis. The lesions of the teeth which may be classed as active causes in the production of suppurative inflammation of this sinus are, — (a) Devitalized pulps. (b) Alveolar abscesses. (c) Malposed teeth. Devitalized Pulps. — A devitalized pulp in the root of a tooth which penetrates the floor of the antrum may give rise to a septic inflamma- tion of the lining membrane of this cavity from the escape of the lique- fied and putrescent pulp-tissue and mephitic gases, without giving the least evidence of the real cause of the trouble other than a slight discol- oration of the tooth. Cases of this character are by no means uncommon, while the obscurity of the cause of the difficulty makes it doubly interesting from the diagnostic point of view. Cases of this obscure nature have fre- quently come under the observation of the writer, which had been ex- amined by some of the very best general practitioners, without finding the cause. The difficulty in the diagnosis is greatly augmented if there are several devitalized teeth and roots in the afifected side of the jaw. The location of the offending tooth then becomes a matter of conjecture, and there is no certainty of making a cure except by the ex- traction of all teeth which have lost their vitality, that may be associ- ated with the diseased antrum. DISEASES OF THE MAXILLARY SINUS. 367 Sometimes the offending tooth will be of such good color as to appear to the eye like a living tooth, and thereby be overlooked. There are three methods of diagnosing pulpless or devitalized teeth : one is to reduce the temperature by the application of a piece of ice. If the tooth be vital, the great change in temperature will cause pain; or the temperature may be reduced by throwing upon the suspected tooth a spray of ether. A second is to illuminate the mouth with the electric lamp, the patient being seated in a dark room. The living teeth will transmit the light very readily, the devitalized teeth will not, the differ- ence in the translucency being very marked. A third is to apply the Faradic current. The devitalized teeth will give no response, while the living teeth will be very sensitive to the shock. This latter method has been used by the writer for many years, and experience teaches that it is the most reliable, as he has never failed to make a correct diagnosis by this method. Alveolar Abscesses. — Devitalized pulps, under ordinary circum- stances, if not interfered with surgically, usually result, sooner or later, in the development of alveolar abscesses. A devitalized pulp in the roots of a superior bicuspid or molar, which results in the formation of an alveolar abscess, may on account of the thinness of the floor of the antrum at these locations point into the sinus, and thus establish a suppurative inflammation. An alveolar abscess which discharges into the antrum of Highmore is the most common factor in the production of suppurative conditions of this sinus. The association between the alveolar abscess and the inflammatory conditions of the sinus is sometimes quite obscure. The patient will frequently give a history of an abscessed tooth which was troublesome for a week or ten days, and then the symptoms subsided. Later, whenever a cold is taken, the tooth is a little tender. Some- times there is a bad-smelling discharge from the nose as the only symp- tom. Another case will present all of the characteristic symptoms of the disease, and the offending tooth will be readily recognized. Devitalized pulps and alveolar abscesses cause suppurative inflam- mation of the antrum by septic infection, and often produce marked symptoms during the acute stage of general septic intoxication. When the latter condition is present, it calls for speedy and heroic treatment, Malposed Teeth. — Malposed teeth are often found in locations where it is impossible for them to take their normal position in the alveolar arch ; in fact, they are found in almost every conceivable posi- tion, and with every line of inclination. Occasionally they are found lying near the floor of the antrum, in a longitudinal direction, or even with an upward inclination. Fig. 141 is from a cast showing the mal- position of the superior cuspids, which were lying close to the floor of the antrum. Fig. 142 indicates the relative position which they occu- 368 SURGERY OF THE FACE, MOUTH, AND JAWS. pied to each other. More rarely they have been found completely inverted. Under these conditions a suppurative inflammation may be established as a direct cause of the irritation produced by the effort on the part of nature to complete the development of the tooth, and Fig. 141. Malposition of the Cuspid Teeth in Woman Forty-five Years of Age. Fig. 142. Positions occupied by the Cuspid Teeth in the Jaw. force it from its bony crypt. As the pus increases in quantity, the surrounding bony walls grow thinner and eventually give way upon the side offering the least resistance. When this side of least resist- ance happens to be the floor of the antrum, the pus is discharged DISEASES OF THE MAXILLARY SINUS. 369 into this sinus, establishing an inflammatory condition of its lining mucous membrane, which may go on indefinitely if not relieved by surgical treatment. Tyler reports (Southern California Practitioner, June, 1899) a case in which a malposed tooth was found located in the nasal septum, the root inclining downward but not penetrating the roof of the mouth. It extended horizontally, directly across the nasal cavity, with its crown imbedded in the inferior turbinated bone. A remarkable case of this character, occurring in the family of a professional acquaintance, and coming under the knowledge of the writer, is of interest in this direction. Mrs. G., mother of the doctor, had for sixteen years been troubled with an offensive discharge from the left nostril. Prior to this she had suffered intensely from pain and swelling in the region of the left antrum, which lasted for several weeks, and then subsided. This condition was accompanied by a pro- fuse discharge of offensive secretions from the left nostril. Later the swelling disappeared, but the discharge never wdiolly ceased. Six years after the first attack, the face again became very painful and much swollen, this time extending farther backward toward the ear, finally developing what was thought to be abscess of the middle ear. Large quantities of pus were discharged from the ear, and at one time it was feared that the suppurative process would extend to the menin- ges of the brain. After several weeks of intense suffering the symp- toms again subsided, and finally the discharge entirely ceased from the ear. After this, however, the discharge from the nose seemed to be increased, and the symptoms were always aggravated by taking cold. The teeth of the left side of the upper jaw had all been extracted as a possible cause of the trouble, except the third molar, which had never erupted. This procedure, however, produced no abatement of the symptoms. Later, the teeth of the opposite side were removed for the purpose of inserting a complete upper artificial denture. About ten years after the last-mentioned attack, while leaning over a washbowl, "brushing her teeth, she suddenly noticed that the left nostril was plugged up with some movable body. On throwing the head back, in an attempt to dislodge it, the mass fell into the fauces, and was ejected from the mouth into the bowd. Upon examination, it proved to be a well-developed left superior third molar, more or less covered with hard concretions of a dark brown color. The discharge from the nose from this time on gradually grew kss, and finally, after a few months, ceased altogether. The probable explanation of the peculiar features of this case are, briefly: First, the third molar was developed in an inverted position, and very near to the floor of the antrum ; second, suppurati-ve inflam- mation was established in the crypt of the tooth-germ from irritation 25 370 SURGERY OF THE FACE, MOUTH, AND JAWS. induced by its development in an abnormal position; third, the pus- cavity ruptured into the antrum; fourth, the abscess which ruptured into the middle ear may have been caused by the tooth, though there is some doubt as to this, as the anatomy of the parts would not favor such a supposition. The tooth probably became dislodged at this time, and escaped into the antrum; fifth, at a later period it must have be- come lodged against the nasal wall of the antrum, causing ulceration, which finally permitted it to pass into the nasal cavity, and thus be expelled. Foreign Bodies. — Foreign bodies of various materials are occa- sionally met with in the antrum as a cause of disease. Those most com- monly found are the roots of teeth which have slipped from the forceps and escaped into the sinus through an enlarged alveolus in attempting to extract them; malposed teeth which have erupted into it, or have found entrance through pathologic conditions; fragments of bone or of teeth which have been forced into it by some crushing injury of the walls of the antrum; portions of lead or other metal which have lodged there as a result of gunshot injuries; and pai tides of food which have found entrance through some artificial opening that has been made for the treatment of a pre-existing diseased condition. The presence of any foreign substance is usually productive of inflammatory conditions of the lining mucous membrane, resulting in subacute or chronic inflammation, with purulent discharge, or of en- gorgement and protrusion of the walls, with possibly graver conse- quences. When there is no positive history of the entrance of such foreign bodies, the diagnosis sometimes becomes exceedingly difficult, and can only be reached by a critical examination of every feature and symptom of the disease, one by one excluding those causes which do not give a marked history, then from the remaining possible etiologic factors, by a still closer analysis and exclusion, arrive at a correct diag- nosis. The diagnosis being assured, operative measures are necessary. These measures comprehend the making of an opening into the an- trum, the search for the foreign body, and its removal. The selection of the point at which to open the antrum should be governed by the surrounding conditions. The unnecessary sacrifice of sound teeth in order to gain easy access to it does not com.mend itself to a wise conservatism. In the extraction of teeth for this pur- pose those should be selected which from their condition and location are of the least value to the individual, provided only that they are in close relation to the floor of the antrum. If a bicuspid or a molar has already been lost, it is preferable to enter the antrum from this point rather than sacrifice remaining sound teeth. DISKASKS OF THE MAXILLARY SINUS. 37I Traumatic Injuries. — Traumatic injuries involving the maxillarv sinus are of rare occurrence, and are the result, generally, of gunshot wounds or crushing injuries of the face, causing fracture and comminu- tion of the superior maxillary bones. Cases of this character almost invariably terminate in suppurative inflammation, — at least this has been the observation of the writer. This is explained by the fact that such injuries always produce compound fractures of the bone, and when associated with the oral cavity are always infected from the secre- tions and alimentary debris, consequently septic inflammation is prone to follow, as is the case with compound fractures of the lower jaw which communicate Avith the mouth. Disease of this character is much more amenable to treatment, as a rule, than are those conditions which result from disease of the teeth, for the reason that in the first the inflammation is generallv of acute type, while in the latter it is usually subacute or chronic; the character of the infection may also be a modifying factor. Catarrhal Affections.— Catarrhal aiTections of the nasal mucous membrane often result in the extension of these conditions to the frontal, sphenoidal, and maxillary sinuses. The mucous membrane lining the accessory cavities is a reflection of the membrane which lines the nasal passages; consequently the inflammatory conditions which affect the mucous tissue of these passages are quite likely to extend to the accessory cavities which open into them through the continuity and functional identity of their lining membrane. Mucous Engorgements. — Among the most common of the catar- rhal inflammations of the nasal passages which may extend to the ac- cessory sinuses and produce mucous engorgements are acute and chronic coryza, and la grippe or influenza. Mucous engorgements, in the opinion of the writer, are much more likely to follow acute catarrhal inflammations than the chronic form. Acute coryza, or cold in the head, is usually the result of exposure to cold, though it is occasionally due to the irritating effects of acrid vapors, or other irritating substances. It also occurs at the com- mencement of certain of the eruptive fevers, as measles, scarlet fever, etc., and in rare cases, the breathing of the vapor of iodin, or of particles of ipecacuanha in those possessing peculiar idiosyncrasies will bring on an attack. The onset of an attack of acute coryza is ushered in by varying degrees of chill, from a slight chilly sensation to a pronounced rigor, a feeling of lassitude and general malaise, followed by a slight increase in body temperature, with myalgia and loss of appetite. The mucous membrane of the nasal passages becomes congested, accompanied by a sense of burning and prickling, with a feeling of dryness and heat. 372 SURGERY OF THE FACE, MOUTH, AND JAWS. This may last for a few hours, or even a couple of days, when a watery, acrid discharge sets in, gradually changing in the course of a few days to a thick yellow mucus, more or less copious in amount, and finally to a free discharge of a purulent character. The duration of the attack may be from three or four days to two or three weeks. These symptoms are the result first of congestion of the mucous membrane and the arrest of the secretions producing the characteristic dryness. This is followed by a free transudation of the liquor san- guinis from the engorged blood-vessels, causing swelling of the mem- brane, and supplying the main portion of the earliest secretion, which is of a serous character. Later, the glandular structures are stim- ulated to an abnormal activity, and a profuse discharge is established, consisting of mucus, epithelial cells, and leucocytes, with a slight ad- mixture of red blood-corpuscles. As the disease progresses, the em- bryonic cells increase in numbers, and the secretion assumes a purulent character. When the nasal mucous membrane is alone affected, the discomfort is referable to the nose only, and consists of an increased secretion, sense of fullness, or complete occlusion, due to swelling of the membrane, and repeated and distressing attacks of sneezing. If the disease extends to the frontal sinuses there is often, as a marked symptom, a severe frontal headache; when the antrum of Highmore is involved, there is usually a more or less severe neuralgia, referred to the infraorbital or malar region. If the inflammatory symptoms are severe, causing considerable swelling and thickening of the mucous membrane, it is likely to result in the closure of the openings into the nasal passages of the accessory sinuses, and consequent retention of the secretions, followed by the symptoms described under the head of suppurative inflammation of the antrum. La grippe is frequently manifested in an acute inflammation of the mucous membrane of the nasal passages, which often extends to the accessory sinuses, leading to mucous engorgement and other more serious involvement, especially of the antrum of Highmore. It was the experience of the writer in the last epidemic of la grippe in Chicago, during the winter of 1891-92, to treat a larger proportion of cases of engorgement of the maxillary sinuses as a direct result of attacks of this disease which were principally confined to the upper air- passages, than from any other or all other causes combined. The prognosis in these cases, as in those arising from acute coryza, is much better than when the cause is some chronic inflamma- tory condition of the mucous membrane. Chronic coryza is the result of repeated attacks of the acute dis- ease, or it may occasionally be of a chronic type from the beginning. The most prominent symptom is an increased secretion of mucus, or of muco-pus, which is discharged through the nose, or through the DISEASES OF THE MAXILLARY SINUS. 373 pharynx into the mouth. The discharge is semi-fluid, having some- what of a purulent character, on account of the copious admixture of embryonic cells and of epithelial scales with the mucus. There is no marked thickening- of the mucous membrane, and its surface is at all times soft and moist. Its color is abnormal, showing a reddened, con- gested appearance, sometimes turgid or purplish. The disease is aggravated by changes in the weather, and is more prominent in the chilly spring and autumn days. Such conditions, when affecting the antrum, rarely cause stenosis of the nasal opening, consequently the discharges escape from time to time into the nose, when the body assumes a favorable position for the drainage of the cavity. The secretions, as a rule, however, are not discharged with sufficient free- dom to prevent their decomposition and consequent fetid odor, though sufficiently so to prevent the sense of fullness or the expansion of the antrum, so common in those cases having retained secretions. CHAPTER XXXVII. DISEASES OF THE MAXILLARY SINUS (Continued). Suppuration of the Antrum of Highmore. Symptoms. — The symptoms of suppuration of the antrum are pain, which is at first dull and deep-seated, later becoming more in- tense, shooting over the face and forehead, sometimes including the ear. Occasionally the pain is very acute, and of a sharp, stabbing character. The cheek becomes swollen and tender; the walls of the antrum are thinned, and later give forth, under pressure, a crackling sound, like that of crushing an egg-shell, or of crumpling parchment. Frequently there is protrusion of the eyeball, sometimes accompanied by amaurosis. This feature is due to the thinning of the floor of the orbit, or roof of the antrum, and protrusion into the orbital cavity, which forces the eyeball outw^ard, and causes paralysis of the optic nerve from pressure upon it. In acute cases, the formation of pus is ushered in with a rigor, followed by elevation of temperature and gen- eral systemic disturbance. In the subacute and chronic forms, the constitutional symptoms may be entirely absent. Generally there is an offensive, purulent discharge from the nostril of the affected side; this symptom, however, may not be present, on account of the closure of the normal opening into the nasal passages, the ostium maxillare, from induration of the lining mucous membrane. In the latter condi- tion the protrusion of the antral walls is usually much greater, and the suffering induced by the pressure of the pent-up inflammatory pro- ducts is often very sev^ere. Sooner or later the walls of the antrum are absorbed, the soft tissues are penetrated, and the fluid escapes. The location at which the rupture of the wall takes place is generally that point which offers the least resistance. This varies greatly in different individuals. The most common locations are the nasal wall, the palate process, and the infraorbital plate, or roof of the antrum. Occasion- ally the buccal wall will give way, or the fluid may follow the root of a tooth which penetrates the floor of the antrum, and discharges into the mouth; more rarely it may burrow backward, after having penetrated the floor of the orbit, and enter the brain through the sphenoidal fissure or the optic foramen. Rupture of the walls of the antrum usually 374 DISEASES OF TllK MAXILLAKV SINUS. 375 causes considerable ulceration and necrosis, which may involve the en- tire maxillary bone. If the discharges enter the cranial cavity, epilep- tiform convulsions are likely to be induced, with other brain-symptoms, closelv followed by a fatal termination. In those cases in which the discharges escape into the nose, the breath is exceedingly offensive, having the odor of a rotten egg, which is due to the presence of hydrogen sulfid gas, liberated by the de- composition of the albuminates contained in the discharges. Blow- ing the nose will sometimes relieve the sense of fullness by causing a flow of the discharges. The more common course is for the discharge to be quite constant, the amount varying from a slight quantity to a considerable amount, and flowing into the nose and- throat when lying upon the unaffected side. During sleep the discharges are often swal- lowed, producing nausea and sometimes vomiting on rising in the morning. The movements of mastication may also cause a discharge of the pent-up secretions while taking food, and thereby induce nausea and vomiting. A case of this character came under the care of the writer some years ago, and the gentleman related that he had not taken a meal with his family, for this reason, and on account of the fetid odor of his breath, for more than six years. The teeth of the affected side are often sore and painful to percus- sion, even though they may not be factors in the production of the disease This is a point that should be borne in mind when conduct- ing an examination in a case of this character. When the disease is due to lesions of the teeth, the affected ones are usually more sensitive and painful to the percussion test than are those adjacent to them; yet in exceptional cases the most careful examination may fail to detect a special tenderness in any of the teeth. Biagnosis.— The diagnostic signs are, the location and the char- acter of the pain, unilateral discharge from the nose (except where both antra are affected, when it would be in all probability bilateral), swell- ing of the face, bulging of the diseased side of the vault of the mouth tenderness of the affected side of the face, crepitation over the thinned walls of the antrum, frequently the presence of diseased teeth, soreness of the teeth to percussion, protrusion of the eyeball, fetor of the breath, nausea or vomiting on rising in the morning. These conditions are not always well marked in every case, but a sufficient number will be present in a majority of them to establish a diagnosis. Differential Diagnosis.— The diseases of the maxillary sinus which mav be confounded with abscess or suppuration of this sinus are angiomata, malignant neoplasms, and bony tumors. Tumors of the antrum can be verv positively diagnosed from suppuration and mucous 376 SURGERY OF THE FACE, MOUTH, AND JAWS. engorgements by means of the electric mouth-lamp or stomatoscope. The patient being seated in a dark room, the lamp is placed in the mouth, and the lips closed over it, when, if the tissues are in a normal condition, the light will be quite readily transmitted through the cheeks and lower eyelids. If the antrum is filled with fluid, like pus or heavy mucus, the light is somewhat impeded, while if it be filled with a solid tumor it is entirely obstructed. An exploratory puncture or incision with the exploring needle or small scalpel will often immediately clear up the diagnosis. Prognosis. — The prognosis is usually favorable, except in those cases in which the discharges have burrowed into the cranial cavity. In a majority of cases a cure is effected by slow degrees, sometimes requiring months, and even one or two years, to accomplish it. The general condition of the patient is an important factor in the prognosis. A tubercular or scrofulous diathesis, or a generally debilitated condi- tion, militates against a rapid cure. In persons of otherwise good health a cure is sometimes effected in a few weeks; the majority, how- ever, extend over a much longer period. Treatment. — For the successful treatment of suppuration or ab- scess of the maxillary sinus, three conditions must always be secured, viz: First, the removal of the exciting cause; second, the complete evacuation of the contents of the sinus; and, third, the establishment of perfect drainage. Failure to secure these conditions is among the principal reasons why the treatment of this disease is many times so unsatisfactory. In order to secure these conditions the sinus should be opened at its most dependent point, which is at the floor of the cavity opposite the alve- olus of the second molar tooth, and if bony septa are present, these should be broken down with the curette or surgical bur. The simplest way of entering the antrum is by extracting the first or second molar tooth, and enlarging and deepening the alveolus of the anterior buccal root. This alveolus is selected because it carries a larger root than the posterior one, hence is more available for this purpose. If these teeth are sound, it is preferable to make an opening between the posterior buccal root of the first molar and the anterior root of the second, as suggested by Heath, rather than to needlessly sacrifice sound teeth. On the other hand, all diseased teeth and roots upon the affected side should be extracted at once, as they are more than likely to be the pri- mary cause of the disease; and if they should not be directly respon- sible, they are usually a source of irritation, and may therefore become a secondary cause of the lesion. In opening the antrum, the ordinary trocar fitted with a canula is a very satisfactory instrument if properly handled. There is danger, however, when the bone is thick and hard, requiring a considerable DISEASES OF THE MAXILLARY SINUS. 377 amount of pressure to penetrate it, that it may suddenly break through, and the point of the trocar penetrate the floor of the orbit. This acci- dent may be guarded against by so holding the instrument that it can only penetrate to the desired depth, or an adjustable metal guard can be placed upon the instrument, which will effectually prevent its going beyond the depth to which it is desired to penetrate. The trocar, Fig. 143. was devised by the writer expressly for this purpose. The guard is fitted into the handle by means of a screw, which makes it possible to penetrate the antrum to any desired depth, while the handle is fitted with a device operated by the thumb which carries the canula forward to the tip of the trocar, and allows the trocar to be withdrawn, leaving the canula in position. The most satisfactory method of opening the antrum is by the use of a spear-pointed drill, revolved by the surgical engine. With this instrument the surgeon can feel his way through the bone so delicately Fig. 143. Author's Antrum Trucar with Guard. (Reduced.) and surely that he can tell when the drill is about to enter the cavity, and even when it pierces the mucous membrane, so that by this method accidents are reduced to the minimum. In order to secure free dis- charge, the drill should leave an opening at least one-fourth of an inch in diameter. This is about as large an opening as can be secured be- tween the roots of the first and second molars without injuring the roots of these teeth; but when the opening is made through the alve- olus there is no reason why it may not with advantage be made larger. When the probe reveals the presence of bony septa, it becomes neces- sary to make the opening somewhat larger. Under such circum- stances, the septum of bone between the anterior and posterior buccal alveoli can be cut through with a long side-cutting bur, which is an enlargement in shape of the dentist's fissure bur. (See Fig. 125.) This will give entrance to a small spoon curette, or the round surgical bur, with which to break down the bony septa. An opening which is made through the external wall of the an- trum between the roots of the first and second molars is preferable to one made through the alveolus of a tooth, for the reason that in the former case the cheek, falling over the opening made through the ex- ternal wall, is a protection against the entrance of food,' while in the latter, unless it is kept plugged, foreign substances constantly enter, which, acting as irritants, tend to keep up the inflammatory symptoms. 378 SURGERY OF THE FACE, MOUTH, AND JAWS. Plugs and drainage-tubes are a source of great annoyance and inconvenience to the patient, and, in the opinion of the writer, are many times a source of irritation, thus retarding the progress of the cure. When the opening is through the alveolus of a tooth, plugs or tubes with stoppers are necessary to prevent the ingress of food; at the same time they prevent the free discharge of the secretions. This condition, in relation to an abscess in any other location of the body, would not be tolerated by an enlightened surgeon for a moment, as it would defeat the very object for which drainage was established. The preference, therefore, should be given, when circumstances will permit, to that operation for opening the antrum which will not require the use of plugs or tubes in the after-treatment. When a drainage- tube is employed, no better form can be chosen than that suggested by Talbot, Fig. 144. Fig. 144. Talbot's Antru.m Tube. (After Talbot.) Some surgeons prefer the method of opening the antrum through the nose, as near to the natural entrance as possible, one purpose of which is to render it impossible for infection to occur through the mouth, as is feared if an opening is made into the antrum through this cavity. This method seems to be open to several important objec- tions, on account of the difficulties in the way if it becomes neces- sary to break down bony septa, or to curette the surfaces of the sinus. This method, however, has its advantages in the treatment of mucous engorgements, for all that is necessary in these cases is to re-estab- lish the discharge of the secretions into the nose; but in those more serious conditions, like abscess of the antrum, from various causes,, entrance through the mouth is to be preferred, because an opening can be made as large as the circumstances require, — large enough to admit the index finger, or larger, as sometimes becomes necessary, especially where septa are to be broken down, or search made for foreign bodies niSITASliS OF THE MAXILLARY SINUS. 379 or malposed teeth. Under- circumstances like these, the tactile sensa- tion of the finger is a much surer guide to a correct understanding of existing conditions than a probe or a sound, which are the only means of detecting these conditions when entering the antrum through the nose. General anesthetics are frequently necessary in operations for opening the antrum, especially in those cases requiring the extraction of teeth, the cutting of bone to any considerable extent, or curetting the mucous membrane. In those cases requiring only the puncture of a thin wall of bone, the local application ,of cocain by hypodermic injection will answer a good purpose. The writer has made several quite extensive operations upon the floor of the antrum with no other anesthetic than cocain; yet he feels safer with ether or chloroform than with cocain, and therefore does not recommend its use when re- peated injections would be necessary to maintain the condition of local insensibility, for fear of establishing the toxic symptoms of the drug. Solutions of cocain of a greater strength than 2 to 4 per cent, are never required in these operations. After an opening has been made into the antrum, it should be thoroughly irrigated with some bland, non-irritating antiseptic solution. The writer prefers the Thiersch solution, or the boric acid solution. Irrigation should be continued until the fluid runs clear. The ordi- nary irrigating bag, with rubber tubing and a glass nozzle, is preferable to any of the syringes recommended for this purpose. Solutions of bichlorid of mercury and carbolic acid have certain disadvantages which should cause them to be discarded in all diseases of the mucous membrane. The bichlorid of mercury solutions are more or less irritating to all mucous surfaces, if of a strength sufficient to be of real value as a germicide, and have the added disadvantage of being readily absorbed in sufficient quantities to produce toxic symp- toms, if by chance the fluid should be retained in the sinus. Carbolic acid is also irritating to mucous surfaces when of a strength to be val- uable for antiseptic purposes. A solution of less than 5 per cent, would be of little value as a germicide, while one of that strength would be irritating. The employment of irritating solutions is, in the mind of the writer, another reason why the inflammatory conditions of the max- illary sinus are so tedious and difficult to cure. This opinion has grown out of a considerable experience in the treatment of this class of diseases, and experimenting with the various methods of treatment with drugs suggested by the recognized authorities on this subject. The peroxid of hydrogen, and medicinal pyrozone,' are remedies which the writer has lost confidence in for this purpose, — not that they are not good scavengers or good disinfectants, but that they frequently 380 SURGERY OF THE FACE, MOUTH, AND JAWS. cause great pain and irritation, even when diluted, from the rapid evolution of oxygen gas, and the consequent pressure upon a highly sensitive membrane when they are injected into the antrum, especially in those cases where the opening made for evacuation and drainage is necessarily small. In the after-treatment the same bland solutions, or sterilized water alone, are to be preferred to solutions which are in the least irritating or over-stimulating. Irrigation should be performed three or four times per diem for the first few days after the operation, preferably after meals and on rising in the morning. As the symptoms subside, irrigation may be gradually decreased to once per diem, and finally withdrawn altogether. Insufflation with powders is not to be recommended, for the reason that there is no assurance that they are invariably dissolved in the secretions. Materials of this character, if left undissolved in the antrum, would be likely to act as foreign bodies, thus continuing the irritation and preventing a cure. No anxiety need be felt in reference to the final closing of the opening made into the antrum. There is more difficulty experienced, as a rule, in keeping it open for a sufficient length of time for proper treatment, except in those cases where plugs or tubes are used. In exceptional cases, where large openings have been made, or plugs and tubes have been used, it may become necessary to stimulate granulation by touching the edges of the opening with nitrate of silver or the galvano-cautery, followed by repeated applications of tincture of iodin, or it may be closed by a plastic operation. The treatment of mucous engorgements is less difficult, from the curative standpoint, than suppurative conditions of the antrum, except in those cases where the secretions have been retained for a period sufficiently long for decomposition to have taken place, when the in- flammatory condition assumes a chronic type, rendering the treatment much more difficult and tedious. In the ordinary cases of mucous engorgement of the antrum re- sulting from acute coryza, or la grippe, drainage can be secured by expanding the natural opening into the nose. This may be accom- plished by passing probes or sounds of gradually-increasing diameter. To avoid the paroxysms of sneezing, and the pain induced by the intro- duction of the probe, the mucous membrane should be sprayed with a 10 per cent, solution of cocain. When the natural opening cannot be found, — and it is not always an easy matter to find it and introduce the probe, — the sinus can be entered at one of those points already indi- cated for draining this cavity, preferably between the roots of the first and second molar teeth. In the experience of the writer, this simple form of antral disease DISEASES OF THE MAXILLARY SINUS. 381 is the most amenable to treatment; thorough drainage alone being all that has been required in many cases to effect a complete and perma- nent cure in from two to three weeks. In the more persistent cases, daily irrigation with the nasal douche, charged with sterilized water or some of the bland antiseptic solutions, will be necessary. If a purulent condition of the secretions should follow the opening of the antrum, it is certain that the condition first mentioned has not been secured; upon a more careful examination it will be discovered that either com- plete evacuation has not been secured on account of dividing septa, or not having punctured the cavity at its most dependent point ; or that the drainage is imperfect, either from the closure of the opening in the mucous membrane, the formation of a clot in the wound, or the en- trance of foreign substances or septic bacteria. It is often difficult to maintain a free opening in the mucous lining of the cavity by the ordi- nary methods, as the tendency of wounds in this tissue is to heal very quickly. To obviate this dif^culty, the sides of the opening may be cauterized with the electro-thermal cautery; two or three applications may be necessary to secure an opening that will remain patulous for a sufficiently long period to accomplish a cure. CHAPTER XXXVIII. DISEASES OF THE MAXILLARY SINUS (Continued). Syphilitic Ulceration of the Antrum of Highmore. — This is a condition of rare occurrence. The antrum, however, sometimes becomes involved when the roof of the mouth is the seat of the destruc- tive syphilitic process, or when the turbinated bones and the nasal wall of the antrum are affected. This manifestation of a syphilitic infection is generally the result of the tertiary form of the disease, and is usually an extension of the af- fection from the nasal fossa. The writer is of the opinion that syphil- itic ulceration of the mucous lining of the antrum is never found except as a tertiary manifestation and an extension of the disease already located in contiguous parts, although he is fully aware that in giving expression to this opinion he places himself in opposition to the views of some excellent observers. In support of this position, reference is made to Morrow, who says, "Familiar sequelae of tertiary syphilis are perforation of the cartilaginous and bony septum, and the palatine roof; caries and necrosis of bone, ozena, and extension of the disease to the antrum, and other accessory cavities, and to the bones of the face and skull." Garretson says, after a careful examination of the syphilitic pa- tients in Blockley Hospital, Philadelphia, extending over a whole year, he could not find a single case of syphilitic disease of the antrum in which the disease had its origin in this sinus. The manifestations of syphilis are quite common in the nasal cav- ity, but they belong essentially to the tertiary stage, the earlier symp- toms being very rarely manifested in this region. Bosworth does not believe the secondary stage of the disease, in the form of mucous patches, ever appears in the nose. It is more than likely that such secondary manifestations of the disease are never found in the antrum of Highmore; though positive or negative demonstration of this statement could not be furnished except by a long and careful search for the proof upon persons who had died while suffering from secondary lesions of the disease. Such exami- nations may have been made and the results published, but the writer does not recall any published account of such a line of investigation. 382 DISKASRS OF THE MAXILLARY SINUS. 383 It is fair, however, under the circumstances, to reason from anal- ogy, that inasmuch as the same type of mucous membrane Hnes the maxillary sinus that lines the nasal passages, and that the secondary lesions of the disease are very rarely if ever found in the nasal passages, the same immunity in all probability is possessed by the antral lining membrane. The tertiary manifestations of syphilis in the nose and antrum usually develop in from five to fifteen years after the initial lesion, or the primary stage of the disease, in the formation of deep- seated ulcerations of a grave and destructive character, pursuing a rapid course, causing a more or less extensive destruction of tissues, and involving the cartilages and the nasal and turbinated bones to such an extent as to cause most horrible deformities. The disease is character- ized bv suppuration and necrosis, accompanied by the discharge of masses of pus, blood, and necrotic tissue, and a most intolerably fetid and penetrating odor which makes the patient an offense to himself and to every one who comes near him. There are two varieties of syphilitic ulceration of the nose in the tertiary form of the disease, viz: superficial ulcer, and deep-seated ulcer. The superficial ulcer is usually found upon the mucous membrane covering the cartilaginous septum. It may destroy the cartilaginous septum and then attack the bony septum, resulting in a more or less complete destruction of this portion of the nose, though it rarely ex- tends so far, being confined generally to the cartilaginous septum. The deep-seated ulcer is by far the most serious and destructive form of tertiary syphilis found in the nasal cavity. It is due to the for- mation of gummata in the deeper layers of the mucous membrane, which later become softened and break down, developing an ulcerative action of a rapid and destructive type. This form of ulceration is usually found upon the turbinated bones, and is' characterized by deep excavating ulcers with ragged, overhang- ing edges ; the surface of the ulcer is bathed wdth yellow pus mingled wdth fragments of blackened gangrenous tissue; and the surrounding mucous membrane is highly congested, often turgid and purplish in color. The ulcerative process rapidly penetrates to the periosteum and the bone, also extending laterally wath equal rapidity, often causing extensive necrosis and exfoliation of the osseous structures of the nose, and sometimes involves the accessory sinuses. There is always an offensive discharge, giving the odor of decom- posing pus and dead bone, accompanying the disease, which makes the presence of these poor unfortunates almost intolerable. The tendency to the formation of crusts or masses of dried pus, mucus, blood, and gangrenous tissue, which adhere closely to the surface, and are exceed- 384 SURGERY or THE FACE, MOUTH, AND JAWS. ingly difficult to dislodge, is another characteristic of the disease. These masses when expelled are in odor and appearance most disgusting and nauseating. As the disease progresses, the nasal wall of the antrum may become involved in the destructive process, which may finally extend to the mucous membrane lining this cavity. When the antrum becomes involved there is usually as an indication a swelling at the angle of the nose and cheek, and in those cases where the nasal wall of the sinus has been lost by necrosis, this fact may be ascertained by exploration with a probe. Diagnosis. — There are no characteristic symptoms of the disease located in the antrum, other than the swelling at the angle of the nose and cheek, that are distinguishable from those found in the nose. The more common location of the disease in the superior maxillary bones is the floor of the nasal fossa, which may be destroyed, leaving a more or less extensive opening between the nose and mouth, making the swallowing of food and liquids difficult, and greatly impairing the voice. The tertiary form of the disease rarely involves the velum palati, the septum alae narium, or the cutaneous surfaces, but is usually con- fined to the cartilaginous septum, the inner nasal bones, the turbinated bones, and the superior maxilla. The deformities which result are the falling in of the nose caused by the loss of its bony supports, and the perforation of the hard palate just referred to. One case only has the writer seen of syphilitic ulceration of the antrum, which did not have its starting point in the nasal fossa. The patient was a man who had been inoculated twenty years before. The disease began as an ulceration of the mucous membrane covering the hard palate opposite the right second molar tooth, resulting in perfora- tion of the hard palate and antrum, with loss of the entire floor of the sinus, together with the teeth, from necrosis. Figs. 145 and 146 are illustrations of the secondary form of the disease which had their com- mencement in the velum palati in the form of ulcers, and later involved the palate bones. In Fig. 145 the opening originally extended consid- erably farther forward, but this has been gradually filled up by the pro- cess of granulation. Differential Diagnosis. — Syphilis of the nose and antrum is often diagnosed as fetid catarrh, ozena, and other forms of disease which are accompanied by foul-smelling odor and discharges. The diagnosis, however, is rendered quite simple if a good view of the nasal cavity can be obtained through the anterior nares, as the parts most likely to be afifected are generally within the range of vision through these open- ings. In order to obtain a good view of the parts, the crusts and dis- DISEASES OF THE MAXILLARY SINUS. 38: charges must first be removed, as these cover and conceal the condi- tions of the tissues beneath. If the disease is fetid catarrh or ozena, Fig. 145. Syphilitic Ulceration of the Velum Palati involving the Posterior Border of the Palate Bones. Fig. 146. Syphilitic Ulceration involving Portions of the Palate Bones and the Velum Palati. the mucous membrane, the septum, and the walls of the nasal cavity will be found intact; while on the other hand, if it is syphilis, ulcera- 26 386 SURGERY OF THE FACE, MOUTH, AND JAWS. tions upon the septum or turbinated bones, or necrosis of bone of greater or less extent, will be discovered. This fact, however, must be borne in mind in making a diagnosis, viz: that ulceration never occurs except as a result of some general dyscrasia like syphilis, tuberculosis, cancer, the exanthemata, etc.; there is, however, no danger of making an error in the diagnosis, for differ- entiation is made comparatively simple by the presence of symptoms which are characteristic of one or the other of the diseases. It is safe therefore to say that if ulceration be found without any of the general symptoms of impaired health which accompany tuberculosis, cancer, or the exanthemata, the disease is in all probability due to syphilis, even though no positive history of infection with the syphilitic virus can be established, for it is often difficult after the lapse of so long a period to arrive at a definite history of the presence of the primary lesion or of secondary manifestations. Treatment. — The systemic treatment of tertiary syphilis is confined to the iodid of potassium in gradually increasing doses, beginning with 10 to 15 grain doses three times per day, adding three grains each day until the toxic manifestations of the drug appear, when a marked imxprovement in the symptoms is usually observed. Mercury is contra- indicated in this form of the disease. It is well occasionally to with- draw all systemic medication. Tonics, sea air, a generous diet with wine or malt liquors, are always indicated, and occasionally this is all that is necessary. The local treatment of syphilitic ulceration of the nose and antrum should be directed to securing cleanliness of the parts, by removing secretions, crusts, and pieces of dead bone which are sources of irrita- tion, stimulating ulceration and retarding the reparative process. The removal of the crusts is greatly facilitated by the use of the post-nasal syringe and the douche charged with antiseptic solutions, — the milder forms, like the Thiersch and the boric acid solutions, being preferable. When the antrum is involved, this cavity can usually be reached through the nose by means of a curved nozzle attached to the syringe or douche. Boric acid solution and cinnamon water, equal parts, is a good disinfectant and deodorizer, and may be used to best advantage with the atomizer. The removal of dead bone should be accomplished at as early a period as possible, but the writer does not believe it is the part of a wise conservatism to attempt its removal until separation has taken place. Necrosis of the Walls of the Maxillary Sinus. — Necrosis of the walls of the maxillary sinus is a diseased condition of somewhat com- DISEASES OF THE MAXILLARY SINUS. 387 mon occurrence, for the reason that there are so many lesions, either of an idiopathic, traumatic, or specific origin, which affect this part of the face and have a tendency to result in inflammatory conditions of the bone, and finally in necrosis. Necrosis of the walls of the antrum may occur as the result of peri- ostitis, induced by certain diseases of the teeth, such as septic perice- mentitis, or alveolar abscess; local arsenical poisoning caused by the escape of the drug into the surrounding tissues when used for the pur- pose of devitalizing the tooth-pulp; fractures resulting from the extrac- tion of teeth contiguous to the antrum; rupture of the walls of the antrum from the accumulation of pus or other fluids in the sinus; gun- shot wounds and other injuries causing crushing and comminution of the walls of the antrum; tuberculosis, syphilis, the exanthemata, and mercurial and phosphorus poisoning. The walls of the antrum most often found necrosed are the nasal wall, caused by specific disease extending from the nasal fossa; the superior wall or orbital plate and the inferior wall or floor of the sinus, from rupture induced by accumulated fluid. The floor of the antrum is also quite frequently the seat of necrosis as a result of the diseased con- ditions of the teeth already mentioned, and from surgical violence in extracting the teeth of this locality. More rarely the anterior and pos- terior walls become necrosed from inflammatory conditions of the sinus and from traumatic injuries. Symptoms. — The symptoms of necrosis of the walls of the maxil- lary sinus are the same as in necrosis located in other portions of the body; briefly: a history of a previous acute inflammation, with great pain, swelling, and discharge of thick pus. Present conditions, pain slight, swelling of the overlying tissues, discharge of offensive smell- ing, purulent pus, numerous sinuses, and denuded bone, which may be felt with a probe passed through the sinuses. Sinuses which lead to dead bone always present a granular appearance at the surface, and have a tendency to bleed on being touched. The most frequent locations of the sinuses in necrosis of the antrum are the roof of the mouth, alveolar ridge and external integu- ment in the regions of the inner canthus of the eye, and the infraorbital foramen. Ugly scars often result from the healing of these sinuses when located in the latter regions, and not infrequently cause ectropion of the lower eyelid. Treatment. — The operative treatment does not differ essentially from that for the same conditions in other locations, except that every means should be employed to prevent the formation of unsightly scars upon the face. A word of caution may not be amiss to the young practitioner in relation to the proper time to operate for the removal of dead bone in the region of the face. A safe rule to follow is not to 388 SURGERY OF THE FACE, MOUTH, AND JAWS. attempt to remove the necrosed bone until separation has taken place between the living and dead portions. Less deformity, in the judgment of the writer, follows such procedure than when an operation is per- formed before this process of exfoliation has been completed. It is wise to frequently examine the sequestrum to ascertain if separation has taken place, and as soon as this can be demonstrated it should be removed. The constitutional treatment must be directed to the build- ing up of the health of the patient and controlling the tendencies of peculiar dyscrasia or constitutional vice. A case at present under treatment, which gave the writer consider- able trouble from its rapid extension until the real nature of the disease was discovered, may be used as an illustration upon this point. The patient, a man forty years old, was referred to the writer by a profes- sional friend. At the time he was first seen there was considerable swelling of the right side of the face below the malar bone, and the teeth and external plate of the alveolar process had been removed between the right central incisor and the first molar of the same side. From general appearances, tertiary syphilis was suspected, but he de- nied ever having contracted the disease, and his word was taken upon that point, and only general tonics administered. At the end of ten days the disease had extended upward to the inferior border of the orbit and to the nasal bone, and backward, involving the floor of the antrum and the palate process to the median line. He was then placed upon the iodid of potassium", 15 grs. three times per diem, increasing the dose each day 3 grs. At the end of two weeks there was a very marked improvement in the conditions, the swelling was less, the disease had not extended beyond the limits just mentioned, exfoliation had already begun, and the case bade fair to make a good recovery, but with the loss of a considerable portion of the superior maxillary bone. It is possible that this might have been prevented had the iodid been admin- istered at first, as would have been done but for the positive assurances of the patient. The wiser plan therefore, in all doubtful cases, regard- less of the statements of the patient, be they never so positive, is to immediately begin a course of anti-syphilitic treatment. CHAPTER XXXIX. CYSTIC TUxMORS OF THE MAXILLARY SINUS. The maxillary sinus is not infrequently the seat of various forms of cystic and solid tumors, but their presence is rarely discovered until they have obtained a considerable size, filling the sinus and expanding its walls. Attention is drawn to the presence of solid tumors by the swelling, and the pain which usually accompanies the formation of these growths and certain forms of malignant neoplasms. Among the cystomata or cystic tumors found in the antrum may be mentioned Mucous Cysts and Polypi. Mucous Cysts of the Antrum, the hydrops antri or dropsy of the antrum of the old writers, is a disease resulting from the cystic degen- eration of the glandular follicles which are very numerous over the entire mucous membrane lining the cavity. The disease is character- ized by the presence of a dark straw-colored, glairy fluid, sometimes gelatinous, and of the consistence of egg albumin, frequently contain- ing considerable quantities of cholesterin which appear in the form of small flakes, floating in the fluid. The accumulation of the fluid is slow, which causes a painless enlargement of the face upon the affected side, with expansion of the antrum and thinning of its walls. The disease was formerly thought to be caused by the retention of the natural secretions, but modern research has proved this view to be incorrect. The retention of the. natural secretions is generally the result of acute inflammatory conditions of the mucous membrane of the nose which have extended to the sinus, and produced occlusion of the ostium maxillare. In cystic degeneration of the mucous membrane of the antrum there is frequently an aggregation of small cysts which makes the treat- ment of the case a more difficult one than when the sinus is filled with a single cyst. In some cases the cyst seems to be developed within the bony wall of the antrum, or between the bone and the periosteum, and by lateral extension fills the cavity and makes it possible under such circumstances to mistake the cavity of the cyst, when it is opened, for the sinus itself. Occasionally serous cysts develop at the roots of devitalized teeth as a result of chronic inflammation. Heath mentions a case reported 389 390 SURGERY OF THE FACE, MOUTH, AND JAWS. by Fischer in which he was able by post-mortem examination to clearly trace such a cyst which occupied the entire antrum, but had no connection whatever with its walls, and was attached only to the roots of a molar tooth by its pericementum. Cysts of this character, though not so extensive in size, are fre- quently found in both the upper and lower jaws; at least this has been the observation and experience of the writer. One somewhat similar case to that mentioned by Heath, occurring in his private practice, may be used as an example of the difficulties sometimes experienced in mak- ing a correct diagnosis. Mrs. O., thirty-five years of age, was referred for treatment of an extensive enlargement of the right side of the face in the region of the antrum, and extending forward to the ala of the nose. There was some difficulty in breathing through the right nostril, due to bulging of the nasal wall of the antrum. The contour of the palate was normal. On examination of the teeth, it was found that the lateral incisor and the first bicuspid were both devitalized, the pulp- canals of each having been filled some years before. Percussion of these teeth elicited tenderness in the first bicuspid, but not in the lateral. The swelling of the face had been noticed for more than a year, and it was slowly increasing in size. There was no discharge from the nose, and no sinus leading to the enlargement. The tumor was firm and un- yielding. These symptoms all pointed to the presence of a solid tumoi of the antrum. As a more positive means of diagnosis an exploratory puncture was decided upon, and inasmuch as the first bicuspid tooth was badly decayed, this was extracted with the intention of puncturing the floor of the antrum through its alveolus, but upon removal of the tooth an ounce or more of a thick, tenacious, straw-colored fluid, filled with flakes of cholesterin, escaped into the mouth. The opening was therefore enlarged with a surgical bur, and the surface of the antrum curetted under the local anesthetic effect of cocain. The wound was afterward kept open for several weeks, the antrum irrigated twice per diem, when the fullness of the jaw subsided and the opening in the antrum was permitted to close. Six months later the patient returned with a recurrence of the disease, and the extraction of the lateral incisor was advised on account of the location of the swelling, which was greatest under the ala of the nose. This she declined to have done, but as a compromise, submitted to the opening of the root-canal. In this way the cyst was reached, and a considerable discharge followed of a fluid similar to that evacu- ated from the antrum. The wall of the cyst was then punctured near the apex of the root of the tooth, and a further discharge followed. Injections of a lo per cent, solution of iodin and glycerol were used twice a week for a month, with marked improvement, after which the opening was allowed to close and the root of the tooth was refilled. CYSTIC TUMORS OF THE MAXILLARY SINUS. 39I A few weeks later the patient returned again with the face much swollen. At no time did she complain of pain except during the treat- ments. This time the lateral incisor was extracted, and it was found that a large cyst had been formed at the apex of the root, communicat- ing with the antrum. A counter-opening was made into the sinus at a point near the apex of the alveolus of the lost first bicuspid tooth, and the cyst and antrum were curetted and then irrigated with Thiersch solution. Following the operation there was a slight discharge of the typical secretion of cystic tumors for a few days, when it ceased alto- gether, and the openings were allowed to close. At the end of five years there had been no return of the disease. Symptoms and Diagnosis. — The disease is of slow and painless growth, the very antithesis of suppuration or empyema of the antrum, which is rapid and painful in its development. Sooner or later the cheek becomes prominent and rounded, sometimes considerably en- larged; protrusion of the eye may occur, the nose is forced to the oppo- site side, the nasal fossa becomes occluded from bulging of the nasal wall of the antrum, and sometimes the palate is depressed to such an extent as to interfere with deglutition. The tumor may be soft and elastic in some places, and hard and resisting at others. Pressure over the elastic portions gives the parchment-like crepita- tion which accompanies bone that is greatly thinned and expanded. There is usually no discharge from the nose. In many respects it closely resembles in appearance solid tumors of the jaws. Errors in diagnosis on this account have been frequently made, through which even excision of an entire jaw has been performed, and the mistake not discovered until it was too late to rectify it. The conservative sur- geon will not fail to take the precaution of an exploratory puncture or incision when making the diagnosis of a doubtful tumor, as this will give him positive data upon which to base his opinion so far as the gen- eral character of the growth is concerned. ■Prognosis. — The disease is prone to recurrence unless the treat- ment is thorough and heroic. The deformity of the face which has been occasioned by the expansion of the bone will gradually but finally disappear after the disease has been cured. Treatment. — The treatment consists of the evacuation of the con- tents of the cyst by free incision at its most dependent portion, curet- ting its inner surface, irrigation with some antiseptic solution, and stimulating injections to promote granulation. In those cases where the distention of the bone has been considerable, a portion of the exter- nal wall should be removed, or crushed in. Irrigation and the stimulating injections should not be discon- tinued until all tendency to the formation of the characteristic discharge has ceased. 392 SURGERY OF THE FACE, MOUTH, AND JAWS. Polypus of the Antrum. — A polypus is a small pedunculated cystic tumor growing from a mucous surface. Polypi of the antrum are similar in structure to those found asso- ciated with the mucous membrane of the nasal passages. There are two varieties, the fleshy and the cystic. They are the result of hyper- trophies — inflammatory hyperplasia — of the submucous connective tissue and of the mucous membrane. When the tumor arises from the submucous layer the connective- tissue elements will predominate and result in the formation of a fleshy polypus; when it arises from the mucous membrane proper, the glandu- lar structures will be in excess and a cystic form will be produced. An intermediate form is sometimes developed, having a loose fibrous struc- ture with glandular elements, resulting in the formation of a semi- gelatinous polypus which very closely resembles the common form of polypus of the nose. Polypi of the antrum are usually very vascular, and cause considerable hemorrhage when they are surgically interfered with. The disease is not a common one, and yet far more frequent than is generally supposed. Luschka in his investigations found that out of sixty subjects examined by him, five had polypi of the antrum, or one in twelve. Symptoms and Diagnosis. — The symptoms do not differ materially from those of mucous cysts of the antrum. Polypi may be present in the antrum for years, and the patient remain entirely unconscious of the fact until by their size they cause absorption of the nasal wall of the sinus or expansion of the bone, with external deformity of the face. The thin nasal wall of the antrum is the one which most frequently gives way from absorption, induced by the pressure of the cysts which occupy this cavity, and for this reason it is sometimes difficult to determine when the polypus occupies the nasal fossa also, whether it originated in the nose or in the antrum. John Bell, Syme, Vidal de Cassis, and others, have maintained that polypus never originated in the antrum, but was always an intrusion from the nose, while Paget, Fergusson, and others hold the opposite view, their opinions being based upon practical demonstration of the fact. It would seem, therefore, that in most individuals who may per- haps have polypi in the antrum, the growths never reach a size to cause any inconvenience or deformity, and consequently their presence rem.ains unsuspected. When the polypus is of sufficient size to have intruded into the nasal passages, the nostril will be more or less completely occluded. Damp weather seems to cause them to swell and more completely close the nasal passages. Prognosis. — The prognosis of polypi of the antrum is generally CYSTIC TUMORS OF THE MAXILLARY SINUS. 393 considered very good, but according to Heath in some instances they seem to have a mahgnant character, or at least are the forerunners of mahgnant disease in the antrum and jaw. The writer's experience has been so Hmited in this particular direction that he does not feel quali- fied to hazard an opinion upon the matter, therefore accepts the teach- ing of the eminent authority just mentioned, especially as polypus of the nose in certain cases seems to possess a tendency to malignant de- generation. Treatment. — The treatment of polypus of the antrum, if it suc- ceeds, must be somewhat in the nature of a radical operation. Thorough extirpation of the growth, either through the nasal wall, the external wall, or the floor of the antrum, is indicated. The first is to be preferred when it can be accomplished in the thorough manner necessary for a cure, as it does not require an incision through the external tissue of the face nor the loss of several teeth, as would be the case if the sinus was to be reached, on the one hand through the cheek, or on the other through its floor. Considerable difficulty is sometimes experienced in trying to remove such growth in the antrum through the nostril, but with polypus forceps properly curved, and a goodly allowance of skill and patience, the antrum may be reached through a previously made opening in the nasal wall, and explored to its farthest extremity. There is, however, an element of uncertainty always present in this operation, as to whether the growth has been entirely removed or not. If the antrum is opened through the external wall the superior maxillary bone must be laid bare, by laying back the lip and cheek as in the operation for exsection of this bone, and the wall of the antrum penetrated with a trephine, chisel, or the surgical saw or bur. If the opening is made through the floor of the antrum, two or three teeth must first be extracted, and afterward the bone can be cut away with the surgical burs. A sufHciently large opening must be made to permit exploration with the index finger. The after-treatment consists of the usual irrigation of the sinus with non-irritating antiseptic solutions, until the tissues of the antrum have healed and the external wound has closed. CHAPTER XL. DISEASES OF THE SALIVARY GLANDS. Inflammation of the Parotid G-land, parotitis, or mumps, is a spe- cific infectious disease, whicli affects one or both parotid glands. Dr. ]\Iichaelis recently discovered the microbe of mumps to be a strepto- coccus, similar to the gonococcus and meningococcus. It occurs most frequently in young males, and most commonly during the period of adolescence. A diphtheritic form of the disease is sometimes observed, but its most common form is the simple inflammation of the gland known as mumps. The disease often assumes an epidemic character, and spreads throughout schools and communities. Incubation Period. — The incubation period of parotitis varies from fourteen to eighteen days for young subjects and from eighteen to twenty-four days for adults. The duration of the disease varies in children's institutions in a like manner, the average being about eighteen or nineteen days; in garrisons the average is twenty-one to twenty-two days. Since the disease is not contagious after its full development, isolation for a period of fifteen days is quite sufficient. (Poinier.) Symptoms and Diagnosis. — The affection may be ushered in by a rigor, nausea, elevation of temperature, and a general feeling of lassi- tude. In a day or two there is dull pain at the back of the jaw, and considerable local swelling, which may interfere with mastication and deglutition. In the milder forms of the disease the patient only com- plains of slight stiffness of the jaws, and pain when masticating food or upon taking acids into the mouth ; while the constitutional disturbances may be so slight as to escape observation. The disease may appear first upon one side, then upon the other, or both sides may be affected simultaneously. One attack gives immunity for the future. The pathology of the disease is still in obscurity. The chief danger to be apprehended in this disease is metastasis to the testes, mammae, and ovaries. Happily these complications are rare. In about three per cent, of the cases metastasis of the testes occurs, producing a true or- chitis, which is rarely found as a primary afifection under any other cir- cumstances. The afifection usually terminates by resolution, and rarely ends in suppuration. 391 DISEASES OF THE SALIVARY GLANDS. 395 Inflammation and suppuration of the glands is sometimes a sequel of typhoid fever, puerperal fever, and erysipelas, and of scarlet fever and variola in children ; or it may be associated with pyemia. Involvement of the neighboring lymphatics in these cases is to be expected. Under such circumstances the disease is attended with great prostration, high temperature, and delirium. The pus coming from such abscesses is of fetid odor. Prognosis.— The prognosis in the latter cases is very grave mdeed, for if the" disease is left to itself the abscess may open into the auditory meatus, or, as an exceptional comphcation, it may pass downward to the chest, or extend in an upward direction along the sheath of the carotid artery to the skull, or behind the pharynx, or upward to the temporo-maxillary joint. Treatment.— In the milder form of the disease the only treatment that is required is protection from taking cold. In the more ordinary form, absolute rest and protection from sudden change of temperature are demanded. If the temperature runs high, this should be controlled by appropriate remedies. Dry heat applied to the side of the face in the form of heated flannels, a hot brick wrapped in flannel, or a rubber bag filled with hot water, will mitigate the pain. Liquid food will be required for a few days. Medicines beyond a saline cathartic and anodynes are rarely needed. Occasionally the attack will leave the patient in a debiHtated condition demanding tonics. In the more seri- ous form of the disease, involving suppuration of the glands, the pus should be evacuated as soon as fluctuation can be discovered, and the cavity irrigated with bichlorid of mercury solution, i to 2000, drainage provided for, and the wound dressed antiseptically. When the pus is superficially located, it is best to make the incision in a line with the course of the facial nerve, so as to avoid the possibility of producing paralysis of the facial muscles by severing this nerve. If a deep incis- ion is necessary, it should be made upon the line and in front of the external carotid artery. The exhibition of quinin and iron, with nour- ishing food, should constitute the systemic treatment, and in cases accompanied with great prostration stimulants should be freely used. Salivary Calculi.— A salivary calculus is a calcareous deposit in a salivary gland or its duct. These concretions occasionally form within the salivary ducts, and much more rarely within the gland itself. Salivary calculi are seldom found within the parotid gland or its duct. The most common location of these concretions is in the duct of Wharton; more rarely in the ducts of the sublingual gland. Calculi of the submaxillary and sublingual glands are somewhat rare, but the greater number of the reported cases have been found associated with the submaxillary glands. Fiitterer found one hundred and fifty-eight cases of salivary calculi in the sub- 396 SURGERY OF THE FACE, MOUTH, AND JAWS. maxillary and sublingual glands mentioned in medical and surgical literature, but he could only secure access to the full reports of sixty- seven of this number. Out of the sixty-seven cases, he found nine were located in the submaxillary gland itself; six were found in the sublin- gual gland or its ducts, and the remainder — fifty-two — were located in the duct of Wharton. Six cases only of calculi in the parotid gland or its duct were found in this search. To recapitulate: Out of seventy- three cases of salivary calculi, affecting the parotid, submaxillary, and sublingual glands and their ducts, six were associated with the parotid or the duct of Stenson; nine with the submaxillary gland alone; six with the sublingual gland or its ducts, and fifty-two with the duct of Wharton. Salivary calculi are seen most frequently between the ages of twenty and forty years. The youngest person reported in the cases gathered by Fiitterer in which a calculus was found, was twelve years of age, and the oldest was seventy years. Burdel reported a case to the French Academy, in which a concretion was found in the sublingual duct of an infant only three weeks old. This calculus was about the size of a grain of wheat, yellow in color, its surface granular, wrinkled, and apparently formed of minute cones cemented together at their base. The analysis showed it to be composed almost entirely of cal- cium phosphate, and a small proportion of nitrogenous organic matter. This no doubt was a concretion of pre-natal formation. Causes. — ^The causes of salivary calculus may be the presence of a foreign substance lodged in the duct, or bacteria, most likely the Leptothrix huccalis. Fiitterer was unable to demonstrate leptothrix, but he still argues that they are the most likely nidus around which the deposit is formed. The presence of a foreign substance in the center of the calculus has been demonstrated in a few cases; but in the great majority no such evidence could be found. There seems to be a close connection between the formation of calculi in the salivary glands and the formation of calculus upon the teeth, as persons with salivary cal- culi of the glands usually have considerable calcareous deposits upon the teeth. Richet first called attention to this fact. It has been the general impression among English surgeons that these deposits in the salivary glands were closely connected with the gouty diathesis. It has been generally stated that these calculi were composed prin- cipally of calcium carbonate and phosphate, and magnesium phosphate. Fiitterer has examined several specimens, and finds calcium phosphate largely in excess of the carbonate. Garretson reports the examination of a calculus taken from the duct of Wharton, which showed the same composition. Ptyalin, xanthin, and uric acid were also found in them by Fiitterer, which would seem to prove the connection of the forma- tion of these concretions with the gouty diathesis. The specific gravity DISEASES OF THE SALIVARY GLANDS. 397 of the calculi in the reported cases varies so greatly that no reliance can be placed upon the result of this part of the examination, from the fact that some were weighed in the dry, and others in the fresh state. Sec- tions of the calculi all show a lamellar arrangement, beginning at the center, which indicates the manner of their increase in size. These calculi form very slowly; perhaps years elapse before their presence gives rise to any serious complications. Symptoms. — ^The symptoms are acute inflammation, accompanied by extensive swelling in the floor of the mouth, at the side of and beneath the tongue. This organ is sometimes lifted up and pushed back into the fauces. Fullness of the submaxillary triangle of the neck is also observed. The pain is frequently very severe. The con- stitutional symptoms are elevation of temperature, nausea, dizziness, and a general feeling of prostration. Upon an examination of the swelling by palpation, the index finger of one hand within the mouth, Fig. 147. Salivary Calculus from the Submaxillary Gland of a Horse. (Reduced one-half.) over the swelling, and the other upon the neck beneath the gland, the form of the swollen gland and duct may be readily outlined. Occasion- ally the calculus can be found as a hard mass within the duct. This, however, would not be possible when the swelling was at all extensive, or the calculus was located within the gland. Inflammation and sup- puration are commonly associated at various intervals with the pres- ence of these formations in the gland or its duct. These calculi are usually oblong or spindle-shaped in form. In size they have varied from one grain to two hundred and seventy, the latter being the largest recorded calculus found in a human subject. The largest calculus in measurement was six centimeters in length, and five and one-half in width. Usually there is but one calculus found in the duct or the gland, but occasionally two or more are found lying together, facets having formed at the points of contact. Garretson mentions a case in which both of the ducts of Wharton were filled with small calculi. Salivary calculi are quite common in the larger animals, like the horse and the ox. The accompanying illustration (Fig. 147) is a calculus taken from the submaxillary gland of a horse; it weighed eleven and one-half ounces in the dried state, and measured six inches in length and two inches in width, having a circumference at its largest part of six 398 SURGERY OF THE FACE, MOUTH, AND JAWS. inches. Although inflammation and suppuration are commonly recur- ring conditions, an external fistula as a result is an exceedingly rare oc- currence. Fistula following operation through the external tissues has occasionally occurred, and it is somewhat difficult to heal. Relapses after complete removal of the calculi are very rare, and it is more than likely that in most of those cases reported as relapsing, all of the cal- culi were not removed at the first operation. Diagnosis. — The diagnosis is usually a simple matter. If the duct is still patulous, a small probe — preferably made of untempered steel, as this metal conducts sound, and the vibrations produced by contact are much better than the ordinary silver probe — may be passed into it until it reaches the calculus, which will be distinguished by the rough, grating sensation imparted to the fingers upon bringing the probe in contact with the stone. If the duct is not open, an exploring needle may be thrust into the swelling at various points, when if a calculus is Fig. 148. Salivary Calculus from the Submaxillary Gland. (After Fiitterer.) present it will most likely be found. Cases with extensive swelling of a chronic character have been mistaken for malignant growths. The difficulty in diagnosis is much greater when the calculus is situated in the gland than when located in the duct. Treatment. — The usual method employed for removing a salivary calculus from either of the glands or their ducts is by an incision made within the mouth over the point at which the calculus lies imbedded, or by dilating the orifice of the duct, and expressing the calculus from its bed; or by lifting it out with the forceps. Occasionally the swelling will be so great that none of these methods will avail, and this is especi- ally true of those cases in which the calculus is lodged within the gland. Fiitterer reports a case of this character which was seen by the writer in consultation, in which two calculi (Fig. 148) were found imbedded in the submaxillary gland, one of which weighed one grain, and the other twenty-three grains. In this case there was extensive suppura- tion and great swelling which had lasted for several days. The pres- ence of the calculi was demonstrated by passing a fine probe into the duct of Wharton. After making an extensive incision down to the cal- culi, and repeated unsuccessful trials to grasp and remove them, the DISEASES OF THE SALIVARY GLANDS. 399 effort was abandoned, and the wound packed with gauze. On the next day the packmg was removed, which was followed by a profuse dis- charge of pus. The calculi were then easily grasped and removed with a pair of long slender forceps. Operations through the external tissues for the removal of calculi are to be deprecated, on account of the dangers of forming salivary fistulse. The after-treatment in these cases is simple. Thorough clean- liness of the mouth and wound, maintained by the use of antiseptic solutions, is all that is required. Salivary Fistulas. — Salivary fistula is a rare, but nevertheless a very troublesome affection. It is usually associated with the duct of the parotid gland, and is very rarely met with in the submaxillary or the sublingual glands. Causes. — It may be caused by traumatic or surgical injuries, or by inflammatory conditions resulting in abscess, or by ulceration. Lacer- ated and gunshot wounds of the cheek, and surgical operations requir- ing incisions of the cheek, are the most frequent causes of the affection. The inflammatory conditions which may result in fistulse of the parotid gland are suppurative parotitis, suppurative inflammation from injury and the presence of calculi, ulceration following mercurial ptyalism, and gangrenous stomatitis. Fistula of the parotid gland has some- times occurred as the result of operations upon this organ for the re- moval of tumors. Diagnosis. — The affection consists of an outward opening of the duct of Stenson upon the external surface of the cheek, through which the saliva flows over the cheek instead of into the mouth. During the stimulation of the gland induced by the act of mastication or the odors of appetizing foods, the saliva pours out over the cheek, and be- comes very annoying. Sometimes the cheek is excoriated by the fluid, and unhealthy looking granulations spring up about the orifice of the fistula. Treatment. — A variety of operations have been proposed for the cure of this affection. They all have the same end in view, namely : to re-establish the flow of saliva into the mouth, and to close the fistula upon the external surface of the cheek. A common method of treat- ment is by cauterization and compression of the fistula. This form of treatment may occasionally succeed in those cases in which the natural orifice in the mouth still remains patulous. In the greater number of cases, however, the orifice in the mouth has been obliterated and calls for an operation to re-establish it. Agnew's method consists of passing a curved needle, armed with silk thread, around the duct, posteriorly to the fistula, from within the mouth. The needle should be entered and emerged at as nearly as possible the same point, care being taken to include the duct, but not 400 SURGERY OF THE FACE, MOUTH, AND JAWS. the skin, within the loop. The thread is then to be tightly knotted, and the ends cut off. The effect of this operation is to produce ulceration within the cheek, while the ligature cutting its way through the con- fined tissue, separates after a few days, and leaves a new and artificial duct through which the saliva may find a free passage into the mouth. If the external fistula does not close immediately, the edges may be pared and brought together with sutures, and covered with a collodion dressing. Deguise's method consists of first making a puncture through the fistulous opening in the cheek obliquely backward to the inner sur- face of the cheek, and passing one end of a leaden wire through it. Second, through the same opening another puncture is made, which is directed obliquely forward, and through which the other end of the wire is passed. The ends of the wire are then brought together and twisted. The loop passing through the fistula conducts the saliva into the mouth, and the fistula closes in a few days. If it does not, it should be closed by the method just described. Van Buren succeeded in closing a salivary fistula, the result of a gunshot wound, by transferring the fistulous orifice from the outer to the inner surface of the cheek. This may be accomplished by first pass- ing a fine silver wire through the skin at opposite points on the edge of the fistulous orifice. The next step in the operation is to loosen the fistulous orifice and the duct from the surrounding tissue, for the dis- tance of about half an inch backward, then make an incision through the wound to the inner side of the cheek, drawing the fistulous orifice through it, and retaining it in its new position by means of the wire. The external opening is to be closed with silver wire sutures. The wound should be treated antiseptically. CHAPTER XLl. NEURALGIA. Definition. — Neuralgia (Greek vevpov, nerve; uAyo?, pain). Neuralgia is a severe paroxysmal pain in the area of distribution of a nerve, or along its course. It has become customary to designate all pains which occur in paroxysms, unattended with local or general elevation of temperature, and distributed along the course of nerve-trunks or nerve-branches, for which no adequate cause can be assigned, as neuralgia. (Putnam.) Neuralgia is not a disease, nor a morbid condition in the sense of its having an individuality, but is a phenomenon, or an expression of a disease or of a morbid general or local condition. Neuralgia has been called "the prayer of the nerves for blood," and "the cry of the hungry nerves for food," but these suggestions as to the etiology of neuralgia do not cover all the causes which produce this most distress- ing and painful phenomenon. Neuralgia is a medical rather than a surgical affection, and rarely comes under the observation of the surgeon except as the result of injurv, or the implication of the nerves in the healing of wounds or cicatrices, or when medical treatment has failed to relieve the pain and surgical operation is sought as a last resource. The conditions which are productive of neuralgia are many and varied, and consist chiefly of diseases which lower the vital powers of the system, such as anemia, or those which interfere with such func- tions as the circulation, respiration, digestion, assimilation, secretion, and elimination; the presence in the system of abnormal substances, as in gout, rheumatism, diabetes, malaria, nephritis, chronic pyemia» syphilis, and metallic poisoning; local conditions which cause reflex peripheral irritation, such as diseases of the teeth, eyes, ears, stomach, uterus, and ovaries; chronic inflammation of the nerve or its sheath; pressure from abnormal growths within the bony canal through which the nerve-trunk passes, or pressure from tumors, and localized anemia or congestion of nerves or nerve-centers. Neuralgia may therefore be the result of an actual diseased condi- tion of the nerve, as for instance in a neuritis, or it may exist with no discernible structural change in the nerve-tissue or the nerve-centers. 27 401 402 SURGERY OF THE FACE, MOUTH, AND JAWS. The changes which may take place in the nerve-tissue under such conditions may be simply molecular, and these, with our present means of examination, are not capable of being demonstrated; but the way in which certain forms of neuralgia behave, as for instance their sudden disappearance from one part to reappear in another and perhaps re- mote location, or their complete disappearance after a short period, confirms the general opinion that these forms are not due to any or- ganic change in the nerve itself. On this account it has become customary to divide all neuralgias into two distinct classes, placing those in which there are appreciable changes in the nerve-tissue under the head of symptomatic neuralgia, and all others under the head of idiopathic neuralgia. In symptomatic neuralgia the pain is dependent upon the neu- ritis or other structural changes in the nerve-tissue or its sheath, while in idiopathic neuralgia the pain does not depend upon any discoverable change or alteration in the nerve-tissue. Of the pathologic anatomy of such a condition there is absolutely nothing known. In the character of the pain in these two varieties of neuralgia, there is very little difference ; but the symptoms which accompany the pain are not alike. The principal difference in the symptoms lies in the greater degree of pain manifested in a neuritis, and the sensitiveness which exists over the nerve-trunk. (Sinkler.) All neuralgias have one common tendency, which is manifested in a greater or less degree, viz: periodic recurrences, but the degree of periodicity varies greatly. These recurrences are most regular and best marked in the malarial neuralgias, and in those dependent upon neurotic conditions like migraine and the periodic headaches. Neuralgia affecting the viscera occurs with less regularity. One variety of neuralgia affecting the ophthalmic division of the trifacial nerve evinces a tendency to daily recurrences at the same hour (usually about nine a.m.) for a certain period. This is particularly marked in those cases dependent upon malarial influences, and catarrhal affec- tions of the frontal sinuses. The writer had under observation recently a case of this character which was due to catarrhal inflammation of the frontal sinuses. The pain was intense for an hour to an hour and a half, the paroxysms being from three to five minutes apart. The patient complained of a stopped-up feeling in the nasal passages and a sense of fullness in the frontal region on rising in the morning. This lasted until the paroxysms ceased, when the sense of fullness also disappeared. The patient made constant effort during the period of the paroxysm to clear the nasal passages, and he believed that as soon as this effort was successful the pain ceased. The neuralgias are also again divided according to their location and their symptomatology, into, — NEURALGIA. 403 1. Superficial. 2. Visceral. 3. Migraine and the migrainoid headaches. The siipcrhcial variety of neuralgia is limited to the course and area of distribution of a single superficial nerve or group of nerves, like tlie sciatic and the trifacial. The z'isccral forms of neuralgia are less definitely localized by the sensations of the patient than in the superficial variety, and as these nerves are deep-seated it is dififiicult to indicate which are at fault. Migraine is a complex sensory neurosis characterized by pain in various locations of the cranium; the occipital region, the vertex, the frontal, or the temporal region. Causes. — The causes of neuralgia may be divided into two forms, predisposing and exciting. The predisposing causes are, — 1. Hereditary tendencies. 2. Periods of life at which certain critical changes take place. 3. Influences associated with sex. 4. The effects of constitutional diseases, such as anemia, gout, rheumatism, phthisis, diabetes, nephritis, malaria, syphilis, and metallic poisoning. The exciting causes are, — 1. Atmospheric conditions, as indicated by a low barometer; and the local action of heat and cold. 2. Injuries and direct irritation of the nerves. 3. Indirect irritation of the nerves (reflex). 4. Acute febrile diseases. Predisposing^ Causes. — Hereditary Tendencies: The fact of the in- heritance of neuralgic tendencies by certain families who give other signs of a neuropathic taint, is so well established that it does not admit of question. The tendency is most marked in the case of migraine, and other periodic headaches. It is also noticed in visceral neuralgias, and particularly so in facial neuralgias, though less marked in the other forms of superficial neuralgias. (Putnam.) Age: Age is an important factor in the predisposition to neural- gic affections, which are most common in middle life, and at those periods which mark the growth and the decline of the sexual functions. According to Anstie, these conditions when once established are in- clined to continue into advanced age, but fortunately cases beginning at this period are relatively rare, though exceedingly intractable. Childhood and youth are usually exempt from superficial neural- gias, though migraine and periodic headaches may develop in children of neurotic temperament. These conditions may later in life give way to more serious neuroses. 404 SURGERY OF THE FACE, MOUTH, AND JAWS. Sex: Women, as a rule, are more liable to certain forms of neu- ralgia than are men. This is particularly noticeable in neuralgias of the trifacial, occipital, and intercostal nerves; while men suffer most frequently from the brachial, crural, and sciatic neuralgias. Putnam thinks this is due to the stronger neurosal element in women, and the neuritic element in men. Constitutional Diseases: Any and all constitutional disorders which by virtue of their action produce an impoverished condition of the blood or retrograde tissue-changes, or the disturbance of vital or other important functions of the body, undoubtedly predispose to neuralgia and other neurotic affections. Among these predisposing constitu- tional causes may be mentioned phthisis, anemia, gout, rheumatism, diabetes, malaria, nephritis, chronic pyemia, syphilis, indigestion, mal- assimilation, perversions in secretion and elimination, conditions of the vaso-motor system which produce local congestion or anemia, and the presence within the system of certain toxic substances such as the metallic poisons. Ehrmann has published an account of four cases in which small doses of potassium iodid produced trigeminal neuralgia. Lead, arsenic, antimony, and mercury are all capable under favor- ing circumstances of so impairing the nutrition of all nerve-tissue as to seriously predispose it to neuralgic attacks. Exciting Causes. — Atmospheric conditions, and Thermal influences: It has long been known that certain atmospheric conditions, especially those preceding a storm, were likely to excite attacks of neuralgia, and that the various forms of neuralgia were more prevalent in the cold and damp seasons of the year, in cold and damp localities, and in per- sons whose occupations compelled them to work in a cold and moist atmosphere, or who were subject to frequent and extreme changes of temperature, than under different circumstances. In a series of observations conducted by a miHtary officer under the direction of S. Weir Mitchell, in relation to the conditions of the atmosphere preceding a storm and the coincident attacks of neuralgia in the stump of an amputated limb, from which the officer suffered most intensely, it was found that the attacks of pain were accompanied by a falling barometer, though the severity of the pain did not neces- sarily bear a proportionate increase with the rapidity or the extent of the fall. The moisture of the atmosphere seemed to have a certain effect, but the attacks occurred even when the storm center was so far removed that no local rainfall took place. The electrical disturbances of the atmosphere could not be studied with accuracy, but there seemed to be a certain relationship between the attacks of pain and the appear- ance of the aurora borealis. (Putnam.) Injuries and Direct Irritation of the Nerves. — Among the principal exciting causes of this class may be named wounds and injuries to NEURALGIA. 405 the nerves; impingement of nerves within cicatricial tissue; pressure from neoplasms and certain inflammatory swellings (gumma, etc.); narrowing- of the bony canals and foramina, and aneurisms. The writer reported a case at the Ninth International Medical Congress, of persistent neuralgia of the temporo-maxillary articulation of eight years' standing, which was due to the malposition of the right ramus, caused by exsection of a portion of the jaw, — from the angle to the first bicuspid tooth, — and contraction of the cicatricial tissue, which was entirely cured by an operation which replaced the ramus in its nor- mal position and thereby relieved the tension upon the articular liga- ments of the joint. The case has already been referred to in another Fig. 1 40. Malposition of the Right Ramus, the Result of Partial Exsection of the Jaw for Sarcoma, which caused Persistent Temporo-Maxillary Neuralgia. chapter as an example of bone-grafting. Fig. 149 is an illustration of the position of the ramus before the operation, and Fig. 150 shows it one year after the operation, the teeth having been lost by pyorrhea alveolaris. Indirect Irritation of the Nerves. — Under this class of exciting causes are grouped all those disorders which produce these effects through reflex or sympathetic action. As an illustration, diseases of the uterus and ovaries not infrequently cause reflex facial, mammary, intercostal, and gastric neuralgia. The writer for several years had under observation a suft'erer from dyspepsia accompanied by severe gastralgia and reflected neuralgic paroxysms in the, left brachial plexus. The reflected pain was always in the same location, and often of so severe a type as to greatly interfere with the use of the arm upon the following day on account of the soreness of the muscles. 4o6 SURGERY OF THE FACE, MOUTH, AND JAWS. The eye is an important center of nervous irritation, and errors of refraction, even when quite slight, are sometimes productive of migraine. Inflammatory conditions of an acute and chronic nature affecting the maxillary and frontal sinuses are also productive of neuralgic attacks. Acute Febrile Diseases. — Acute fevers are occasionally the exciting cause of neuralgia. Thus, Nothnagel describes neuralgias which came on during the first week of typhoid fevers. Putnam mentions a case which came under his own observation, in which "a severe facial neu- ralgia appeared during the first Aveek of an insidious attack of pneu- monia in an individual who was not of neuralgic habit, and before the fever or inflammation had become at all severe." Fig. 150. Final Result, One Year after Operation. Teeth were Lost by reason of Pyorrhea Alveolaris. It is possible that other acute affections may have a similar effect. Trifacial Neuralgia. — From the surgical standpoint the super- ficial forms of neuralgia are the only varieties of especial niterest to the surgeon, as these only are amenable to treatment by surgical proced- ures. Neuralgia of the trifacial and sciatic nerves, the brachial plexus, and the neuralgia of stumps and scars, are the most common forms of the superficial affection. Neuralgia of the trifacial nerve (tic douloureux) is the form which most frequently comes under the observation of the dentist and the oral surgeon. Trifacial or trigeminal neuralgia appears in two forms, viz: acute and chronic. The acute form of the affection is frequently associated with or de- pendent upon acute inflammatory conditions of the teeth and alveolar NEURALGIA. 407 processes, acute affections of the eye and ear, and of the maxillary and frontal sinuses. Thfs form of neuralgia is usually of short duration, and gfenerally disappears upon the subsidence or the removal of the exciting- cause. The chronic form is often persistent in its character; the exciting cause difficult to find; and the affection does not always disappear upon the removal of the supposed cause on account of the structural changes which may have taken place in the nerve-tissue or the sheath of the affected branches or of their blood-vessels. It not infrequently hap- pens that more than one abnormal local or constitutional factor may be involved in the causation of the various forms of neuralgia; failure in one direction should therefore lead to renewed search in some other, with the hope of finally discovering the other factors in the case, and removing them if possible. Xeuralgia may exist in any of the nerves of the body as a result of neuritis, but it is most frequently observed in the sciatic and trifacial nerves. The frequency with which the various branches of the trifacial nerve are the seat of neuralgia may be stated to occur in the following order: the superior maxillary division, the inferior maxillary division, and lastly, the ophthalmic division. In neuralgia of the superior maxillary division, the pain is some- times located in the dental branches, being referred to the upper teeth, gums, and maxillary bone; at other times it affects the infraorbital branch, the pain being referred to the integument of the cheek, the side of the nose, and the upper lip. Infraorbital neuralgia is frequently associated with neuralgia of one of the other branches of the fifth nerve, usually with the first division. When affecting the inferior division, the pain is most frequently located in the lower teeth, the gums, and the integument of the lower lip and the chin. \\'hen located in the ophthalmic division it most often affects the supraorbital branch, the pain spreading out over the forehead, the eyebrow, and the upper eyelid. It is a common occurrence for the patient to refer the pain in the beginning of a paroxysm to the point of exit of the nerve from its bony canal, for instance at the infraorbital, mental, and supraorbital foramina. Sympionis. — Neuralgia of the fifth nerve rarely appears until after middle life, and in old persons it frequently resists the most intelligent treatment. The fact that the affection does not appear as a rule until after middle life, when the senile changes are beginning to take place, would seem to indicate a connection between these changes and the appearance of this form of neuralgia. 408 SURGERY OF THE FACE, MOUTH, AND JAWS. The pain is of the most excruciating character. There is no other disease, with possibly the exception of tetanus, which from the severity of the suffering is so calculated to arouse the sympathies and com- miseration of the surgeon and those in attendance upon the case, as the severe forms of tic douloureux. In tic douloureux, or "epileptiform neuralgia," as Trousseau termed it, the pain comes on suddenly, sometimes preceded as in epi- lepsy by an aura. The character of the pain is acute, occurring in dis- tinct paroxysms, with longer or shorter intervals, sharp, stinging, or lancinating, gradually increasing in intensity for a few moments, until it reaches a climax, and as gradually and quickly subsiding, to be again followed by another paroxysm of equal degree of intensity. The pain is so fearfully severe in some cases as to cause the patient to moan or cry aloud with every paroxysm, and after the paroxysm is past to sit in terror waiting the onset of the next attack. This may continue for hours without cessation, or the paroxysms may last but for an hour or two, the remainder of the day being quite free from pain; or it may be excited at any time by talking, laughing, mastication, or even passive movements of the muscles of mastication, speech, or expression. A slight noise or a light touch may precipitate a paroxysm. In some cases the patient will be entirely free from pain during the night, but upon awakening in the morning the slightest movement of the muscles of the face precipitates the paroxysms of pain. Occa- sionally the pain will be severe during the night, and the patient com- paratively free during the day, and able to go about his daily vocation ; while in others the pain may be induced at any time by the movement of the muscles, so that the question of taking food becomes for several days at a time one of great dread; in fact, patients frequently abstain from the taking of aliment except in a liquid form for days together. The pain and the dread of the returning paroxysms make life a burden. Besides the pain, other symptoms of lesser note occur in facial neuralgia. Increased secretion of the lachrymal, salivary, and mucous glands is a frequent occurrence. The hair of the face or side of the head becomes dry and brittle, and is inclined to fall out, or it may lose its color rapidly, regaining it after the attack has passed. (Putnam.) There is increased secretion of urine. Anstie noticed unilateral furring of the tongue. The muscles to which the pain is referred may some- times become paretic. Temporary amaurosis, and sometimes loss of the eye of the affected side, may take place in tic douloureux. The senses of hearing, taste, and smell may likewise be temporarily lost. Causes. — Among the more common exciting causes of trifacial neuralgia expressed in the various divisions of the fifth nerve, may be mentioned the following conditions: In the ophthalmic division in- flammatory affections of the conjunctivae, diseases of the globe of the NEURALGIA. 409 eye and iritis, and catarrhal conditions of the frontal sinuses. In the superior and inferior maxillary divisions, inflammatory conditions of the teeth and jaws, particularly pulpitis, pericementitis, and periostitis of the alveolar processes; structural changes in the teeth, like inter- stitial calcification of the pulp, pulp-nodules, and exostosis of the root. Fig. 151 is from a case of neuralgia of the third division of the trifacial nerve induced by the formation of a pulp-nodule. Difficult erup- tion of the teeth, particularly of the lower third molars; exposed sensi- tive dentine from caries, abrasions, or fractures which have caused a loss of the enamel ; and lastly, inflammatory and other diseased condi- tions of the maxillary sinuses, which are particularly associated with neuralgia of the superior maxillary division. Syphilitic manifestations of a secondary and tertiary nature may produce inflammatory infiltration of the nerve-sheath, or neuritis, and cause neuralgia in either or all of the branches of the fifth nerve. Osseous growths within the bony canals or the foramina through which these nerves pass is not an infrequent exciting cause of neural- gia. These growths may be in the form of tubercles arising from the walls of the canals, or in the form of a diffuse exostosis ; in either case a narrowing of the canal or its foramen is the result, pressure upon the nerve is induced, and as the patient grows older there is caused a pro- gressive neuralgia. The various forms of irritation, both direct and indirect, not infre- quently set up a neuritis in the various branches of the nerve, as dem- onstrated by Putnam and others. Dana found striking evidences of arterial disease in three cases of typical trifacial neuralgia, but no note- worthy changes in the nerves. He believes the cause of neuralgia to "be obliterating arteritis, and gives as his reasons for this opinion that "the disease occurs at an age when degenerative changes begin in the arteries and follow a certain fixed distribution." Tuffler found positive evidence of neuritis in one case examined by him of neuralgia of the inferior maxillary nerve. In this case the nerve was "swollen and reddened both within the dental canal and before its entrance." Sinkler also found like evidences of neuritis in a •case of neuralgia of the inferior maxillary nerve. Diagnosis. — The manifestations of trifacial neuralgia are so char- acteristic that an error in the diagnosis could hardly be made. Valleix discovered certain points of tenderness in cases of facial neuralgia which are designated as "points douleureux." These are located in the ophthalmic division, at the supraorbital foramen, on the upper eyelid, at the line of union of the nasal bone with the cartilage, at the inner angle of the orbit, and in the eyeball itself. Another point is near the parietal eminence. In the superior maxillary branch the painful points are situated 4IO SURGERY OF THE FACE, MOUTH, AND JAWS. at the infraorbital foramen ; at a point over the most prominent part of the malar bone; an uncertain point on the gum of the superior maxilla^ a similar point upon the upper lip, and another upon the palate. Fig. 151. Inferior Moi.ar — \'ertical Section. Showing Pulp-nodule ("eiilargedi. NEURALGIA. 4II In the inferior maxillary division the painful points are found over the auriculo-temporal branch just in front of the ear; another over the inferior dental foramen, and still another over the mental foramen. The presence or absence of these "points douloureux" are not positive diag'nostic signs, though as a general rule tenderness will be found over the foramina named. CHAPTER XLII. TREATMENT OF TRIFACIAL NEURALGIA. Trifacial neuralgia is sometimes amenable to treatment by cer- tain drugs. Their therapeutic effect is, however, often very disappoint- ing, and one after another may be tried with little or perhaps no benefit. Success in the direction of treatment by drugs will depend upon the age and the general condition of the patient, and the causative agents which are responsible for the affection. It must be regarded, how- ever, as one of the most intractable of diseases. The long list of remedies which have been recommended from time to time attest the difficulties that are met with in attempts to eradicate the disease. It is especially necessary in the treatment of facial neuralgia to look beyond the relief of the particular attack under observation and search for the cause or causes which have provoked the attack. These conditions have already been referred to, and should receive that treatment which is appropriate to the individual ailment. It may be assumed, however, that in a majority of the cases of protracted neuralgia, neuritis is present, and this condition should re- ceive appropriate treatment by local applications and galvanism. As many cases of trifacial neuralgia are due to the impairment of the general health, remedies which are directed to the building-up of the system are sometimes successful in curing the affection. Quinin, arsenic, a.nd iron have been found useful in this direction; the precipitated subcarbonate of iron administered in large doses has been found exceedingly beneficial. Gclsemiiim has been found by many authorities to be one of the most potent remedies in the treat- ment of neuralgias of the fifth nerve. It gives its best results, how- ever, in those cases which are dependent upon diseased conditions of the teeth. Sinkler has found it useful in neuralgia of all the branches of the fifth nerve. The writer has had a like experience in most of the cases in which it has had a fair trial. In one case, however, recently under his care, this drug at first gave complete relief administered in the form of sulfate gclseminine, gr. 1-30 every two hours until the con- stitutional effect was produced. In the next attack, which came on seven days afterward, it had no appreciable effect when carried to the point of drooping eyelids and dimness of vision. The fluid extract is 412 TREATMENT OF TRIFACIAL NEURALGIA. 413 generally considered the best preparation, but because of its unrelia- bility in strength the writer prefers the sulfate gelseminine . Valerianate of zinc was at one time highly recommended, but it is not at the present time held in much esteem. Cannabis indica is a remedy of value in some cases. To obtain the best results it should be given in full doses, and repeated as often as the patient can tolerate. Seguin and others have highly recommended the use of aconite. This drug, to be of value, should be administered until numbness and tingling are felt in the lips and face. It should, however, be adminis- tered with great caution. Its value no doubt lies in its power to dimin- ish arterial tension. Belladonna^ though highly recommended, does not appear to re- ceive the confidence of the profession as a valuable remedy. Thompson has recommended phosphorus in large doses for its curative effects. Gow^ers reports a case that was entirely relieved by a three months' treatment with phosphorus. Others, however, have not succeeded in obtaining the same results. It has the objection of being irritating to the stomach. Cimicifiiga combined with cannabis indica has been extolled as valuable in those cases dependent upon or connected with rheumatism. Ringer, Hare, and others have highly recommended croton chloral — butyl chloral — in the treatment of tic douloureux. Hare administers it in five-grain doses every two hours, and finds that its influence is not only palliative but curative. Antipyrin, phenacetin, and salol have all been recommended as valuable agents, particularly in the rheumatic forms of the affection. Opium has no curative value, but it is often necessary to adminis- ter morphin hypodermically to control the severe paroxysms of pain. Cocain is sometimes administered in the same manner, and for the same purpose. In cases presenting a syphilitic history, iodid of potassium in twenty-grain doses, increased to thirty or forty grains three times per day, has sometimes proved curative. Electricity, when judiciously applied, is of great value. The gal- vanic current is the most beneficial. Authorities differ as to which pole should be applied to the painful spot. Sinkler recommends the negative pole. Gowers thinks the direction of the current is of no great importance. The writer uses the positive pole at the painful spot, and a current of from one to three milliamperes. The current may be applied for from two to five minutes. As local applications, menthol and the oil of peppermint often afford temporary relief. Surgical Treatment. — Various surgical operations have been 414 SURGERY OF THE FACE, MOUTH, AND JAWS. recommended for the relief of superficial neuralgia. These opera- tions are, subcutaneous division of the trunk of the nerve, resection of the trunk of the nerve, nerve-stretching, evulsion, and the tying of arteries leading to nerve-trunks and nerve-centers. Subcutaneous division of nerves is productive of immediate relief from the pain for a short time, but eventually, after a few weeks or months, the pain returns as a result of the reunion of the divided nerve. The division of a nerve as shown by Waller in experiments upon warm-blooded animals, produces in order of time : First. Paralysis of motion, or of sensation, or of both according as the nerve which has been divided is motor, sensory, or mixed ; this paralysis is immediate and local. Second. Loss of excitability of the nerve, coming on gradually and becoming complete within a few days; direct muscular excitabil- ity persisting for an indefinite time, especially to the galvanic current. Third. Degeneration of the peripheral end of the nerve, also a gradual process, visible within a day or two, well marked at the end of three or four days, and complete in about ten days. Fourth. Regeneration of the previously fully degenerated periph- eral end of the nerve, a still more gradual process, commencing in- definitely, but clearly visible about a month after the lesion has been produced and requiring from three to six months to complete itself; which results in : Fifth. Restored sensibility, motility, and excitability. Excision gives somewhat better results, in that the interval be- tween the operation and the return of the pain is much longer; usually there is complete relief for six or seven months and occasionally for two or three years. As a rule, the more extensive the piece removed, the longer will relief be afforded. It is customary to remove at least half an inch, and as an added safeguard against reunion, to bend back the peripheral end of the segment upon itself. Nerve-stretching has been followed by complete relief for a time, but so far the reports upon this method do not seem to indicate any better results than are obtained by simple section of the nerve. Andrews reports a case in which stretching of the stump and tearing awav of the cicatrix in a case of neuralgia of the inferior maxillary division upon which he had operated one and a half years before by excision with complete relief, but in which the pain had again become severe, was completely successful in abating the trouble. Evulsion is sometimes productive of better results than excision, as many times a longer section of the nerve can be removed than by cutting it with a knife or neurotome. This method consists of grasp- ing the nerve — after it has been separated from its vessels — as far back as possible, with hemostatic forceps, and forcibly tearing it away. AI'.Ml-.XI' Ol' lUl l-"AtJ.\I. NKIKALC.IA. 415 Si(bcufa)icoiis Diz'ision of the Supraorbital Nerve is accomplished by entering- a tenotome knife between the eyebrows midway between the nerve and tlie median line, and passing horizontally beneath the skin until its point is beyond the nerve; its edge is then turned back- ward and pressed against the bone, and the nerve, lying between it and the bone, is divided by withdrawing the knife. Or, the knife may be entered at the same point, but passed close to the bone instead of just under the skin, its edge turned downward toward the margin of the orbit, and the nerve divided by sweeping the knife downward across the mouth of the supraorbital foramen. (Stimson.) A, B, Incisions for Excisionof the Supraorbital Nerve ; C, Incision for Excision of the Infraorbital Nerve, after the method of Tillaux. Excision of the Supraorbital Nerve may be made through incisions above or below the eyebrow. When made above, the incision may be an inch long and parallel to the eyebrow, with its center directly over the supraorbital notch or foramen. (Fig. 152, A.) The incision is carried down to the bone, the distal end of the nerve seized with for- ceps, dissected out, and excised. The incision made below the eyebrow requires the eyebrow to be drawn up, and the eyelid down, so as to make the tissues tense. An incision is then made close to the lower edge of the supraorbital arch, an inch long, through the skin, orbicularis muscle, and tarsal ligament. (Fig. 152, B.) The nerve is then traced backward from the notch as far as necessary by depressing the eyeball and the levator palpebrse with a spatula, and dividing the nerve with curved scissors. Excision of the Superior Maxillary Nerve is made by ,a curved in- cision about an inch and a half long following the lower border of the orbit; a second incision at right angles to the first, one inch in length, 4l6 SURGERY OF THE FACE, MOUTH, AND JAWS. is next made upon a line drawn from the supraorbital notch to the mental foramen, which will intersect the infraorbital foramen and expose the nerve. (Fig. 152, C. ) A silk thread is now passed beneath the nerve and tied for the purposes of identification and traction. The orbital tissues are then lifted by dissecting up the periosteum from the floor of the orbit, and elevated with a spatula; the infraorbital canal found and broken through, the nerve isolated and lifted from its bed with a curved hook, and divided with curved scissors at a point as far back in the orbit as possible. Traction upon the ligature will draw the nerve from its canal, when it may be severed below the ligature. Hem- orrhage is rarely troublesome, though occasionally it may be necessary to use a little packing to control the hemorrhage within the orbit. Fig. 153 shows scar resulting from two different operations for infraorbital neuralgia; A, Liicke's operation; B, Tillaux's operation. Removal of Meckel's Ganglion. — This operation is sometimes un- dertaken after the removal of the superior maxillary nerve. This is done by an operation devised by Carnochan, which consists of a T- shaped incision below the orbit, the horizontal line reaching from can- thus to canthus, and the vertical one nearly to the mouth; the tissues are dissected from the facial surface of the bone, and the infraorbital nerve found and secured with a ligature. The outer wall of the antrum is next perforated with trephine or chisel, the infraorbital foramen being included. The posterior wall of the antrum is also perforated in the same manner, care being taken not to wound the internal maxillary artery, which lies immediately behind and in close relation to the bone. The groove in the floor of the orbit is next broken "through, and after dividing the nerve upon the cheek it is drawn down and through the perforation in the posterior wall of the antrum. Tension upon the nerve offers a sure guide to the ganglion, by tracing it back into the spheno-maxillary fossa, and to the foramen rotundum, where it may be divided by long, slender, curved scissors. Hemorrhage may be controlled with gauze or sponges fastened to sponge-holders. For the purpose of illuminating the deeper portions of the wound an electric light or a head mirror are absolutely necessary. Excision of the Inferior Maxillary Nerve. — This nerve may be divided in three locations, at its exit from the mental foramen, in the canal, and before its entrance into the canal. Excision at the Mental Foramen. — This is accomplished within the mouth by an incision in the gingivo-labial fold above the foramen, which is located just behind the root of the first bicuspid tooth. The soft parts are dissected from the bone with an elevator or periosteo- tome, until the nerve is reached, which is usually about an inch or an inch and a quarter below the tip of the cuspid tooth. The nerve may then be seized with forceps and drawn as far from the canal as TREATMENT OF TRIFACIAL NEURALGIA. 417 possible, and divided with scissors close to the bone, and upon the peripheral side close to the soft tissues. Excision -cvithin the Canal.— This can be most successfully made by the Garretson operation (Fig. 154, A), which consists of making an in- cision about two inches long from the angle of the jaw forward. The Fig. 153. A, Incision for Liicke's operation for Excision of the Infraorbital Nerve; B, Incision for Tillaux operation. incision should, for cosmetic reasons, be kept well under the lower bor- der of the jaw. This incision will divide the facial artery, which must be secured. The tissues are now lifted from the outer surface of the bone by a periosteotome, for the entire length of the incision. The ex- ternal plate of the jaw is next trephined at the opposite ends of the in- cision, and about a quarter of an inch above the lower border of the 28 4i8 SURGERY OF Til li FACE, MOUTH, AND JAWS. jaw; the perforations made by the trephine are next united by two parallel incisions in the bone by a small circular saw, revolved by the surgical engine, — the trephine is driven by the same power, — when with an elevator the section of bone can be lifted from its place, thus exposing the inferior dental nerve and vessels lying in the canal. The nerve is then isolated and lifted from its bed with a blunt hook, and a section removed. Care should be taken not to wound the artery, as hemorrhage is sometimes troublesome. Agnew's operation consists of trephining the jaw at the angle directly over the canal (Fig. 154, B), and removing a section of the nerve. Fig. 154. A, Garretson operation ; B, Agnew operation ; C, Pancoast operation; D, Cryer operation. (After Cryer.) Excision before its entry into the canal may be made either through the mouth or through the cheek. In operating through the mouth, the jaws must be extended as far as possible with a mouth-gag placed upon the opposite side (Fig. 155). The mucous membrane is first incised at a point on the anterior border of the ascending ramus, midway between the crowns of the upper and lower second or third molar teeth, while the jaws are in this extended position. The finger is next inserted between the internal pterygoid muscle and the ramus. The tubercle situated at the opening of the foramen is now felt (Fig. 156, S) ; and the nerve brought to the surface by means of a blunt hook, grasped with hemostatic forceps, and TREATMENT OF TRIFACIAL NEURALGIA. 419 a section removed. Hemorrhage is sometimes profuse. Care must be exercised not to mistake the long internal lateral ligament for the nerve. Pancoast performed excision of the nerve by first removing the coronoid process by an incision through the cheek (Fig. 154, C). There is a serious objection to this operation, for the reason that it destroys the use of the temporal muscle. Fig. 155- Mason Gag. In operating through the cheek by an external incision, after the method of Cryer, an incision is made over the center of the ramus, beeinnine at the zvgomatic arch and extending downward an inch and Fig. 156. The Inferior Maxillary Bone— Internal Surface of the Right Side. G, Genial tubercles ; M, Mylo-hyoid ridge; O, opening of the inferior dental canal ; H, Mylo-hyoid groove ; S, Pterygoid tubercle ; A, Anterior or coronoid process ; P, Posterior or condyloid process. a half; the semilunar notch is now exposed and deepened with surgi- cal burs to the depth of about one inch, when the opening thus made through the bone exposes the nerve. (Fig. 154, D.) It is now picked up and a section removed. The wounds are to be sutured, and if treated with antiseptic precautions, will commonly unite by first inten- tion. CHAPTER XLIII. CONGENITAL FISSURES OF THE LIP AND THE VAULT OF THE MOUTH. Fissures of the upper lip, superior maxillary bones, and soft pal- ate are the result of arrested development of the parts involved, and consequent failure. of these parts to form a junction and coalesce. The fissure may be of any degree from a slight notch in the lip or a bifurca- tion of the uvula, to a complete cleft of the lip, alveolar process, palate bones, and velum palati; or a double cleft of the lip and bony palate and almost entire absence of the velum. The slightest degree of fissure is represented by a superficial notch or scar in the upper lip, and by a mere suggestion of a bifurcation of the uvula. The most common forms are fissures of the lip and the velum. Fissures of the lip often occur without cleft of the velum or maxillary bones, while on the other hand cleft of the velum frequently occurs without fissure of the lip ; the cleft in the palate may even extend forward to the alveolar process, and still not be associated with a fissure of the lip; but where the fissure extends through the alveolar process the writer has always found it associated with a fissure of the lip. 'Tn some rare instances, however, the alveolar process alone may be fis- sured." Fissures of the lip and palate may be unilateral or bilateral; but are most frequently unilateral, and most commonly upon the left side. Figs. 157 and 158 are photographs of cases which have come under the care of the writer, and are inserted for the purpose of illus- trating some of the extremes in unilateral fissures of the lip and the vault of the mouth. In the child (male) represented by Fig. 157, there Avas complete cleft of the hard palate, velum palati, and right side of the lip, with marked protrusion and eversion of the intermaxillary bone; in all other respects the child was perfectly formed. No history of hereditary ten- dency or of maternal impressions could be deduced. Fig. 158, also a male child, has complete cleft of the hard palate, velum palati, and left side of the lip, with marked protrusion of the intermaxillary bone. The deformity of the face in this case is much greater than in the preceding one, while in other respects the child was 420 CONGENITAL FISSURES OF THE LIP, ETC. 421 defective in development, having an immense congenital scrotal hernia, — larger than a goose-egg, — and the fourth and fifth toes of the left foot united. Bilateral fissure of the lip and maxillary bones with protrusion of the intermaxillary bones and median cleft of the soft palate occasion- ally occurs. (Fig. 159.) The writer has operated ui)on several cases of this character associated with extensive protrusion of the intermax- illary bones. Figs. 160 and 161 show a rather extreme case. In each of these cases there was no union of the palate process with the vomer on either side. Fig. 157. Complete Cleft of the Hard Palate, Velum Palati, and Right Side of the Lip, with MARKED Protrusion of the Intermaxillary Portion of the Jaw. Child 9 weeks old. In exceptional cases the fissures may extend upward on either side of the nose, or backward, involving the base of the skull. Median fissure is very rare. Salter mentions three cases, one described by Rokitansky, one met in his own practice, and a specimen in the Museum of the Royal College of Surgeons, London. Occasionally there is an entire absence of the maxillary bones, and consequently of the incisor teeth. A case of this character recently came under the observation of the writer in a female child six weeks old, in which there was a com- plete cleft of the hard and soft palates and fissure of the lip on the left side, with entire absence of the intermaxillary bone and the vomer. The cleft through the alveolar process measured five-eighths of an inch in width. The tip of the nose was greatly depressed, being but very slightly elevated above the level of the cheeks. The cartilaginous 422 SURGERY OF THE FACE, MOUTH, AND JAWS. nasal septum was also absent. The whole condition caused one of the most ugly deformities imaginable. There was no history of heredity or of maternal impression. In Salter's case of median fissure, the right intermaxillary bone was slightly deficient, with absence of the central incisor; the lateral, however, was in position standing close to the cuspid and separated from the left central by a deep fissure. Fig. 158. Complete Cleft of Hard Palate, Velum Palati, and Left Side of the Lip, with marked Protrusion of the Intermaxillary Portion of the Jaw. Child 8 months old. Broca has reported quite recently a case of complete fissure of the upper lip with absence of the median tubercle. Median fissure of the face is more often associated with the lower lip and inferior maxilla than with the upper portion of the face. A remarkable case of this character (Fig. 162) is reported by A. Wolfier, as occurring in an infant that came under his notice when it was twenty-three days old, in which the lower lip was cleft, the inferior maxilla separated upon the median line, but held together by a cica- tricial band; the fissure extending downward into the neck to the CONGENITAL FISSURES OF THE LIP, ETC. 423 supra-Sternal fossa; the anterior portion of the tongue was Hkewise divided into two halves upon the median line. These deformities were successfully corrected by surgical operations. Sometimes there are other defects of development associated in the individual with fissure of the palate, due to the same general Fig. 159. Double Hare-Lip, with protrusion of the intermaxillary bone, and non-union of the maxillary bone with the vomer on both sides, making what might be termed a double cleft in the hard palate. The cleft m the soft palate was exceedingly wide, showing very imperfect development. causes. These defects are occasionally of an extreme character and serious nature, and interfere with the performance of the natural func- tions of the body. Origin. The origin and causes of hare-lip and cleft palate are to be sought for among the pre-natal influences, and are generally con- ceded to be faults in the developmental process. These influences to be operative must occur prior to the tenth week after conception. The formation of the maxilla begins at a very early period of intra-uterine 424 SURGERY OF THE FACE, MOUTH, AND JAWS. life, viz, at about the twenty-eighth day, by the development of four tiny buds, tubercles, or processes near the central portion of that sur- FlG. 1 60. Double Hare-Lip with Protruding Intermaxillary Bones. Side view. Fig. 161. Double Hare-Lip with Protruding Lvtermaxillary Bones. Front view. CONGENITAL FISSURES OF THE LIP, ETC. 425 face of the nulinicntary head which is destined to form the face (Fig. 163), which are denominated the superior or frontal processes or tuber- cles, and the lateral or oblique maxillary processes or tubercles. Fig. 162. Median Fissure of the Lower Lip and Chin. (After Wolfler.) Fig. 163. Superior Tubercle. Lateral Tubercle. Superior Tubercle. Lateral Tubercle. Head of an early Human Embryo, showing the Disposition of the F.\cial Fissures and OF the Superior and Lateral Tubercles. (After His.) 426 SURGERY OF THE FACE, MOUTH, AND JAWS. The superior processes elongate downward, and at the same time approach each other toward the median Hne, where they finally coalesce to form the intermaxillary bones and the central portion of the upper lip. The latter processes likewise elongate and approach each other toward the median line, where they finally meet the superior processes and unite with them, thus forming the lateral halves of the superior maxillary bone, palate bones, the cheeks, and lateral portions of the upper lip and the velum palati. Non-Union of Superior and Lateral Processes. — The frontal pro- cesses rarely fail to unite upon the median line; but it is not uncommon for the oblique maxillary processes of either side to fail to unite with the frontal processes, and occasionally both sides fail; thus, in the former case producing a fissure upon the right or left side, and in the latter a double fissure. Fissures of the lip are the result of the same causes, viz: failure of the central portion of the lip to unite with the lateral portions, while clefts in the velum palati are the result of a non-union of the lateral half with its fellow upon the median line. Arrested Development. — In many cases there is a deficiency in the various tissues which go to make up the complete superior max- illary bone, palate bones, lip, and soft palate; hence the primary cause would seem to be an arrestment of the developmental process in these particular parts. The writer has seen several cases in which the velum palati especially was very deficient and only rudimentary in character, while in others there was a marked deficiency in all of the tissues of these parts, leaving a broad, yawning aperture. The extent of the fissure will depend very largely, if not entirely, upon the time at which the arrestation of development occurred; the earlier the period the more extensive the cleft, and vice versa. At about the fortieth day after conception the superior and lateral processes have united, and by the end of the tenth week the vault of the mouth has been completed by the union of the velum palati and uvula through their entire length; this process begins at the anterior aspect, and progresses backward, the uvula being the last portion to unite. In certain cases of hare-lip and cleft palate there is a sufficiency of tissues, the only fault seemingly being a failure of union of the parts at the proper time. These cases when treated surgically in the early months of infanc3% generally secure normal position of the parts and a complete restoration of function. The fundamental influences, however, which underlie the causa- tion of these defects in development have not yet been reached, and all theories which have so far been advanced to account for them belong to the realm of speculation and conjecture. Faulty Nutrition. — Some have thought the trouble to be caused CONGENITAL FISSURES OF THE LIP, ETC. 427 by a fault in the diet, through the exclusion of meat as an article of food, or the introduction of an insufficient quantity of calcium phos- phates into the system of the mother during gestation. As an argument in favor of this view it might be stated that the lions in the Zoological Gardens of London were fed for several years upon meat from large animals having bones too large for them to crusli and swallow; this was followed by the birth of cubs with cleft palate, — 99 per cent., — which lived but a short time on account of their inability to suckle. The lions were then occasionally given a small animal, like a goat or sheep, the bones of which were readily crushed by their teeth, and the young afterward born had perfectly formed palates. At the Zoological Garden of Dublin a like experience was en- countered, and was counteracted by feeding the pregnant lions with ground bones and foods containing calcium phosphates. Dr. J. Ewing Mears reports the same condition prevailing among the offspring of the lions at the Philadelphia Zoological Garden. Neither of these arguments is entitled to very much weight, for the reason that it is a fairly well-established fact that union of the superior and lateral maxillary processes in the human subject is not dependent upon ossification of these structures, for union or coales- cence takes place in advance of ossification, and this process is not completed along the line of the sutures until some time after birth. It is also a well-established physiologic law that in the pregnant woman, if there is not a sufficient amount of calcium salts ingested to support the extra demands made upon the system for the proper devel- opment of the osseous framework of the fetus, and to recoup the waste in her own tissues, the material already stored up in her body is drawn upon to supply the demands of the fetus. Changes in the constituent elements of the bones are of common occurrence as a result of malnutrition. Dalton says, "Next to the chlorid of sodium, the phosphate of calcium is considered the most important ingredient of the body. It is met with universally in every tissue and every fluid," and "whenever the nutrition of the bone during life is interfered with from any pathologic cause, so that its phosphate of calcium becomes deficient in amount, a softening of the osseous tissue is the consequence, by which the bone yields to external pres- sure and becomes more or less distorted." In fractures occurring during gestation, union is often delayed, sometimes until after delivery. Padieu describes a case in which frac- tures of the tibia and fibula occurred nine days after the suppression of the menses, and in which union was delayed until the end of gestation. The process of union began ten days after delivery, and was completed at the end of a month. . 428 SURGERY OF THE FACE, MOUTH, AND JAWS. The pelvis, though looked upon at all other times as a compara- tively solid framework, frequently becomes relaxed in its articulations during pregnancy, so that the sacro-iliac and pubic joints become movable. Many women are in the habit of discarding from their aliment during pregnancy all those foods which contain an abundance of cal- cium salts, and restrict themselves, as nearly as possible, to a fruit diet, believing that by such practice the bones of the child will be imper- fectly calcified, and thus parturition be robbed of much of its sufifering. There is, however, no scientific evidence that such a result is obtained, while on the other hand, as in those cases affected with hyperemesis, though the child when born may be small and much emaciated, it has the appearance of being properly formed, and its bones as dense as in the majority of normal pregnancies. Heredity. — The question of hereditary influence is one that calls for more than a passing notice, for a priori it would strike one as likely to be an important factor in the production of defects of development. The facts, however, which have been adduced are not of sufficient strength to establish it. A few isolated instances have been reported in which there seemed to be an indirect inherited tendency in a certain family to produce offspring with hare-lip and cleft palate. Oakley Coles mentions two families in which there was a marked tendency in this direction. In the first family there were three with cleft palate, one seventeen years of age, another thirty, and the third thirty-five; the first and last were women. The man, who is married, has a family without a single instance of the father's deformity. The second family was composed of five children, two of whom had fis- sure of the lip and palate; the first child was bom perfect, the second had single- hare-lip and cleft palate, the third child was perfect, the fourth had double hare-lip and cleft palate, and the last child was perfect. The maternal grandmother also had cleft palate. Lawson Tait believes that heredity is a strong factor in the production of this deformity, and says he has known it to skip three generations and then appear in an hereditary form. E. F. Plicque reports a case of hare-lip in a female, in which he thinks the deformity is undoubtedly inherited. The family history is as follows: Both parents of the patient were entirely free from any congenital defect. One of her father's brothers had supernumerary fingers. A brother of her mother was born with hare-lip, but both of his children were free from the deformity. His sister, the mother of the patient, has given birth to nine children, five of whom had hare- lip but no palatal defect. Another sister of the patient's mother, who was free from congenital defect, gave birth to two children with hare- CONGENITAL FISSURES OF THE LIP, ETC. 429 lip and cleft palate of an uncommonly severe type. A brother and a sister of the patient, both of whom had congenital hare-lip, had mar- ried, but neither of their five children had any sign of the defect. Manley says in all of his cases there was either a history of heredity or of maternal impression. The writer recently operated upon a child six months old, with double fissure of the upper lip and hard palate, with protrusion of the intermaxillary bones and only rudimentary velum, this being the sec- ond child born of the same parents, in whom the tendency was marked. The first child was born with fissure of the left side of the upper lip; the second child was born perfect, and the third child wdth the defect first described. There was no history of similar defects of develop- ment in the family of either of the parents. Maternal Impressions. — It is interesting to note in this connec- tion that most w^omen who are so unfortunate as to give birth to deformed children, especially those with deformities of the face and mouth, feel very confident that it is the result of maternal impressions induced by fright, the sight or knowledge of a like deformity, etc. How much, if any, there may be of scientific truth in this popular no- tion the writer is not prepared to say, more than that in all popular notions there is generally somewhere hidden away a kernel of truth. When we know more about the influence which the nervous system exerts over cell-life, the effects of the physical and mental conditions of the parents at the time of conception, and of the female parent during gestation, we shall be better able to consider the question from a scientific standpoint; till then it would be mere speculation. Prognosis. — Most of the fissures and perforations of the hard palate are susceptible of radical cure by plastic surgical operations; the excep- tions being those cases where there is marked deficiency in develop- ment, or loss of tissue, and even in these there is reason to hope that the operation of transplanting new tissue from some adjacent locality will be so perfected as to become not only feasible as an operation, but successful in re-establishing the functions of the parts. In clefts of the velum palati where the fissure is very wide and the deficiency in tissue is considerable, it is better to depend upon the artificial velum, rather than to attempt a cure by surgical measures; for unless the velum can be restored to its normal length so as to perfectly close the naso-pharyngeal opening, the operation w^ould be a failure, from the practical standpoint, for restoration of function is the main object in view. The enthusiasm of the surgeon has many times carried him be- yond the limits of a wise conservatism in the treatment of these cases, especially in operations upon the velum, with the natural result, failure. Consequently there are those who decry all attempts at cure by a surgi- 430 SURGERY OF THE FACE, MOUTH, AND JAWS. cal procedure, and maintain that in all cases mechanical appliances accomplish the best results in restoring the functions of the parts. A wise conservatism in both directions will, in the writer's opinion, give the best results in the individual case, for in no department of surgery- is good judgment of more value to the patient. The mortality of operations for fissure of the lip and palate, according to the investigations of Hoffa, is greatly influenced by the deformity itself. From the records of 114 cases of hare-lip, twenty- seven deaths occurred, giving a mortality of 23.7 per cent. ; while out of III cases of complete fissure of the lip and palate operated upon, there were forty-three deaths, making the mortality 38.73 per cent. Boiling maintains that although the mortality rate is high in oper- ations for the correction of these deformities, it does not very much exceed that of children of the same age. Although the writer has not statistics at hand to substantiate his opinion upon this question, he yet feels sure that this rate of mortality is considerably higher than for such operations among American surgeons. CHAPTER XLIV. CONGENITAL FISSURES OF THE LIP AND THE VAULT OF THE MOUTH (Continued). Surgical Treatment. The operations which are practiced for closing the fissures of the palate are designated as uranorrhaphy and staphylorrhaphy. Uranoplasty or uranorrhaphy is the operation for closing a fissure in the hard or bony palate, while staphyloplasty or staphylorrhaphy is the term ap- plied to the operation for closing a cleft in the soft palate or velum palati. Chiloplasty or chilorrhaphy is the operation for closing a fis- sure in the lip. Lemonnier, a French dentist, is credited with having been the first to suggest and to successfully operate for the closure of fissures of the palate by surgical operation, the record having been published in 1766. Lemonnier succeeded in closing a fissure in both the hard and soft palates, by paring the edges of the cleft with a knife, and approximating them by the use of sutures. Perforations in the hard palate he success- fully closed by exciting granulation of their borders. Eustache, a physician of Beziers, in 1799 recommended the same procedure to a patient for whom the day before he had split the soft palate for the purpose of removing a polypus of the pharynx. The operation, however, was declined by the patient. In 1800 he pre- sented a paper upon the subject of closing congenital fissures of the soft palate to the Academic de Chirurgie at Paris, asking their approval of the operation, but this they declined to grant. Von Graefe revived the operation in 18 16, and reported to the Medico-Chirurgical Society of 'Berlin that after many unsuccessful efforts to close fissures of the soft palate he had at last obtained success by freshening the edges by the application of muriatic acid and the tincture of cantharides, and then approximating them with sutures. The operation was modified by Roux, in 18 19, who closed a fissure of the palate by paring the edges and applying sutures. Warren, of Boston, in 1820, being ignorant of the efforts of the other surgeons, performed successfully a similar operation. After this time the operation became generally known and practiced. To Sir William Fergusson, of England, however, belongs the 431 432 SURGERY OF THE FACE, MOUTH, AND JAWS. credit, more than to any other surgeon, of first demonstrating and giv- ing to the world a scientific basis for the requirements of the operation of staphylorrhaphy. The first important question in relation to the surgical treatment of cleft palate is that of the age of the child which gives the best pros- pect of a successful issue of the operation, and the restoration of the parts to normal function. Experience has taught the writer that skillful operations for clos- ure of fissures of the palate Avhen performed during the early months of infancy are more successful in restoring the functions of deglutition and articulation than when postponed, as is generally advised, until after the eruption of the deciduous teeth, or even to as late a period as the fifteenth year. In order to obtain the best results, the operation should be completed before the child begins the first attempt at articu- late speech. When delayed until after speech has been acquired, it is much more difficult to overcome the peculiar nasal tone that always ac- companies the voice in persons with perforations, or clefts, of the bony palate or velum. Another argument in favor of early operation is the facility and comparative safety with which infants can be brought under the control of anesthetics, and the ease with which anesthesia can be maintained, and this is a great desideratum in all operations upon the mouth. Chloroform has the preference, with the writer, for operations upon little children. In complete clefts of the upper lip and maxilla there is a noticeable broadening of the face upon the affected side ; the distance from the median line of the apex of the nose to the antero- inferior angle of the malar bone is greater than upon the perfect side, and there is also accompanying this a decided spreading out and flatten- ing of the ala of the nose. When the lip has not been closed this broad- ening of the face and flattening of the ala of the nose increase with the growth of the individual. (Fig. 164.) On the other hand, in those cases where the lip has been closed early, this widening is not only pre- vented, but there seems to be a slight narrowing of the cleft, due no doubt to the muscular contraction of the united lip. An early operation should therefore be recommended for the closure of the lip and, where the strength of the child will permit, of the fissure in the bony palate and velum as well, provided the condition of the velum gives promise of successful restoration of function. A second operation for the closure of the velum can be done a few months later if the condition of the child is not favorable for such procedure at the time of closing the fissure in the hard palate. Operations. — In operations about the mouth the choice of anes- thetics must be governed by the age of the patient and the general con- ditions of health. Under no circumstances should general anesthetics be administered for this operation if the patient is suffering from acute CONGENITAL FISSURES OF THE LIP, ETC. 433 nephritis or Bright's disease. Chloroform is the pleasantest for all mouth surgery, especially in operations upon the velum, on account of Fig. 164. Hare-Lip and Cleft Palate. Fig. 165. Chloroform Inhaler and Drop-Bottle. the fact that it is not so liable to cause vomiting or irritation of the bronchial mucous membrane as is ether, though it has the disadvantage 29 434 SURGERY OF THE FACE, MOUTH, AND JAWS. of being much more dangerous to life. Little children, however, as a rule, bear chloroform much better than adults, and it may therefore be administered with comparative safety, and also much better after- effects. A most convenient method of administering chloroform is by use of the inhaler and drop-bottle (Fig. 165), though it may be admin- istered upon a handkerchief or a napkin. When administering ether, the inhaler, Figs. 166 and 167, will be found most convenient and useful. Fig. 166. Ether Inhaler. Fig. 16; Ether Inhaler. The position of the patient in operations upon the vault of the mouth is one that needs careful consideration, on account of hemor- rhage, which is often quite profuse when operating upon the hard palate by the Langenbeck method, and the difficulties sometimes ex- perienced in getting good illumination of the parts. The position shown in Fig. 168 is the best under nearly all circumstances, as it per- mits the blood to escape by the nostrils instead of into the throat, and at the same time gives a good view of the parts if the operator stands at the head of the patient. The instruments needed in performing a staphylorrhaphy are: a CONGENITAL FISSURES OF THE LIP, ETC. 435 mouth-gag, Mason's (Fig. 155) or Whitehead's (Fig. 169), a sharp- pointed curved bistoury (Fig. 170), a pair of mouse-tooth tissue-forceps (Fig. 171), a pair of curved needles — right and left — with handles (Fig. 172), a suture pick-up (Fig. 173) and a wire-twister (Fig. 174), a pair of small, long-handled scissors, silk and silver wire sutures, per- forated shot, and a shot compressor. Fig. 168. ■ill ,. Position of Head during Opkrations on the Mouth. Fig. 169. Whitehead Gag. In operating upon a simple hare-lip, a bistoury or the hare-lip scissors may be used for paring the edges of the cleft. (Fig. 175.) In a flap operation upon the lip the bistoury or a small scalpel is the best for this purpose. A pair of lip-compressors (Fig. 176), will also be found serviceable for controlling the hemorrhage. The lip may be united either with the hare-Kp pins and the figure-of-8 suture, or wdth the interrupted suture of silk or catgut. 436 SURGERY OF THE FACE, MOUTH, AND JAWS. Fig. 170. Curve-pointed Staph vlorrhaphv Bistourv. Fig. 171. Special Staphylorrhaphy Tissue Forceps. Fig. 172. Author's Jackson-Eve Staphylorrhaphy Neelles. Fig. 173. Suture Pick-up. Fig. 174. Special Wire-Twister. Fig. 175. Hare-Lip Scissors. Fig. 176. Lip Compressors. CONGENITAL FISSURES OF THE LIP, ETC. 437 Hare-Lip.^ — In uniting- fissures of the lip it is important to con- serve as much of the tissue as possible, in order that the lip may not be unnecessarily contracted. Various methods have been devised to give a normal shape to the free border of the lip and to prevent the notched condition which so often follows hare-lip operations. In all operations for closing fissures of the lip it is important to dissect the lip from the alveolar process upon either side of the cleft for a considerable distance backward, in order to gain as much tissue as possible and to prevent strain upon the freshly-united edges of the cleft. The common method of uniting a cleft in the lip is simply to pare the edges with a curved bistoury, inserting it at the angle of the cleft upon one side and then upon the other, and carrying it through the lip to the vermilion border, removing a paring the full thickness of the lip, or obtaining the same result by trimming the edges with the hare-lip scissors. The edges are then brought together with sutures of silk, catgut, or hare-lip pins. The lip-compressor may be necessary to con- trol the hemorrhage from the coronary arteries until the sutures are ready to be placed. Tying of these vessels is rarely if ever necessary. Fenger, of Chicago, has lately devised a new operation for hare- lip, which consists essentially of utilizing the parings of the fissure to lengthen the border of the lip, splitting the edges of the flaps and unit- ing the edges of the mucous membrane and the skin by separate lines of sutures, this part being similar to the operation of Tait for uniting the lacerated perineum, and also that of Marcy for closing the velum palati. Fillebrown, of Boston, recommends the following operation, which is similar to that devised by Nelaton, for relieving the notched condition of the lip so frequently seen in the border after operation for single fissure of the lip: "A male, aged thirty, a patient in the Harvard Dental Hospital, came to have an obturator constructed for cleft palate. The cleft in- volved the hard as well as the soft palate, and originally a hare-lip. The lip had been operated on, and of course much improved, but the characteristic notch was present. (Fig. 177.) "It had long been my belief that this deformity could be remedied, and I hailed with pleasure the opportunity to apply the remedy. "The operation performed for it is shown in the illustration here presented. It was the result of study, experiment, advice, and acci- dent, and its success entirely fulfilled my expectations and hopes. "By comparing the two cuts and noting the position of the letters, the operation will be fully understood. "The line a-b. Fig. 178, represents the cicatrix left by the former operation. The line c-d shows the line of the incision transversely across the lip. 438 SURGERY OF THE FACE, MOUTH, AND JAWS. "Fig. 179 shows the incision made vertical by drawing the hp, down and inserting a suture and drawing the points g-h, representing c-d of Fig. 178, close together. This converted the horizontal in- cision into a vertical one, and lengthened the lip at that point by just the length of the cut. "Fig. 177 shows the case as photographed just previous to the operation. The notch was so considerable as to show the patient's lateral incisor tooth continually. "Fig. 180 shows the case as photographed after the lip had healed. "The approximation of the lips was perfect, and but very little narrowing of the red border was perceptible. Fig. 177. Fig. 178. fa I c -= =» a Fig. 179. e ? • Fig. 180. Fillebrown's Operation. "The excessive size of the nostril was reduced by a V-shaped in- cision, taking out a piece of the wall of the nostril and drawing the edges together. This was entirely independent of the lengthening of the lip. "The operation proved an entire success." In cases of single cleft of the lip and palate the writer advises the closing of the lip as soon after birth as the condition of the child will permit, and the operation upon the bony palate and velum from the sixth to the twelfth month. In operating for single hare-lip, preference is given to the Mirault method as most likely to produce a lip of normal length and width. This consists of bringing down a flap from one side, sliding it across the cleft, and attaching it to the pared opposite side. Fig. 181 is the result of a Mirault operation upon the child. Fig. 157, photographed ten days after the operation. The intermaxillary bone was brought into position by fracturing the bone upon the left side and uniting the edges of the cleft in the maxilla by a wire suture. Owen's operation, Figs. 182 and 183, is quite similar, although the incision for making the flap is carried into the lip somewhat deeper. This incision gives the fullness to the lip where most needed. CONGENITAL FISSURES OF THE LIP, ETC. 439 In closino- the hard palate in these cases the writer prefers the Langenbeck operation— muco-periosteal flap— from the fact that in a majority of instances it succeeds in filling the gap with osseous tissue. In cases of double cleft of the lip and palate with protrusion of the intermaxillary tubercle, operation should be advised at the earliest Fig. i8i. Result of Operation for Depression of the Intermaxillary Portion of the Jaw and Closure of the Hare-Lip. Ten Days after Operation. possible dav, as these children are prevented from taking the breast or even the bottle ; feeding by the spoon is therefore the only method that can be used, and on account of the difficulty in swallowing, they as a rule do not obtain sufficient nourishment to properly sustain the functions of life, and as a result many dwindle away and die. Early correction of the deformity in the anterior portion of the mouth is therefore imperative. 440 SURGERY OF THE FACE, MOUTH, AND JAWS. It is customary with most surgeons in operating upon these cases to cut away the protruding" intermaxillary tubercle and close the lip upon the median line. This certainly is the easier method, but it is open to serious ob- jections; first, because this portion of the maxilla contains the incisor Fig. 182. Fig. 18,1. Owen's Operation. Owen's Operation. teeth; second, because it removes the bony column upon which the nose rests; and third, because it produces an extreme narrowing of the face in the incisor and cuspid regions, with more or less complete stenosis of the nostrils, a deformity which can never afterward be remedied. The preferable method is to replace the intermaxillary tubercle by removing an inverted V-shaped section from the vomer, carrying the Fig. 184. Hanesby Truss. tubercle into position and retaining it there by a wire passed through holes drilled in the vomer anteriorly and posteriorly, to the point of section, and allowed to remain until union has taken place. If the lateral surfaces of the tubercle now come in contact with the lateral halves of the maxilla, the occluding surfaces should be freshened, and one or more fine silk sutures passed through the gum- tissue upon either side. When the surfaces do not occlude and the separation to be overcome is not very great, forcible pressure can be CONGENITAL FISSURES OF THE LIP, ETC. 44I made upon the malar bones by the hands of the operator until the surfaces meet, and afterward held in position by means of the Hanesby truss (Fig-. 184) or rubl^er bandage, as suggested by Garretson. In closing the lip, it is preferable to utilize the central portion if it is of sufficient width to admit the passage of sutures, rather than to cut it away, and unite the lip upon the median line. The Golding-Bird operation is the one usually practiced by the writer in these cases; it consists in removing the vermilion border on all sides, leaving the prolabium with straight edges. The lateral halves of the lip are then dissected from their attachment to the bone, and pared to fit the trimmed prolabium. In order to obtain a suffi- cient amount of tissue to form a good lip, it sometimes becomes neces- sary to carry an incision around the ala of the nose and into the cheek. A deep suture is passed near the border of the lip, just above the edge •of the mucous membrane, and another at the lower border of the ala •of the nose to give proper shape to the nostrils, — it is often impossible to pass more than these, — and the edges of the skin and mucous mem- brane brought into nice apposition with fine interrupted silk sutures. To relieve tension and protect the wound it is covered with a collodion ■dressing, and over this an adhesive strip. The writer prefers to replace the maxillary tubercle and close the lip at the same time. Operation upon the fissured palate should be deferred till a later period. This operation he has performed several times with uniformly good results. One child was but six days old, but the operation was borne well, and he took the breast three hours •afterward. The others were between two and six months old. Fig. 185 shows the results in a case of double hare-lip with protruding inter- maxillary bones, four months after the operation, in a child three years of age. "Uranorrhaphy. — In operations upon the bony palate — urano- plasty — the writer usually prefers the Langenbeck method, which con- sists of first paring the edges of the cleft; second, making an incision through the soft tissues covering the hard palate close to the teeth, and lifting these tissues from the bone with a curved periosteotome, sliding them over the fissure, and uniting the periosteal surfaces together with the cobbler's stitch or suture. This method of stitching is a modifica- tion suggested by the writer, and gives more satisfactory results than the old method of uniting the edges by the interrupted suture. Fergusson's operation consisted of drilling the bony palate at ■short intervals from before backward, and then splitting it with a •chisel. The edges of the cleft having been previously pared, are then ■united by silver wire sutures. Billroth has recently modified the Langenbeck operation for clos- ing fissure of the hard palate and velum, by approximating the internal 442 SURGERY OF THE FACE, MOUTH, AND JAWS. wings of the sphenoid. This he accompHshes by dividing the mucous membrane at the sides of the velum, and fracturing the bone with a chisel. The mucous membrane is then utilized to close the cleft. His object is to do away with the necessity of dividing the muscles of the velum, particularly the circular or sphincter muscle which surrounds the naso-pharyngeal opening, and which has its anterior fibers in the velum palati. Fig. 185. Double Hare-Lip, with Protruding Intermaxillary Bones. Four Months after Operation. Rotter, of Munich, describes an interesting case of a child six: years old, upon whom he had operated previously by the Langenbeck method for an uncommonly wide fissure; the muco-periosteal flaps had united upon the median line by first intention through their entire length, but left an opening upon the left side near the teeth, about four- tenths of an inch in width, giving free communication between the mouth and nasal cavity. To close this opening he raised a flap of skin, from the forehead (Fig. 186), having a long pedicle attached, and the CONGENITAL FISSURES OF THE LIP, ETC. 445 gap in the forehead was immediately closed with sutures (Fig. 187). He then placed upon the raw surface of the flap numerous epidermal grafts after the method of Thiersch, placed the flap against the fore- head with the raw surface undermost, and held it in position by a bandage. At the end of eight days the grafts had taken, and the flap was covered with skin upon both sides. The next steps were to lengthen the incision along the right side of the nose to the cleft in the lip, raise the right ala of the nose, freshen the edges of the opening in the palate, stitch the flap into position, close the fissure in the lip, and re- place the ala of the nose. (Fig. 188.) Fig. 186. Rotter's Operation for Cleft Palate. (Afier Roller.) The case was successful, and Rotter exhibited the child two years later to the Congress of German Surgeons. One of the remarkable facts in the case was that though the flap was covered upon both sides with skin, the moisture in which it was constantly bathed seemed to have no deleterious effect upon it. Rotter states that only two other cases are on record in which tissues had been transplanted for a like purpose from other locations than the palate itself, the first by Blaisus, the second by Thiersch. Davies-Colley has also devised a mode of operating for the closure of wide clefts in the hard palate. This operation consists in forming a triangular muco-periosteal flap upon one side of the cleft, while upon 444 SURGERY OF THE FACE, MOUTH, AND JAWS. the Other side a raw surface is prepared by raising and reflecting" a longitudinal flap in such a way that it can be turned over as on a hinge into the cleft. The first flap is now implanted upon the second, bring- ing their raw surfaces together and suturing them in this position. Another method of closing a wide cleft in the hard palate is that suggested by T. Smith, which consists in raising muco-periosteal flaps from the sides of the vomer, operating upon one side at a time, by turning down the flap, leaving it attached at the lower border of the vomer, and suturing the edge of the flap to the border of the cleft which had been prepared to receive it by freshening its edge. Fig. 187. Fig. li Rotter's Operation for Cleft Palate. (After Rotter.) Rotter's Operation for Cleft Palate. (After Rotter.) Brophy, of Chicago, has recently devised a new method of approx- imating the edges of fissure of the palate which is unique and original, and for which he claims a decided advantage over other operations. The method consists substantially in passing two double silver wire sutures through the superior maxillary bone, within the mouth; the posterior one inserted just behind the malar process, and high enough to pass over the palate plate of the bone, emerging at the same point upon the opposite side; the anterior one is passed through the bone just in front of the malar process. A lead button having two eye- holes is threaded upon the wire, and the ends twisted together. The edges of the cleft having been previously freshened, the wires are CONGENITAL FISSURES OF THE LIP, ETC. 445 twisted until the edges of the cleft are brought together. If the re- sistance is such that the edges do not readily approximate, the malar process is divided on either side by the aid of a heavy scalpel. The edges of the cleft are united by sutures in the usual way. This operation would seem to be valuable if performed during the early months of infancy, while the bones are still imperfectly calcified, in those cases where the deficiency of tissue is slight and the edges of the fissure but moderately separated. Where the cleft is wide and the deficiency of bony tissue considerable, it might succeed in closing the defect in the palate; though it would establish another deformity equally grave in character, viz: partial or complete stenosis of the nasal passage of the affected side. It is to be presumed, therefore, that Brophy w^ould not advise this operation, only in selected cases where this condition could not result. In the cases first mentioned it would seem to have an advantage over the Langenbeck muco-periosteal operation; but in fissures of any considerable width, or in double fissure, the latter procedure would be preferable. In a case of cleft palate in w^hich the Langenbeck as well as the Davies-Colley operation failed to cover the immense congenital defect, Carl Black recently implanted a portion of the tongue. The ease wdth which even extensive resection of the tongue is tolerated by carcinoma- tous patients induced him to form a lateral flap from the tongue, which, after being turned and reflected near the base, was united with the freshened edge of the cleft of the same side. The gaping wound-mar- gins of the side of the tongue were then accurately united, and the floor of the mouth and the lingual angle were packed with iodoform gauze. During the after-treatment a mild solution of boric acid was sprayed through the nostrils every fifteen minutes. Liquid diet was given exclusively. After nine days the base of the flap w^as severed, and one w^eek after, the flap was united with the opposite margin of the cleft according to the usual uranoplastic procedures. Staphylorrhaphy. — A modification of Nekton's operation for bifid uvula and single hare-lip has, in the hands of the writer, given good results when applied to closing the velum palati. This method is especially adapted to those cases where the cleft in the velum is the only oral defect. The usual method is to freshen the edges of the velum with a bold hand — most surgeons claiming that successful union is more often obtained by this method than when less tissue is cut away. This, so far as obtaining good union is concerned, is a self-evident fact; but why sacrifice tissue w-hen there is generally so little in the first place to operate upon? The main object is to restore function, and this can only be accomplished by restoring the velum and uvula to their proper 446 SURGERY OF THE FACE, MOUTH, AND JAWS. width and length, so as to insure a perfect occlusion of the naso- pharyngeal opening. In paring the cleft by either the bold or conservative method, the parings are usually sacrificed. B}' the method which is now presented the parings are utilized to broaden and lengthen the velum and form a new uvula. In the act of deglutition the velum palati is drawn up against the walls of the pharynx, the base of the uvula filling the depression upon the median line formed by the approximation of the two sides of the pharynx, thus perfectly closing the naso-pharyngeal opening and pre- FlG. li ■Cleft of the Soft Palate. Showing Line of Incision in the Author's Modification of NiiLATON's Operation for Bifid Uvula applied to Cleft Velum. venting escape of food into the nasal passages in the act of swallow- ing, and materially assisting in the production of articulate speech by preventing the escape of certain sounds through the nasal passages. By the modified Nelaton operation every particle of tissue is saved and carried to that part of the velum where it is most needed to im- prove the shape, the width, and the length. (Fig. 189.) The method is similar to that often practiced upon single hare- lip, viz: a curved, pointed bistoury is inserted just above the apex of the cleft, and carried downward toward the uvula of one side, about ■one line from the cleft at the apex, gradually increasing the distance as the bistoury approaches the uvula to about two lines from the edge of CONGENITAL FISSURES OF THE LIP, ETC. 447 the clelt and three lines from the posterior border of the vekim. This .incision is repeated upon the opposite side. The apex of the paring is then carried backward, and the fresh- ened edges of the palate, after having been split to the depth of about one-fourth of an inch, are approximated and sutured. The object in splitting the palate is to gain a broader surface of tissue at the edges of the cleft, and thus increase the chances of primary union. Three or four sutures are usually inserted, silver wire being given the preference as less likely to induce suppuration or ulceration about the sutures. Tension is relieved when necessary by dividing the tensor palati muscle upon either side, but this procedure is by no means always indicated. The after-treatment consists in keeping the wound and sutures as clean as possible by swabbing and spraying the parts with the Thiersch antiseptic solution at least every two or three hours. The sutures are allowed to remain from four to ten days, according to indications. KiNGSLEY's Artificial Velum. (After Kingsley.) Meclianical Treatment. — The mechanical treatment of cleft pal- ate by means of artificial vela has through the inventive genius of Dr. Norman W. Kingsley been brought to a very high degree of perfec- tion. In no department of mechanical surgery has a greater achieve- :ment been recorded than in the invention of the artificial flexible velum. All efforts in the direction of mechanisms for closing congenital defects in the palate which preceded the apparatus of Kingsley were crude, clumsy, rigid aflfairs, and of but little practical utility to the patient. The discovery by Goodyear of the process of vulcanizing rubber made it possible for Kingsley to construct an appliance from a material which by its adaptability could be readily formed in moulds made from .accurate impressions of the defective parts, and adjusted to them in such a manner as to be free from irritation. The form of the appli- ance is such that it is under complete control of the muscles of the parts, rising and falling with the contraction and relaxation of the [levator palati muscles, thus opening and closing the naso-pharyngeal 448 SURGERY OF THE FACE, MOUTH, AND JAWS. Space and preventing the regurgitation of fluids into the nose and making it possible with proper training of the vocal organs to attain comparatively perfect speech. Fig. 189 represents a typical case of Fig. 191. Cleft Palate Treated by Kingslev's Artificial Velum. congenital cleft of the velum palati. Fig. 190 shows the mechanical construction of the velum and plate to retain it in its position in the mouth. In Fig. 191 the velum is shown in its position. CHAPTER XLV. TUMORS. Before entering upon a description of the tumors of the face, mouth, and jaws, it will be of advantage to consider briefly the origin, structure, growth, character, and classification of tumors in general. Definition. — Tumor (Latin Tuniere, to swell). A tumor is an enlargement or swelling of a part. A better defin- ition, and one more in accord with the later and stricter use of the term, is "any new growth not the result of inflammation or hyper- plasia." In the later classification of tumors by pathologists, a sharp dis- tinction is drawn between tumors, inflammatory swellings, and reten- tion cysts. Inflammatory hyperplasia of tissue due to infection by micro-or- ganisms is sometimes mistaken for a neoplasm, and vice versa. The difference between them, however, may be recognized by several im- portant features in their history. In inflammatory swellings, the growth and extension are often very rapid and progressive, but not continuous nor permanent. There is lack of definite outHne; they are amenable to agents which promote absorption by neutralizing or re- moving the primary cause, and they are subject to early and acute degenerative changes. An acute suppurative inflammation, on ac- count of its violent local and general symptoms, is rarely mistaken for a malignant neoplasm; while, on the other hand, new growths are usually characterized by their definite outline, slow but progressive growth, permanency of the new-formed tissue, and their resistance to internal medication. In certain forms of innocent tumors, like neuroma and osteoma, growth becomes spontaneously arrested when they have reached a definite size. The nearer the new growth resembles normal tissue, the greater the probability that it will be spontaneously arrested in its growth. Occasionally, in rapid-growing malignant neoplasms, such inflammatory symptoms as enlargement of the superficial veins and edema may be present. Senn emphasizes the fact that the nearer a malignant tumor resembles an inflammatory swelling the greater is its malignancy. 30 449 450 SURGERY OF THE FACE, MOUTH, AND JAWS. Origin. — Xearly all new growths originate from misplaced em- bryonic cells, and this constitutes the matrix from which the tumor is developed. Cohnheim was of the opinion that all tumors were of con- genital origin, and were developed from a matrix of embryonic tissue, Fig. 192. c ^x> Manner OF Production OF Traumatic Epithelial Cyst, f After Garr6.) a, skin ; b, subcutaneous tissue; c, dislocated fragment of skin. while Garre, Senn, and others believe they may be occasionally of post- natal origin, and independent of causes arising from the action of micro-organisms, — that they may be derived from pre-existing mature cells, which in consequence of injury or disease fall short of complete Fig. 193. Beginning of Healing of the Skin-Defect and Commencing Proliferation from the Margins of the Implanted Skin. (After Garre.) differentiation, thus forming a tumor-matrix, from which a neoplasm may be developed in the same manner as from embryonic cells which have been misplaced during fetal life. Figs. 192, 193, and 194 illus- trate the origin of a post-natal epithelial tumor. Fig. 194. -