HX64071022 R K522 I V9 1 91 7 Applied anatomy and RECAP !:\:';i; f'iifci I 1' tKi i* ':ti)m' it'll'; fill ll'i'^i! fi'!() li i»^'''i'il!!' 1 il'f llii Mill i V II II mm m 1 |H;l!ljni t! il »M;!'i,n! •ifi.i.i/f;!' ll i!i'l''' !'i'" i"'ii 'i'l* ' ii:*'iiiililh;l! hi I'l iiilllil il) I I IIH"!' illi! !! mmmm 'ii:ii' liilll^ t lie i;i I: ilii ;' I' I'll -■ lit' 4'i. i» , llilli'l:l!l;%iil: 'i I' i iiiiiiL, 1 -*i; i '^0/f_^ \^ ■? •^/"'WSI OBELION NASION J\ m it.,-r^ "^""V.-, ' ^\ ""^ 1/ IS&/ i& / TEMPORAL \ " J^ lambda Fig. 5.— Side view of skull (Sobotta and McMurrich). the zygoma, the maxilla, the teeth, and the anterior portion of the mandible, with the mental process in front. The three most prominent foramina seen are the supra-orbital in the frontal bone, the infra-orbital in the maxilla, and the mental in the mandible. These three foramina are in a vertical straight line. Lateral View.— The lateral aspect of the skull (Fig. 5) presents the mastoid process, the external auditory BONES 29 meatus, the auditory process, the glenoid fossa, the zygomatic arch, the temporal fossa, the zygomatic fossa, the condyloid and coronoid processes of the mandible. The principal sutures seen are the lambdoid, between the occipital and parietal bones, the squamous, between the temporal and parietal bones, and the coro- noid, between the frontal and parietal bones. Certain prominent points of the skull have been given special names for convenience. These are shown in the illus- tration. BASE OF THE SKULL Inferior or External Surface (Hg. 6). — This surface presents from before backward the hard palate, sur- rounded by the upper teeth, the zygomatic arch, the pterygoid process of the sphenoid, the posterior nares, the pterygoid fossa, the eminentia articularis, the glenoid fossa, the tympanic plate, the styloid process, the mastoid process, the petrous portion of the temporal bone, the basilar and condyloid processes of the occipital bone, and the external occipital protuberance. The important foramina seen are: the anterior, posterior, and accessory palatine foramina, the foramen ovale, the foramen spinosum, carotid, middle lacerated, stylo- mastoid, posterior lacerated or jugular, anterior and posterior condyloid, and foramen magnum. The internal or upper surface of the base of the skull is divided into three fossae— the anterior, middle, and posterior fossae of the skull (Fig. 7). The anterior fossa presents the cribriform plate and the crista galli of the ethmoid bone, the orbital plate of the frontal bone, and the body and lesser wing of the sphenoid bone, at the junction of which is the anterior 30 APPLIED ANATOMY O OJ O. O SI Ph Ph Ph W pqOHftic/i US fa BONES 31 32 APPLIED ANATOMY clinoid process. The middle clinoid process is given off from the side of the body of the sphenoid. The foramina seen are: the orifices for the olfactory nerves, the nasal slit, the anterior and posterior ethmoid foramina, and the optic foramen. The middle fossa is composed of the body and greater wing of the sphenoid bone, the anterior surface of the pe- trous portion, and the squamous portion of the temporal bone. In it are seen the sella turcica, the depression for the Gasserian ganglion, the anterior lacerated foramen or sphenoid fissure, the foramen rotundum, the foramen ovale, the foramen spinosum, the middle lacerated for- amen, and the orifice of the carotid canal. The posterior fossa is made up of the basilar process of the occipital, at the anterior end of which is the pos- terior clinoid process, the horizontal portion of the occipital bone, and the posterior surface of the petrous portion of the temporal bone. It presents the internal auditory meatus, the posterior lacerated or jugular foramen, the anterior and posterior condyloid foramina, and the foramen magnum. The Orbit The orbit is a quadrilateral pyramid in shape, its base being directed forward and a little outward. Seven bones enter into its formation, viz.: frontal, sphenoid, ethmoid, palate, malar, maxilla, and lacrimal. The roof of the orbit is composed of the orbital plate of the frontal bone and part of the lesser wing of the sphenoid bone. The floor is made up of the orbital surface of the maxilla and the orbital processes of the malar and palate bones. BONES 33 The outer wall is formed by the orbital surface of the greater wing of the sphenoid and part of the malar bone. The inner wall is formed by the nasal process of the maxilla, the os planum of the ethmoid, and the lacrimal bone. The openings into the orbit are ten in number, as follows: Optic foramen, at the apex, transmitting the optic nerve and the ophthalmic artery. Sphenoid fissure, near the apex, transmitting the third, fourth, ophthalmic division of the fifth, and sixth nerves, and the ophthalmic vein. The anterior ethmoid foramen on the inner wall, transmitting the nasal nerve and anterior ethmoid vessels. The posterior ethmoid foramen, on the inner wall, transmitting the posterior ethmoid vessels. The lacrimonasal canal has its opening at the anterior portion of the inner side of the orbit, and com- municates with the inferior meatus of the nose. The infra-orbital canal begins in the floor of the orbit, and transmits the infra-orbital nerve and vessels. The sphenomaxillary fissure is in the posterior portion of the orbital cavity, and transmits the infra-orbital nerve and vessels. The malar foramina, two in number, are in the outer wall of the orbit, and transmit nerves and vessels to the cheek. Bony Roof of the Mouth The bony roof of the mouth comprises the hard palate; the anterior three-fourths are made up of the palatal processes of the maxilla;, and the posterior one-fourth by the horizontal plates of the palate bones. At the posterior margin of the latter externally are the hamular processes of the sphenoid bone. The palatal processes 3 34 APPLIED ANATOMY of the maxilla are formed from three processes, the wedge-shaped intermaxillary bone in front containing the germs of the incisor teeth, and the two lateral processes or true maxillae. The intermaxillary bone is formed by the union of the right and left premaxillary bones, which in early hfe are separated by a suture. The orthodontist in certain cases is able to open this suture in the process of widening the dental arch. In the anterior portion of the hard palate, at the junc- tion of the palatal processes of the maxillae and the inter- maxillary bone, is the anterior palatine fossa, which contains four openings, two being the foramina of Scarpa, situated anteroposteriorly, and transmitting the nasopalatine nerves, and two situated laterally, the foramina of Stenson, transmitting the anterior palatine vessels. In the suture between the maxilla and the palate bone are the posterior and accessory palatine canals, for the transmission of the posterior palatine nerves and vessels. The Nasal Fossae The nasal fossae, two in number, are situated one on either side of the median line of the face, separated by a thin plate of bone — the nasal septum. The nasal fossae are composed of a roof, a floor, a septum, and outer walls. The roof of the nasal fossas consists of three portions —anterior, middle, and posterior. The anterior por- tion extends upward and backward, and is composed of the under surfaces of the nasal bones and the nasal spine of the frontal bone. The middle portion is hori- zontal, and is composed of the cribriform plate of the £OiVES 35 36 APPLIED ANATOMY ethmoid bone. The posterior portion slopes downward and backward, and is composed of the body of the sphe- noid and the alae of the vomer. The floor of the nose is formed by the palatal processes of the maxillae in front and the horizontal processes of the palate bones behind. The septum of the nose lies vertically in the median line and runs in an anteroposterior direction. The principal structures forming it are the vomer behind and below, the vertical plate of the ethmoid in front and above, while in the recent state a triangular notch in front is filled in with the triangular cartilage. In addi- tion, the crests of the maxillary and palate bones, the rostrum of the sphenoid, and the nasal spine of the frontal bones assist in forming the nasal septum (Fig. 8). The bones entering into the formation of the lateral wall of the nasal chamber are : the nasal, the nasal process of the maxillary, the lacrimal, the ethmoid, the inferior turbinated, the palate, and the pterygoid process and body of the sphenoid. The inferior turbinated bone and the turbinated processes of the ethmoid bone divide the lateral wall of the nasal chamber into several horizontal compartments or meati, three being the number usually described. In the majority of skulls, however, four meati are present, and in a few cases five or even six have been found. The several meati have communications with the maxil- lary sinus and other pneumatic spaces (Fig. 9) . The inferior meatus is situated between the floor of the nose and the inferior turbinated bone. Into it opens the lacrimonasal duct, which conveys tears from the orbit. BONES 17 Fig. g. — An anteroposterior section within the nasal chamber, with the middle turbinate bone and portion of ceil walls turned up (Cryer). The middle meatus is found betweeji the inferior and^i middle turbinated bones. Into 'it open the •maxillary-' sinus, the frontal sinus, and the anterior and middle^ 38 APPLIED ANATOMY ethmoid cells. All these air-spaces open into the middle meatus through the hiatus semilunaris, a semi- circular groove continuous with the infundibulum, which is the outlet of the frontal sinus. Many authorities do not regard the infundibulum as distinct from the hiatus semilunaris, the so-called infundibulum being, in their opinion, the upper part of the hiatus. The narrow opening from the frontal sinus into the hiatus semilunaris or infundibulum is sometimes known as the ostium frontale. The hiatus semilunaris is bounded toward the median line by the unciform process of the ethmoid bone, this hook-like projection overlapping the ostium maxillare, which is the opening into the maxillary sinus. Above the unciform process is the bulla ethmoid- alis, a rounded prominence of bone formed by the bulging of the middle ethmoid cells. The parts just described, the unciform process, the hiatus semilunaris, and the bulla ethmoidalis, are hidden from view by the middle turbinated bone, and can usually be seen only by removing the latter. The superior meatus is situated between the middle and superior turbinated bones, which are both parts of the ethmoid. When only three meati are present, the sphenoid sinus, the posterior ethmoid cells, and the cell in the orbital process of the palate bone, all open into this meatus, but when there are four meati, the sphe- noid sinus and the posterior ethmoid cells open into the fourth or supreme meatus. The sphenoid cells especially, in the majority of cases, open into the highest meatus, whether three, four, or five meati be present. When more than three meati exist, they are formed by addi- tional turbinated masses on the ethmoid bone. BONES 39 The nasal chambers are bound in front by the anterior nares, and behind by the posterior nares. The space of the anterior nares is inclosed by the nasal bones above, the maxillae laterally and below, while it is divided into two portions by the triangular cartilage of the nasal septum. The posterior nares is bounded above by the cribri- form plate of the ethmoid and body of the sphenoid bones, laterally by the vertical plates of the palate bones, and below by the horizontal plates of the palate bones. The vomer divides the space vertically into two portions. The Maxillary Sinus The maxillary sinus or antrum of Highmore (Fig. lo) is the largest pneumatic space communicating with the nasal fossa, and is situated in the body of the maxillary bone. In the typical specimen the cavity is somewhat pyramidal in shape, with its base directed toward the nasal fossa, and its apex extending toward and sometimes into the malar bone. Though this may be given as the t>pical shape, yet the maxillary sinus varies very much in form and size in different individuals, and on the two sides in the same individual. The cavity is lined with mucoperiosteum surmounted by a layer of ciliated col- umnar epithelium. The roof of the maxillary sinus is formed by the orbital plate of the maxillary bone, which separates it from the orbit. It presents a ridge of bone inclosing the canal for the passage of the infra-orbital vessels and nerve. The prominence of this ridge varies in different subjects. In the negro race especially, where the bones are very thick, it is scarcely perceptible. 40 APPLIED ANATOMY The anterior wall is formed by the facial portion of the maxilla. It contains the anterior dental canal, trans- mitting nerves and vessels to the incisor teeth. The floor of the maxillary sinus is composed of the \ rontal binus Fig. lo. — Transverse section of face, showing probe passing from maxillary sinus through ostium maxillare and liiatus semilunaris into frontal sinus (Cryer). alveolar process. It presents conic elevations corres- ponding to the apices of the roots of the molar and some- times of the premolar teeth. It may also present partial septa extending transversely. Complete septa are never found in the maxillary sinus. BONES 41 The posterior wall of the maxillary sinus is formed by the zygomatic plate of the maxilla, which separates it from the sphenomaxillary fossa. The proximal or nasal wall is formed chiefly by the maxilla, aided by the inferior turbinated, ethmoid, and palate bones (Fig. 11). This partition separates the Fig. 11. — Anteroposterior division throuRh the maxillary sinus (Cryer). maxillary sinus fro'm the nasal fossa. At the upper ante- rior portion of this wall is found an oval foramen — the ostium maxillare — which affords communication between the maxillary sinus andnniddle meatus, opening directly into the hiatus semilunaris. This is the only normal 42 APPLIED ANATOMY opening of the antrum of Highmore, but in certain pathologic conditions more than one opening may be present, when the normal opening becomes closed by pressure of the engorged mucous membrane covering the Fig. 12. — Front view of skull with frontal sinuses exposed (Cryer). bulla ethmoidalis. Under normal conditions there is communication between the maxillary sinus and the frontal sinus through the ostium maxillare, the hiatus semilunaris, and the ostium frontale. By this com- munication disease from the teeth may spread through the antrum to the frontal sinus and the other pneumatic spaces. The Frontal Sinuses The frontal sinuses (Fig. 12) are two irregular air- cells situated in the facial portion and the orbital proc- BONES 43 esses of the frontal bone. They vary greatly in size, shape, and position, and there may be three, four, or five cells, each wath a separate opening. Each frontal sinus is separated from its fellow by a bony septum, which may be in the median line or to one side of it. Partial septa also often exist. In typical cases the frontal sinus opens at its lower part into the hiatus semilunaris of the middle meatus of the nose. The opening is known as the ostium frontale. Multiple sinuses may open into one another or into the anterior ethmoid cells. The sphenoid sinuses are two in number, situated in the body of the sphenoid bone. The bony septum between them is often deflected to one side or the other. They empty into the highest meatus of the nose. The ethmoid air-cells occupy the lateral masses of the ethmoid bone, and are divided into three sets — anterior, middle, and posterior. The anterior and middle eth- moid cells open into the middle meatus of the nose through the hiatus semilunaris, while the posterior ethmoid cells empty into the superior meatus. Review Questions Name the bones forming the cranium. Name the bones forming the face. Describe the princ ipal portions of the sphenoid bone. Describe the ethmoid bone. What cavities does the ethmoid bone assist in forming? Describe the maxilla. What cavities does the maxilla assist in forming? Describe the general features of the mandible. Describe the external surface of the mandible. Describe the internal surface of the mandible. Describe the internal structure of the mandible. Describe in a general way the development and growth of the mandible. Describe the variations occurring in the angle of the mandible accord- ing to the age of the individual. Dcs< ribc the hyoid bom-. 44 APPLIED ANATOMY What prominent landmarks are seen in an anterior view of the skull? What prominent landmarks are seen in a lateral view of the skull? What prominent landmarks are seen on the under surface of the base of the skull? What prominent landmarks are seen on the upper surface of the base . of the skull? Name the bones forming the orbit, giving their relations. Name the openings into the orbit, giving the structures that pass through each. Describe the bony roof of the mouth, naming the bones forming it, and giving their relations. What foramina are found in the roof of the mouth? What structures do they transmit? Name the teeth which develop in the different formative bones of the upper jaw. Name the bones forming the roof of the nasal fossae, giving their relations. Give the names and position of the bones forming the floor of the nose. Describe the nasal septum, giving the bones forming it. Name the bones forming the lateral wall of the nasal chamber.. Describe the various meati of the nose. Name the openings into the various meati of the nose. Describe the hiatus semilunaris and the adjacent structures. What bones bound the anterior nares? What bones bound the posterior nares? In what bone is the antrum of Highmore situated? Describe the shape and boundaries of the maxillary sinus. Name and give the situation of the outlet of the maxillary sinus. Trace the course of disease from the maxillary sinus to the frontal sinus. Give the general situation and outlet of the frontal sinus. CHAPTER II THE TEMPOROMANDIBULAR ARTICULATION The temporomandibular joint is formed by the articulation of the condyle of the mandible with the glenoid fossa of the temporal bone. It is a compound joint, allowing elevation and depression of the mandible, forward and backward gliding, and also lateral motion. The condyle of the mandible is the rounded prominence surmounting the condyloid process. The condyle is broader in its lateral direction than anteroposteriorly, and is covered with articular cartilage. The glenoid fossa is a shallow depression in the temporal bone, situated just in front of the ear. It is bounded in front by a ridge — the eminentia articularis — and posteriorly by the tympanic plate of the temporal bone. The fossa is divided into an anterior portion and a posterior portion by the Glaserian fissure, which contains the processus gracihs of the malleus, and transmits the tympanic branch of the internal maxillary artery. The anterior part of the glenoid fossa is the articular portion. The posterior- portion contains a process of the parotid gland. There are four ligaments connected with this joint, and also an interarticular fibrocartilage with two syn- ovial sacs. The ligaments are as follows: 1. Capsular ligament. 2. External lateral ligament. 45 46 APPLIED ANATOMY 3. Internal lateral ligament (sphenomandibular) . 4. Stylomandibular ligament. The capsular ligament surrounds the joint and is at- tached above to the margins of the glenoid fossa, and below to the neck of the condyle. It also sends fibers in to blend with the interarticular fibrocartilage. The external lateral ligament is a thickening of the capsular ligament, and extends from the tubercle of the zygoma to the outer side of the neck of the condyle. The internal lateral ligament runs from the spine of the sphenoid to the lingula of the mandible. The stylomandibular ligament runs from the tip of the styloid process of the temporal bone to the angle of the mandible. The interarticular fibrocartilage is an oval disc, convex above and concave below, thicker at its periphery than centrally, placed between the condyle and the glenoid fossa. It is held in place by fibers from the capsular ligament, and also receives a slip from the external pterygoid muscle, which draws it forward on the eminentia articularis when the jaw is protruded. The synovial sacs, containing synovial fluid, are two in number, situated one above and one below the inter- articular fibrocartilage. Review Questions Describe the bony surfaces forming the temporomandibular joint. Describe the h'gaments and other structures of the joint. CHAPTER III MUSCLES AND FASCIA The Cervical Fascia The cervical fascia is divided into the superficial and the deep layers. The superficial cervical fascia hes immediately beneath the skin, and connects the latter with the deeper structures. In its meshes is found the platysma myoides, a broad, thin sheet of muscle extend- ing from the clavicle to the lower border of the mandible, where it blends with the muscles of expression about the mouth. Through the superficial fascia run the external anterior and posterior external jugular veins and the superficial cervical nerves. The deep cervical fascia or cravat fascia forms a complete investment for the deeper structures of the neck. It is attached behind to the spinous processes of the cervical vertebrae, splits into two layers to invest the trapezius muscle, and forms a single layer at the- anterior border of that muscle, to cross the posterior triangle of the neck. When the posterior border of the sternomastoid muscle is reached, the fascia again divides into two layers, one going in front of and one behind the muscle. From the anterior Vjorder of the sternomastoid a single layer passes across the anterior triangle to meet the fascia of the opposite side in the median line of 47 48 APPLIED ANATOMY the neck. The cervical fascia is attached below to the clavicle. Above, it is attached to the lower border of the mandible, the zygoma, the mastoid process, and the superior curved line of the occipital bone. This fascia gives off many processes which invest various structures of the neck. Two layers are given off to invest the parotid gland, known as the parotid fascia. The follow- ing are the deeper processes: (i) A process comes off near the anterior border of the sternomastoid muscle, which passes behind the depressor muscles of the hyoid bone, invests the thyroid gland, and covers the front of the trachea. (2) A process known as the prevertebral fascia passes behind the trachea and esophagus and in front of the prevertebral miiscles. (3) The carotid sheath, in- closing the carotid artery, the internal jugular vein, and the pneumogastric nerve, is derived from layers i and 2. The Surgical Square and Triangles of the Neck The surgical square of the neck is bounded in front by the median line; behind, by the anterior border of the trapezius muscle; above, by the lower border of the man- dible and a line drawn from the angle of the mandible to the mastoid process of the temporal bone; below, by the clavicle. The coverings of the square of the neck are the skin, the superficial fascia, — in which lies the pla- tysma myoides, — and the deep fascia. The sternocleidomastoid muscle runs diagonally across the square of the neck, from its posterior superior angle to its anterior inferior angle, dividing it into an anterior and a posterior triangle (Fig. 13). The anterior triangle is divided into three smaller triangles by the anterior and posterior bellies of the MUSCLES AND FASCTM 49 digastric muscle and the anterior belly of the omohyoid muscle, which traverses the square diagonally from its anterosuperior to its postero-inferior angle. The three anterior triangles are the inferior carotid, the superior carotid, and the submaxillary triangles. The posterior triangle of the neck is divided by the posterior belly of the omohyoid muscle into the sub- clavian and occipital triangles. Fig. 13. — Triangles of the neck: A, Submaxillan,' triangle; B, superior car- otid triangle; C, inferior carotid triangle; D, occipital triangle; E, supraclavic- ular triangle (Campl/ell). The inferior carotid triangle is bounded in front by the median line, behind by the sternomastoid muscle, and above by the anterior belly of the omohyoid muscle. It contains the common carotid, the inferior thyroid, and the vertebral arteries, the internal jugular and middle and inferior thyroid veins, and the pneumogastric and phrenic nerves. The superior carotid triangle is bounded in front by 50 APPLIED ANATOMY the anterior belly of the omohyoid muscle, above by the posterior belly of the digastric muscle, and behind by the sternomastoid muscle. It contains the common carotid and its bifurcation into the internal and external carotid arteries, the superior thyroid, the ascending pharyngeal, the Hngual, the facial, the occipital, and the posterior auricular arteries; the superior thyroid, the ranine, the lingual, the facial, and the internal jugular veins, and the descendens hypoglossi and pneumo- gastric nerves. The submaxillary triangle is bounded below by the anterior and posterior bellies of the digastric muscle, and above by the lower border of the mandible and a line drawn from the angle of the mandible to the mastoid process. This triangle contains the external carotid, the facial, the lingual, and the posterior auricular arteries; the internal jugular, the lingual, and the facial veins; the pneumogastric, the glossopharyngeal, and the hypoglossal nerves, and the submaxillary gland. The submaxillary triangle is the most important to the oral surgeon and the dentist, because it lies immediately beneath the oral cavity, and is most often affected by diseases of the mouth. The occipital triangle is bounded in front by the sterno- mastoid muscle, behind by the anterior border of the trapezius, and below by the posterior belly of the omo- hyoid muscle. It contains the transversalis colli artery and the spinal accessory and cervical plexus of nerves. The subclavian triangle is bounded below by the cla,vicle, in front, by the sternocleidomastoid muscle, and behind, by the posterior belly of the omohyoid muscle. It contains the subclavian, the vertebral, the thyroid MUSCLES AND FASCIA 5 I axis, the internal mammary, and the superior inter- costal arteries, the subclavian vein, and the brachial plexus of nerves. The Tongue The tongue, when the mouth is closed, " occupies the space from the anterior teeth backward nearly to the postpharyngeal wall, and from the floor of the mouth nearly to the roof. It almost completely fills the space, which is quite different in form from that shown in most text-books. Professor Bonder has spoken of the space between the roof of the mouth and the tongue as acting somewhat on the same principle as the vacuum chamber in an upper artificial denture, i. e., when the air is exhausted by the action of the tongue a partial vacuum is created when the tongue is relaxed, by the action of which the weight of the lower jaw, with the tongue, is overcome to a certain extent " (Cryer) (Fig. 14). The muscles of the tongue are divided into two groups, the extrinsic group and the intrinsic group. The extrinsic muscles of the tongue are : The hyoglossus, the geniohyoglossus, and the styloglossus. The palato- glossus is also attached to the tongue, but vvill be des- cribed with the muscles of the soft palate. The hyoglossus muscle arises from the greater and lesser cornua of the hyoid bone, and is inserted into the pos- terior and lateral portions of the tongue. It is supplied by the hypoglossal nerve. Its action is to aid in depress- ing the tongue. The geniohyoglossus is a fan-shaped muscle arising from the superior genial tubercle of the mandible. It spreads out and passes backward, its upper fibers being 52 APPLIED ANATOMY MUSCLES AND FASCIA 53 inserted into the under surface of the body of the tongue, and its lower fibers running to the hyoid bone. This muscle is suppHed by the hypoglossal nerve. Its action is to draw forward and protrude the tongue. The styloglossus muscle arises near the apex of the sty- loid process and passes forward, downward, and inward to the posterior part of the tongue, where it divides into a longitudinal portion, passing forward, and an oblique portion, passing downward. Its nerve-supply is derived from the hypoglossal. The styloglossus assists in re- tracting and elevating the tongue. The intrinsic muscle of the tongue is the lingualis. The principal bulk of the Hngualis is a longitudinal set of muscular fibers, arising at the base and extending between the hyoglossus and the geniohyoglossus muscles to the apex of the tongue. It mingles with the fibers of the extrinsic muscles. The linguaHs is suppHed by the hypoglossal nerve. Its different portions have vari- ous complex movements. Muscles of the Pharynx and Soft Palate This group includes the superior, middle, and inferior constrictors of the pharynx, the stylopharyngeus, the palatopharyngeus, palatoglossus, tensor palati, levator palati. and azygos uvulae. The constrictor muscles of the pharynx are three prac- tically continuous sheets of muscle placed one below the other. They arise from various bony and cartilaginous points in front of the pharynx, and are inserted poste- riorly into a median raph^. The superior and middle constrictors receive their nerve supply from the pharyn- geal plexus, and the inferior constrictor is supplied by 54 APPLIED ANATOMY the pharyngeal plexus and the external laryngeal nerve. These muscles, by contracting one after the other from above downward, are the principal agents in the function of deglutition. The stylo pharyngeus muscle arises from the styloid process near its base, passes downward and inward between the superior and middle constrictors of the pharynx, and is inserted into the lateral walls of the pharynx and the posterior border of the thyroid cartilage. It is supphed by the glossopharyngeal nerve and assists in elevating the pharynx. The palato pharyngeus muscle arises from the posterior portion of the soft palate, and is inserted into the lower part of the pharynx and the upper and posterior border of the thyroid cartilage. This muscle and its fellow of the opposite side form the posterior pillars of the fauces. The nerve-supply of this muscle is derived from the sphenopalatine or Meckel's ganglion. Its action is to elevate the pharynx in deglutition, to open the Eustach- ian tube, and to keep the soft palate in position during respiration. The palatoglossus arises from the under surface of the soft palate near the base of the uvula, and is inserted into the side and base of the tongue. This muscle and its fellow of the opposite side form the anterior pillars of the fauces. Its nerve-supply is from the facial. The action of this muscle is to depress and draw slightly forward the palate and elevate and draw back the tongue. The tensor palati muscle arises from the scaphoid fossa at the root of the pterygoid plates, the spinous process of the sphenoid bone, and the side of the Eus- MUSCLES AND FASCI/E 55 tachian tube. Its tendon passes around the hamular process of the sphenoid bone and is inserted into the aponeurosis of the soft palate and transverse ridge on the lower surface of the palate bone. The nerve-supply is derived from the otic ganglion. The muscle renders the palate tense and opens the Eustachian tube. The levator palati muscle arises from the lo\yer surface of the petrous portion of the temporal bone, and is inserted into the soft palate. Its nerve-supply is from the sphenopalatine ganglion. The action of the muscle is to raise the soft palate and to narrow the orifice of the Eustachian tube. The azygos uvula: arises from the posterior spine of the palate bone, and is inserted into the uvula. It is supplied by the facial nerve. The action of the muscle is to contract the uvula. Muscles of Mastication The following are the muscles of mastication. Tem- poral, masseter, internal pterygoid, external pterygoid. The accessory muscles are buccinator, platysma myoides, digastric, mylohyoid, geniohyoid. The temporal muscle arises from the temporal fossa and from the temporal fascia. It is inserted into the coronoid process of the mandible. It is supphed by a branch of the mandibular division of the trifacial nerve. The function of the temporal muscle is to pull the lower jaw upward and backward. The masseter muscle consists of a superficial portion and a deep portion (Fig. 15). The superficial portion arises from the anterior two-thirds of the lower border of the zygoma. It is inserted into the lower part of the 56 APPLIED ANATOMY outer side of the ramus of the mandible. The deep portion arises from the posterior third of the lower border of the zygoma, and from its entire inner surface. It is inserted into the upper portion of the outer side of the ramus of the lower jaw. The nerve-supply of the masseter muscle is derived from the mandibular division of the trifacial. The superficial portion of the ^11^ a. Fig. 15. — Masseter muscle (Campbell). masseter draws the lower jaw forward and upward. The deep portion draws it backward and upward. The internal pterygoid vcmscle (Fig. 16) arises from the inner surface of the external pterygoid plate and ptery- goid fossa of the sphenoid bone, and from the tuberosities of the palate and maxillary bones. It is inserted into the inner side of the ramus and angle of the mandible. MUSCLES AND FASCIM 57 The nerve-supply of the internal pterygoid is derived from the mandibular division of the trifacial. This muscle elevates the lower jaw. The external pterygoid muscle arises by two heads, one from the outer surface of the external pterygoid plate of the sphenoid and the other from the zygomatic surface of the greater wing of the sphenoid. It is n s *^ M 1 "> mm ll^ ^^^^B '^^V/'jP P-- A Hl^ P^^^ ^^■BpT^^^B^' \ :^J^'' lig. 16.— Internal i)terygoid muscle (Campbell). inserted into the anterior part of the neck of the condyle of the mandible, and into the interarticular fibrocartilage of the temporomandibular joint. The nerve-supply to this muscle is derived from the mandib- ular division of the trifacial. The two external ptery- goid muscles acting together draw the lower jaw forward. When the mandible is depressed to a certain extent, 58 APPLIED ANATOMY it is further depressed by the action of these muscles. Acting separately, the external pterygoids draw the mandible to one side or the other. The slip to the inter- articular fibrocartilage pulls the latter forward on to the eminentia articularis when the condyle moves forward. The huccinator muscle arises from the posterior part of the alveolar processes of the maxilla and mandible, and from the pterygomaxillary ligament. It is inserted into the orbicularis oris muscle, and blends with the other muscles of expression of the face. It is supplied by a branch of the mandibular division of the trifacial nerve, and also by the facial nerve. This muscle com- presses the cheek, and assists in keeping the food between the teeth. The platysma myoides is a broad, thin sheet of muscle arising from the clavicle, the acromion, and the super- ficial fascia of the neck. It runs upward within the meshes of the superficial fascia, and is inserted into the lower border of the mandible, where it blends with the superficial muscles of the face. It is supplied by the facial and superficial cervical nerves. The platysma helps to depress the lower jaw and open the mouth. The digastric is a bi-bellied muscle, which arises from the digastric groove on the mastoid process of the temporal bone, and from the lower border of the mandible near the symphysis. The two heads converge into a tendon, which is attached to the hyoid bone by a fibrous loop from the stylohyoid muscle. The posterior belly of the digastric is supplied by the facial nerve, and the anterior belly by the mylohyoid branch of the trifacial. The digastric muscle aids in depressing the lower jaw. The mylohyoid muscle, with its fellow of the opposite MUSCLES AND FASCIA 59 side, forms the muscular floor of the mouth. It arises from the mylohyoid ridge on the inner surface of the body of the mandible, passes downward and inward to be inserted into the body of the hyoid bone, and into a median raphe in the floor of the mouth. It is supplied by the mylohyoid nerve, a branch of the mandibular division of the trifacial. This muscle slightly assists in depressing the mandible. The geniohyoid muscle arises from the inferior genial tubercle of the mandible, and is inserted into the anterior portion of the hyoid bone. Its nerve-supply is from the hypoglossal. It aids in depressing the lower jaw. Muscles of Expression About the Mouth The muscles of expression of the face (Fig. 17) differ from other voluntary muscle in that none of them have bony insertions, and some of them have no bony origin. The oral group consists of the orbicularis oris and those muscles that are inserted into it. The orbicularis oris forms the sphincter of the mouth. It is elliptic, and its fibers interlace with those of the other muscles of expression. The remaining muscles are inserted into the orbicularis oris, and are as follows, beginning at the median line above: Levator labii superioris alcequc nasi, arises from the upper and outer part of the nasal process of the maxilla. Levator labii superioris, arises from the maxilla im- mediately below the orbit. The depressor labii superioris arises from the incisor fossa of the maxilla. The zygomaticus minor arises from the lower surface of the malar bone. 6o APPLIED ANATOMY The zygomaticus major is just behind the zygomaticus minor, arising from the lower edge of the malar bone, near the zygomatic suture. The levator anguli oris arises from the canine fossa, immediately below the infra-orbital foramen. Fig. 17. — Muscles of the right side of the head and neck (American Illus- Iraled Medical Dictionary): i. Frontalis; 2, superior auricular; 3, posterior auric- ular; 4, orbicularis palpebrarum; 5, pyramidalis nasi; 6, compressor naris; 7, levator labii superioris alaeque nasi; 8, levator labii superioris; g, zygomaticus major; 10, orbicularis oris; 11, depressor labii inferioris; 12, depressor anguli oris; 13, anterior belly of digastric; 14, mylohyoid; 15, hyoglossus; 16, stylo- hyoid; 17, posterior belly of digastric; 18, the masseter; 19, sternohyoid; 20, anterior belly of omohyoid; 21, thyrohyoid; 22, 23, lower and middle constric- tors of pharynx; 24, sternomastoid ; 25, 26, splenius; 27, levator scapula;; 28, anterior scalenus; 29. posterior belly of omohyoid; 30, middle and posterior scalenus; 31, trapezius. The risorius muscle arises from the deep fascia cover- ing the masseter muscle. It is not always present. The depressor anguli oris {triangularis menti) arises from the external oblique line of the mandible. The depressor labii inferioris {quadratus menti) arises MUSCLES AND FASCIA 6l from the mandible along the line extending from the s}'mphysis to the mental foramen. The levator lahii inferioris arises from the upper por- tion of the incisor fossa of the mandible. The action of the foregoing muscles is indicated by their names. The nerve-supply is through branches of the facial. Muscles Attached to the Mandible (Fig. 2) To the iimer surface of the body: Gcniohyoglossiis, to the superior genial tubercle. Geniohyoid, to the inferior genial tubercle. Digastric, to the digastric fossa. Mylohyoid, to the mylohyoid ridge or internal oblique line. Superior constrictor of pharynx, just behind the third molar tooth. Outer surface of the body of the mandible : Platysma myoides, depressor anguli oris, and depressor labii inferioris, to external oblique line. Levator lahii inferioris, to incisor fossa. ■ Levator menti, to symphysis. Buccinator , to outer surface of alveolar process of molar teeth. Inner surface of ramus: Internal pterygoid. Outer surface of ramus: Masseter. Coronoid process: Temporal. Neck of condyle: External pterygoid. 62 applied anatomy Review Questions Describe the cervical fasciae. Give the boundaries and coverings of the surgical square of the neck. Name the triangles of the neck, giving their boundaries and the most important structures found in each. Which triangle is the most important to the oral surgeon, and why? Give the position of the tongue, and name its_ extrinsic and intrinsic muscles. Name the muscles of the soft palate, giving origin, insertion, and nerve-supply. Name the muscles of mastication. Name the accessory muscles of mastication. Give the origin, insertion, nerve-supply, and function of the temporal, masseter, internal pterygoid, and external pterygoid muscles. Name the muscles inserted into the sphincter of the mouth. Give their function and nerve-supply. Name and locate the muscles attached to the mandible. CHAPTER IV BLOOD-VESSELS The blood-supply of the head (Fig. i8) is carried mainly by the common carotid and vertebral arteries. The right common carotid artery is a branch of the innominate artery. The left common carotid comes directly from the arch of the aorta. Apart from this, the arteries of the two sides are similar. The surgical line of the common carotid artery ex- tends from the sternoclavicular articulation to a point midway between the angle of the mandible and the mastoid process of the temporal bone. While this is the direction of the artery in the neck, its upper termi- nation is at the level of the upper edge of the thyroid cartilage. The common carotid artery lies in the carotid sheath, a process of the cervical fascia (p. 48) which also incloses the internal jugular vein and the pneumo- gastric nerve. The vein lies external to the artery, while the nerve is between and behind the two. The descen- dens h>poglossi nerve, a branch of the hypoglossal, passes down the neck on the front of the carotid sheath. The structures within the carotid sheath lie just beneath the inner edge of the sternocleidomastoid muscle. At the level of the upper edge of the thyroid cartilage, in the superior carotid triangle, the common carotid bifurcates into the interna! and external carotid arteries. The internal carotid artery (Fig. 19) passes upward 63 64 APPLIED ANATOMY to the carotid canal in the petrous portion of the tem- poral bone. It is divided into four portions — cervical, petrous, cavernous, and intracranial. Fig. 1 8. — The chief arteries of the neck: A, Common carotid; B, external caro- tid; C, internal carotid; D, vertebral (Deaver, modified). The cervical portion is at first more superficial than, and to the outer side of, the external carotid artery. It then passes more deeply, in relation with the superior BL OOD- VESSELS 65 constrictor of the pharynx, which separates it from the tonsil, and the transverse processes of the three upper cervical vertebrae. The artery is inclosed in a sheath in company with the internal jugular vein and the pneu- mogastric nerve. Fig. ig.— The carotid region and the chief structures (Campbell). Note the relation of the internal jugular vein, the common carotid artery, and the pneumogastric nerve. The petrous portion of the internal carotid is inclosed in the carotid canal in the petrous portion of the temporal bone. The cavernous portion is inclosed by the cavernous sinus, and begins just above the middle lacerated fora- men within the brain case. 5 66 APPLIED ANATOMY The intracranial portion begins at a point where the artery passes through the upper wall of the cavernous sinus, and gives off the terminal branches. The cervical portion of the internal carotid artery seldom gives off any branches. The petrous portion gives off the tympanic branch. The branches of the cavernous portion are : Meningeal, pituitary, and cavernous. The branches of the intracranial portion are : Ophthal- mic, anterior cerebral, middle cerebral. The ophthalmic artery is the largest branch of the internal carotid. It passes through the optic foramen, and gives off the lacrimal, supra-orbital, central retinal, ciliary, posterior and anterior ethmoid, muscular, palpebral, frontal, and external nasal branches. The anterior and middle cerebral arteries assist in the formation of the circle of Willis. BRANCHES OF INTERNAL CAROTID ARTERY. Cervical portion. None. Petrous portion. Tympanic. r Meningeal. Cavernous portion. ■ Pituitary. '■ Cavernous. ' ' Lacrimal. Supra-orbital. Internal carotid. Intracranial portion. ^ L Ophthalmic. ' Anterior cereb ^ Middle cerebr Central retinal. Ciliary. Posterior ethmoid Anterior ethmoid. Muscular. Palpebral. Frontal. External nasal, ral. al. BL O OD- VESSELS 6y The External Carotid Artery. — The external carotid artery (Fig. i8) is given off from the common carotid in the superior carotid triangle. It passes up the neck to a point opposite the neck of the condyle of the man- dible, where it gives off its terminal branches in the sub- stance of the parotid gland. ]Most of the branches of the external carotid artery are given oft in the superior carotid triangle. The branches are: Ascending pharyngeal, to the upper part of the phar- ynx. Superior thyroid, to the thyroid gland, larynx, and various muscles. Lingual, to the tongue. Facial. — This branch runs upward and inward to the angle of the lower jaw, passes over the facial notch in the lower border of the mandible near the angle, thence to the angle of the mouth, the ala of the nose, and the inner canthus of the eye. The occipital artery passes backward and upward and supplies the structures in the region of the occiput. The posterior auricular artery passes upward and backward to supply the region behind the ear. The superficial temporal artery is one of the terminal branches of the external carotid, and is given off in the substance of the parotid gland. It passes upward in front of the ear, accompanied by the auriculotemporal nerve, and is distributed to the temporal region of the scalp. The internal maxillary artery (Fig. i8) is the other terminal branch of the external carotid, and is given off in the substance of the parotid gland. It winds 68 APPLIED ANATOMY around the inner side of the neck of the condyle of the mandible, between it and the internal lateral Hgament, passes between the two heads of the external pterygoid muscle, and enters the sphenomaxillary fossa, where it breaks up into its terminal branches. The artery may be divided into three portions: (i) The maxillary division, extending from the external carotid to the internal lateral Hgament. (2) Pterygoid division, between the two heads of the external pterygoid muscle. (3) Sphenomaxillary division, in the sphenomaxillary fossa. The branches of the lingual artery are: hyoid, dorsaHs hnguas, sublingual, and ranine. The branches of the facial artery are : id) On the neck : Ascending palatine, tonsillar, submaxillary, submental. (6) On the face: Inferior labial, inferior coronary, supe- rior coronary, lateralis nasi, angular. The branches of the internal maxillary artery are as follows: {a) Maxillary portion: Tympanic, middle meningeal, small meningeal, and inferior dental. (6) Pterygoid portion: Deep temporal, pterygoid, masseteric, and buccal. (c) Sphenomaxillary portion: Alveolar to the upper teeth, infra-orbital, descending palatine, vidian, pterygopalatine, and nasopalatine. The vertebral arteries are given off from the subclavian arteries, and pass upward one on either side of the neck, through the foramina in the transverse processes of the cervical vertebrae, entering the skull through the foramen magnum. The arteries of the two sides join at the posterior inferior extremity of the pons Varolii to form the basilar. The basilar artery at the anterior extremity of the pons divides into the posterior cerebral arteries. These BLOOD-VESSELS 69 anastomose with the anterior cerebral branches of the internal carotid arteries through the posterior com- municating arteries. The circle of Willis is completed Fig. 20. — Diagram of the circle of Willis: A, Basilar artery; B, posterior cerebral; C, posterior communicating; D, internal carotid; F, anterior cerebral; G, anterior communicating (Campbell). in front by the anterior communicating artery, which joins the two anterior cerebral arteries (Fig. 20). Veins of the Head The veins of the head may be divided into external and intracranial. Practically all the venous blood from the head is conveyed by the internal and external jugular veins. The following table gives the principal veins of the head and their tributaries: 70 APPLIED ANATOMY EXTERNAL VEINS. Temporal. It- -n T , •„ r Temporomaxillary. 1 ^ , . , r- i , • Internal maxillary. J _ . . , < External luffular. bubclavian. Posterior auricular. > Facial. ~) Anterior division of )- Common facial. temporomaxillary. J Lingual. Pharyngeal. Superior thyroid. Middle thyroid. Occipital. Internal jugular. The internal jugular vein is formed by the union of the lateral and inferior petrosal sinuses at the posterior lacerated or jugular foramen. These sinuses and their tributaries convey venous blood from the structures of the interior of the skull, including the brain and its membranes, orbit, etc. Venous blood is conveyed from the upper teeth by the alveolar vein into the internal maxillary vein; that from the lower teeth is carried by the inferior dental vein to the internal maxillary vein. The course of blood from the heart to the right upper teeth and back again to the heart is as follows: Aorta, innominate, right common carotid, external carotid, internal maxillary, and alveolar arteries; alveolar, internal maxillary, temporomaxillary, external jugular, subclavian, and innominate veins, superior vena cava, to heart. In supplying the teeth of the left side the course of blood is the same, except that it passes directly from the aorta into the left common carotid artery, instead of first traversing the innominate. The lower teeth receive blood from the inferior dental instead of the alveolar branch of the internal maxillary. BL O OD- VESSELS 7 1 By anastomosis is meant the free communication of blood-vessels. Practically all blood-vessels anastomose with adjacent trunks. The best example of an anasto- mosis is the circle of Willis at the base of the brain (p. 69), where branches of the internal carotid and vertebral arteries of the two sides communicate to form a complete circle. A collateral circulation is an accessory source of blood- supply to a part by anastomosis of vessels, whereby nutrition is maintained after the main source of blood- supply is cut off. A good example of this in the neck is seen in the anastomosis of the princeps cervicis branch of the occipital with the profunda cervicis branch of the superior intercostal, which comes from the subclavian, so that if the blood-supply to the occipital region through the external carotid artery be cut off from any cause, blood would still be carried to the part by the branch of the subclavian. Review Questions Give the surgical line of the common carotid artery. Name and give the relations of the structures within the carotid sheath. Give the point of bifurcation of the common carotid artery and its branches. Give the course and branches of the internal carotid artery. Give the course and branches of the external carotid artery. Give the course and branches of the facial artery. Give the course and branches of the internal maxillary arlcry. Describe the circle of Willis. Give a general outline of the veins of the face and neck. What is meant by anastomosis of blood-vessels. What is meant by collateral circulation? Give examples. CHAPTER V LYMPHATICS The lymphatic glands of the face are as follows : (a) Parotid, of which there are two groups, one placed on the surface of the parotid salivary gland, and the other more deeply in the substance of the gland, (b) Zygo- matic, beneath the zygoma, (c) Buccal, on the surface of the buccinator muscle, (d) Internal maxillary, on the inner side of the ramus of the mandible. The lymphatic glands of the neck are superficial and deep. The superficial groups are: (a) Submaxillary, beneath the body of the mandible, in the submaxillary triangle, (b) Suprahyoid, in the median line of the neck, (c) Cervical, along the course of the external jugular vein. The deep cervical glands are found along the course of the internal jugular vein, and are divided into an upper and a lower group. Practically all the lymphatics of the head drain into the deep cervical glands, which communicate below with the mediastinal glands. The following table gives the various structures of the face and neck, and the lymphatic glands connected with them (Treves) : Skin of face and neck Submaxillary, parotid, and superficial cervical glands. External ear Superficial cervical glands. Lower lip Submaxillary and suprahyoid glands. 72 L YMPHA TICS 73 Buccal cavity Submaxillary and upper set of deep cer- vical glands. Lower jaw Submaxillary glands. Anterior portion of tongue Suprahyoid and submaxillary glands. Posterior portion of tongue Upper set of deep cervical glands. Tonsils and palate Upper set of deep cervdcal glands. Upper part of pharynx Parotid and retropharyngeal glands. Lower part of pharynx Upper set of deep cervical glands. Lan^-nx, orbit, roof of mouth . . . .Upper set of deep cervical glands. Nasal fossae Retropharyngeal and upper set of deep cervical glands. CHAPTER VI THE CRANIAL NERVES The cranial nerves, with their foramina of exit from the brain-case, principal distribution, and function, are as follows: Name. Foramen. DlSTRIBUTION. Function. First: olfactory. Olfactory^ Nose. Smell. Second: optic. Optic.. Eye. Sight. Third: oculo- Sphenoid fis-" Orbit. Motor to mus- motor. sure. cles of eyeball. Fourth: troch- Sphenoid fis- Superior ob- Motor. lear. sure. lique muscle of eyeball. Fifth: trifacial. [a) Sphenoii sure. dfis- Ophthalmic. Sensory. (b) Rotundi im. Maxillary. Sensory. (c) Ovale. Mandibular. Sensory. Mo- tor to mus- cles of masti- cation. Sixth: abducens. Sphenoid sure. fis- External rectus muscle. Motor. Seventh: facial. Stylomastoid. . Facial muscles. Motor. Eighth: audit- Internal audit- ■ Internal ear. Audition and ory. ory meatus. equilibration. Ninth: glosso- Jugular. Tongue, phar- Sensory. pharyngeal. ynx, middle ear. Stylo- pharyngeus. Taste. Motor. Tenth : pneumo- Jugular. Alimentary, res- Sensory and gastric. piratory, and circulatory systems. motor. THE CRANIAL NERVES n N.\iIE. Foramen. Distribution. Function. Eleventh: spinal Jugular. Stemomast o i d IMotor. accessor>-. and trapezius muscles. Twelfth: hj-po- Anterior condy- Tongue and Motor. glossal. loid. muscles of hyoid bone. The Fifth Nerve The fifth or trifacial nerve (Fig. 21) is the great sensory nerve of the face and head. It also suppUes motor fibers to the muscles of mastication. The deep Fig. 21.— The distribution of the three divisions of the fifth nerve fLeidy). origin of the trifacial nerve is from a sensory nucleus and a motor nucleus in the floor of the fourth ventricle. The superficial origin is from the side of the pons Varolii, where the nerve emerges as an anterior motor and a posterior sensory root. The sensory root term in- 76 APPLIED ANATOMY ates in the Gasserian ganglion, situated at the apex of the petrous portion of the temporal bone, within the brain-case. The motor root passes out through the foramen ovale and joins the sensory portion of the mandibular division immediately outside this foramen. The Gasserian or semilunar ganglion is a crescent- shaped structure, with its convexity directed forward, situated in a depression at the apex of the petrous portion of the temporal bone. The ganglion is joined posteriorly by the sensory root of the trifacial nerve. The motor root of this nerve does not enter the ganglion, but passes around it and joins the inferior division from the ganglion outside the foramen ovale to form the mandibular nerve. The branches of the Gasserian ganglion, three in number, are given off from its anterior portion, and are as follows: First, or ophthalmic division. Second, or maxillary division. Third division, which unites with the motor root to form the mandibular nerve. The ophthalmic division passes forward along the outer wall of the cavernous sinus, passes through the sphenoid fissure, and breaks up into three branches, frontal, lacri- mal, and nasal. The frontal nerve passes forward in the orbit, and divides into two branches, the supra-orbital and the supratrochlear. The supra-orbital nerve passes through the supra-orbital foramen, and supplies the skin of the forehead. The supratrochlear nerve leaves the orbit near its inner angle and supplies the skin of that region. The lacrimal nerve passes forward in the orbit, and THE CRANIAL NERVES Tj breaks up into branches which supply the lacrimal gland, the conjunctiva, and the upper eyelid. The nasal nerve passes obhquely forward from the sphenoid fissure, between the two heads of the external rectus muscle, to the anterior ethmoid foramen. It divides here into the internal nasal and the infratrochlear nerves. The branches of the nasal nerve are: Branch to dura mater, branch to ophthalmic ganghon, long ciUary, posterior ethmoid, infratrochlear, internal nasal, and external branches, which are septal, lateral, and anterior. The internal nasal nerve passes through the anterior ethmoid foramen into the brain-case beside the cribri- form plate. It then enters the nasal sHt beside the crista galli, passes into the nasal chamber, and breaks up into the terminal branches, septal, lateral, and anterior. The Maxillary Division. — The maxillary division passes forward from the Gasserian ganglion, and leaves the cranium through the foramen rotundum. It crosses the sphenomaxillary fossa, and enters the orbit through the sphenomaxillary fissure. The nerve then becomes the infra-orbital, enters the infra-orbital canal in the floor of the orbit, and runs forward to open on the face at the infra-orbital foramen, where it breaks up into its terminal filaments. The branches of the maxillary nerve are: Meningeal, orbital or temporomalar, spheno- palatine, superior dental, and infra-orbital. The meningeal branch is given off within the cranium and passes to the dura mater. The orbital, or temporomalar branch, is given off in the sphenomaxillary fossa. It enters the orbit through the sphenomaxillary fissure, and divides into two branches, the temporal and the malar. The temporal 78 APPLIED ANATOMY branch, after giving off a filament which communicates with the lacrimal nerve, passes into the temporal fossa through the sphenomalar canal. It pierces the tem- poral muscle, and is distributed to the skin of the region. The malar branch passes through the malar canal to supply the skin over the malar bone. The sphenopalatine branches, two in number, are given off in the sphenomaxillary fossa, and pass to Meckel's ganglion, forming its sensory roots. The superior dental branch is given off in the spheno- maxillary fossa, and passes through the posterior dental canals to supply the upper molar and premolar teeth and the gums. The infra-orhital nerve is the terminal branch of the maxillary division of the trifacial. It lies in the infra- orbital canal, and opens on the face at the infra-orbital foramen, where it breaks up into its terminal branches. This nerve sends a branch down in the anterior wall of the maxillary sinus, which supplies sensation to the canine and incisor teeth of the upper jaw and the muco- periosteum of the maxillary sinus. The Mandibular Division. — The third or mandibular division of the trifacial is its largest branch. It is formed by the junction of the third portion of the sensory root from the Gasserian ganglion with the motor root. The two leave the cranium separately through the for- amen ovale, and unite immediately afterward to form one trunk. About a quarter of an inch lower down, be- hind the external pterygoid muscle, the trunk branches into a smaller anterior and a larger posterior division. The branches of the mandibular nerve may be divided into three groups, as follows: THE CRANIAL NERVES 79 {a) From the main trunk: Recurrent branch, and nerve to the internal pterygoid muscle. The recurrent branch enters the cranium through the foramen spinosum, and is distributed to the mastoid cells and the petrous portion of the temporal bone. The nerve to the internal pterygoid is the motor nerve to the muscle named. It also contains sensory fibers which pass to the otic ganghon. (6) Branches from the anterior division: Deep temporal, masseteric, external pterygoid, buccal. These branches supply motor fibers to the muscles named. {c) Branches from the posterior division: Auriculotem- poral, lingual, and inferior dental. The auriculotemporal nerve passes up with the super- ficial temporal artery to supply the skin of the auricle and the temple. The lingual nerve runs downward and forward on the internal pten,^goid muscle to the inner side of the lower jaw, near the last molar tooth, where it Hes just under the mucous membrane. It then runs forward to the tip of the tongue. The lingual nerve is joined behind the ramus of the jaw by the chorda tympani nerve. The lingual nerve supplies common sensation to the tongue. The inferior dental nerve passes downward and enters the cribriform tube of the mandible through the inferior dental (mandibular) foramen. It passes forward to the symphysis menti, and then recurs to open on the face as the mental nerve at the mental foramen. The branches of the inferior dental nerve are: Mylo- hyoid, dental and gingival, and mental. The mylohyoid nerve is given off just before the in- ferior dental nerve enters the mandibular canal. It 8o APPLIED ANATOMY runs along the mylohyoid groove of the mandible with the mylohyoid vessels, and carries motor fibers to the mylohyoid muscle and the anterior belly of the digastric muscle. The dental and gingival branches pass up the tubules coming off from the main tube of the mandible, to supply the teeth and gums. The mental nerve is the terminal branch of the inferior dental. After emerging from the mental foramen, it breaks up into filaments which supply the skin of the chin and lower lip. Sympathetic ganglia associated with the trifacial nerve. These ganglia are four in number, and are as follows: Ophthalmic, sphenopalatine, otic, and submaxillary. These ganglia supply sympathetic fibers to the various parts to which their branches are distributed, for ex- ample, motor fibers to the ciliary muscle, secretory to the submaxillary gland, etc. The ophthalmic, ciHary, or lenticular ganglion is a small body, about the size of a pin-head, situated in the back of the orbit, between the optic nerve and the external rectus muscle. Its sensory root is derived from the nasal branch of the trifacial nerve. Its motor root is derived from the internal oblique branch of the oculo- motor nerve. Its sympathetic root is derived from the cavernous plexus. The branches of the ophthalmic ganglion are the short ciliary nerves, eight to ten in number, which pass to the ciHary muscle of the eyeball. The sphenopalatine, or MeckeVs ganglion, is situated in the sphenomaxillary fossa, near the maxillary division of the trifacial nerve. Its sensory roots are two in THE CRANIAL NERVES 8 1 number, and are the sphenopalatine branches of the maxillary nerve. The motor and sympathetic roots are combined as the Vidian nerve. This nerve is formed by the great superficial and great deep petrosal nerves. The great superficial petrosal nerve is the motor root of Meckel's ganglion, and is derived from the facial nerve."^ The great deep petrosal nerve is the sympathetic root, and is derived from the carotid plexus of the sympathetic. The branches of Meckel's ganglion are — (a) Ascend- ing, (6) internal, (c) descending, ((/) posterior. The ascending branches are small twigs to the perios- teum of the orbit and the mucous membrane of the sphenoid and posterior ethmoid sinuses. The internal or anterior branches supply the mucous membrane of the nose and roof of the mouth as the naso- palatine nerve, which passes through the anterior palatine canal and foramen of Scarpa. The descending branches are the anterior, posterior, and external palatine nerves. The anterior palatine nerve descends through the posterior palatine canal, runs forward on the hard palate to supply the mucous mem- brane of the mouth, and communicates with the naso- palatine nerve. The posterior palatine nerve passes through one of the accessory palatine canals to the uvula, tonsil, and soft palate. The external palatine nerve passes through the other accessory palatine canal to supply the tonsil and soft palate. The posterior branches of Meckel's ganglion pass to the nasopharynx. The otic ganglion lies on the mandibular nerve just after it leaves the foramen ovale. Its motor and sen- sory roots reach it through the nerve to the internal 82 APPLIED ANATOMY pterygoid muscle. Its sympathetic root is derived from the plexus around the middle meningeal artery. It sends branches to the parotid gland, motor twigs to the tensor palati and tensor tympani muscles, and a communicating branch to the chorda tympani nerve. The submaxillary or submandibular ganglion lies on the submaxillary gland, and is connected with the man- dibular division of the trifacial nerve. Its sensory root comes from the trifacial nerve through the lingual branch. Its motor root is derived from the facial through the chorda tympani. Its sympathetic root is derived from the plexus around the facial artery. This ganghon sends branches to the submaxillary gland, Wharton's duct, and the sublingual gland. TABLE OF SYMPATHETIC GANGLIA, ASSOCIATED WITH FIFTH NERVE Name. Division. Sensory root. Motor root. Sympathetic root. Branches and distri- bution. Ophthal- Ophthal- Nasal Internal Cavernous Short ciliary nerves to mic. mic. branch of trifacial. oblique branch of oculomotor. plexus. ciliary muscle. Spheno- Maxillary. Spheno- Great su- Great deep (a) Ascending, to or- palatine palatine perficial petrosal bit, sphenoid, and or branches petrosal from caro- ethmoid sinuses. Meckel's. of maxil- branch of tid plexus, (b) Internal or ante- lary. seventh. through rior, to mucous through Vidian. membrane of nose Vidian. and mouth, as naso- palatine. (c) Descending, as an- terior, posterior, and external palatine nerves, to mucous membrane of palate and tonsils. (d) Posterior, to naso- pharynx. Otic. Mandibu- Internal Internal Plexus Parotid gland, tensor lar. pterygoid pterygoid around mid- tympani, and tensor branch of branch of dle menin- palati muscles. trifacial. trifacial. geal artery. Submax- Mandibu- Lingnal Facial Plexus Submaxillary gland. illary. lar. branch of through around Wharton's duct, sub- trifacial. chorda tympani. facial artery. lingual gland. THE CRANIAL NERVES 83 Ophthalmic. TABLE OF THE FIFTH NERVE AND ITS BRANCHES f Supratrochlear. I Supra-orbital, j Superior branch. I Inferior branch. Branch to dura mater. Branch to ophthalmic ganglion. Long ciliary. f Septal. Internal nasal. . <. Lateral. (^ Anterior, f Temporal. 1 Malar. Maxillary. Frontal Lacrimal Nasal. Temporomalar. Sphenopalatine. Superior dental. r ^ , , Palpebral. Infra-orbital J Nasal. Labial. Mandibular. From main trunk . Anterior division. Posterior division. f Recurrent. I Internal pterygoid. r Deep temporal. Masseteric. External pterygoid. 1^ Buccal. Auriculotemporal. Lingual. C Mylohyoid. Inferior dental. < Dental. (, Mental. THE Seventh Nerve The seventh cranial or facial nerve (Fig. 2 2) is the motor nerve to the muscles of expression of the face, and also supplies the scalp, external ear, platysma myoides, buccina- tor, posterior belly of the digastric, and stylohyoid muscles. The deep origin of the facial nerve is in the floor of the fourth ventricle. Its superficial origin is from the med- ulla, between the olivary and restiform bodies. The facial nerve enters the internal auditory meatus in company with the auditory nerve. At the end of the 84 APPLIED ANATOMY meatus it passes into a narrow bony canal, the aqueductus Fallopii. This canal has a tortuous course through the petrous portion of the temporal bone, and terminates at the stylomastoid foramen, where the facial nerve makes its exit from the skull. It breaks up into its terminal branches in the substance of the parotid gland. Fig. 22.— Branches of the facial nerve spread over the face like a fan (Campbell). The branches of the facial nerve are divided into two groups : {a) Before its exit from the stylomastoid foramen. Nerve to stapedius muscle, chorda tympani, connecting branches with pneumogastric, branches to glosso- pharyngeal. The nerve to the stapedius passes through a fine bony canal and supplies the muscle named. THE CRANIAL NERVES 85 The chorda tympani nerve passes in a bony canal through the petrous portion of the temporal bone, crosses the tympanic cavity, enters the canal of Huguier at the side of the Glaserian fissure, and unites with the Ungual branch of the trifacial nerve, under the lower border of the internal pterygoid muscle. The chorda tympani probably originates from the glossopharyngeal, and carries fibers of the special sense of taste. The communicating branches pass to ganglia of the pneumo- gastric and glossopharyngeal nerves. ih) After the exit of the seventh nerve from the stylo- mastoid foramen: Posterior auricular, stylohyoid, digastric, styloglossal, temporofacial, cervicofacial. The posterior auricular nerve arises near the stylo- mastoid foramen. It passes backward and divides into auricular and occipital branches. The auricular branch supplies the retrahens aurem, and the occipital supplies the occipitalis muscle. The stylohyoid nerve supplies the muscle named. The digastric branch is distributed to the posterior belly of the digastric muscle. The styloglossal branch supplies the styloglossus and stylopharyngeus muscles. The temporofacial division passes upward and forward in the substance of the parotid gland and breaks up into three branches: (a) Temporal, to the muscles of the temple and side of the forehead, (b) Malar, to orbicu- laris palpebrarum and corru gator supercilii. (c) Infra- orbital, to the muscles connected with the upper lip. The cervicofacial division passes downward and forward in the substance of the parotid gland, and breaks up into the following branches: (a) Buccal, to the buccinator 86 APPLIED ANATOMY and orbicularis oris muscles. (5) Supramaxillary, to the muscles of the lower lip and chin, (c) Inframaxillary, to the platysma myoides. The geniculate ganglion is situated on a bend of the facial nerve in the aqueductus Fallopii. Its branches are as follows: {a) Great superficial petrosal nerve. (6) Small superficial petrosal nerve. (c) Branches to the sympathetic system. {d) Branches to the tympanic plexus. {e) Branches to the pneumogastric nerve. (/) Branches to the glossopharyngeal nerve. The great superficial petrosal nerve passes through the hiatus Fallopii on the anterior suriace of the petrous portion of the temporal bone, then inward beneath the Gasserian ganglion to the middle lacerated foramen. Here it joins the great deep petrosal nerve, and with it passes through the Vidian canal in the sphenoid bone as the Vidian nerve, and enters Meckel's ganglion as its motor root. The small superficial petrosal nerve joins the otic ganglion as its motor root. The branches to the sympathetic system pass to the plexus around the middle meningeal artery and tympanic plexus. It is generally taught that the facial is purely a motor nerve. Studies of cases in which the Gasserian ganglion had been removed or the function of the fifth nerve other- wise completely destroyed, tend to show that sensibility to deep pressure over the facial muscles in these cases is still present to a certain extent. From this it may be assumed that the facial nerve contains fibers of deep sensibility from the muscles supplied by it. After exit from stylomastoid foramen. THE CRANIAL NERVES 87 TABLE OF THE SEVENTH NERVE AND ITS BRANCHES. \ Stapedius. Before exit from stylomastoid fora- J Chorda tympani. men ' Branch to pneumogastric. [ Branch to glossopharyngeal. r „ . . , f Auricular. I Posterior auricular. , ^ . . , V Occipital. Stylohyoid. Digastric. Styloglossal. [ Temporal. Temporofacial. \ Malar. [ Infra-orbital. [Buccal. Cervicofacial. \ Supramaxillary. [ Inframaxillary. Review Questions Name the cranial nerves in their regular order, giving their foramina of exit from the brain-case, distribution, and function. Give the deep and superficial origins of the fifth nerve. Give the name, position, and branches of the sensory ganglion of the fifth nerve. Give the course of the motor root of the trifacial nerve. Name the three divisions of the trifacial nerve, giving their foramina of exit from the skull. Give the branches of the ophthalmic division of the trifacial nerve. Give the branches of the maxillary division of the trifacial nerve. Give the branches of the mandibular division of the trifacial nerve. What sympathetic ganglia are connected with the fifth nerve? Give their positions, roots, and branches. What are the functions of the fifth nerve? Ciive the deep and superficial origins of the seventh nerve. Give the course of the seventh nerve from its superficial origin to its terminal branches. Give the branches of the facial nerve. Give the name, position, and branches of the ganglion associated with the seventh nerve. What are the functions of the seventh nerve? CHAPTER VII GLANDS The special mucous and salivary glands associated with the oral cavity are the parotid, submaxillary, sub- lingual, labial, buccal, Hngual, and palatal glands. Parotid Gland The parotid gland (Fig. 23) is the largest of the sali- vary glands, its weight averaging one ounce. It is Fig. 23. — The parotid gland (Campbell). a compound racemose, salivary gland, its principal secretion being ptyahn, an amylolytic ferment. GLANDS 89 The parotid gland is situated in the parotid space. This triangular space is bounded in front by the ramus of the mandible; behind, by the mastoid and styloid processes and the tympanic portion of the temporal bone; and below, by a line drawn from the angle of the mandible to the tip of the mastoid process. The gland does not exactly conform to the conlines of this space, but overlaps its boundaries. The deep portion of the gland passes inward and comes into relation with the vertebra? and base of the skull. The upper portion passes into the posterior part of the glenoid fossa. The anterior portion overlaps the masseter muscle. The accessory parotid or socia parotidis, when present, lies on the masseter muscle below the zygomatic arch. The parotid gland is invested by processes of the deep cervical fascia. The duct of the parotid gland, or Stenson's duct, is about two and a half inches long, and varies in diameter, its orifice being its narrowest part, only permitting the entrance of a small probe. The duct runs forward across the face from the anterior border of the parotid gland, about a finger's breadth below the zygoma, over the masseter muscle, curves inward to pierce the buc- cinator muscle, and opens in the vestibule of the mouth in a papilla opposite the upper second molar tooth. The blood-supply of the parotid gland is derived from the external carotid, internal maxillary, superficial temporal, transverse facial, and posterior auricular arteries. The veins follow a similar course to the ar- teries. The nerves are derived from the facial, auriculo- temporal, great auricular, and the sympathetic plexus of the external carotid artery. 90 APPLIED ANATOMY The external carotid artery and its terminal branches and the facial nerve pass through the substance of the parotid gland. The parotid lymphatic glands he upon it and within its substance. The Submaxillary Gland The submaxillary gland is a compound racemose gland and secretes a mucosalivary fluid. It is, there- fore, a mixed gland. It is smaller than the parotid gland, being about the size of a hazel-nut. The sub- maxillary gland is situated in the submaxillary fossa, on the inner side of the body of the mandible. Above and in front of the gland is the mylohyoid muscle, which separates it from the sublingual gland. Behind, the submaxillary gland is separated from the parotid gland by the stylomandibular ligament. In relation to the neck the submaxihary gland lies in the submaxillary triangle, and is covered by the skin, superficial fascia, platysma myoides, which lies in the superficial fascia, and the deep fascia. The outlet of the submaxillary gland is known as the duct of Wharton. This runs backward under the mylo- hyoid muscle, around the posterior edge of the muscle, and over its upper surface, to open through the floor of the mouth in a papilla at the base of the tongue. The blood-supply to the submaxillary gland is derived from the submaxillary branch of the facial artery. Its nerve-supply is from the submaxillary ganglion. GLANDS 91 The Sublingual Gland The sublingual gland is smaller than the submaxillary gland. It is a compound racemose gland and secretes mucus only. The sublingua,! gland is situated in the sublingual fossa of the inner surface of the body of the mandible, immediately beneath the mucous membrane of the mouth. Below it is the mylohyoid muscle. The gland consists of several small lobes, which open into the floor of the mouth by separate small ducts, the ducts of Rivinus, eight to twenty in number. A larger duct, the duct of Bartholin, runs from the posterior lobules and empties into Wharton's duct. The labial, buccal, lingual, and palatal glands are small racemose or compound tubular glands, situated in the mucous membrane covering the lips, cheeks, tongue, and hard and soft palate, which secrete mucus. Review Questions Name the mucous and salivary glands which empty into the oral cavity. Describe the parotid gland, giving its position, relations, duct, and function. Describe the submaxillary gland, giving its position, relations, duct, and function. Describe the sublingual gland, giving its position, relations, duct, and function. What is the function of the lingual, labial, buccal, and palatal glands? CHAPTER VIII THE TONSILS AND THE MOUTH The Tonsils The tonsils (Fig. 24) are two oval masses of lymphoid tissue, situated one on either side of the tonsillar space. This space is found between the anterior and pos- Fig. 24. — Surface markings shown within the mouth: A, Hard palate; B, soft palate; C, uvula; D, pillars of fauces; E, tonsils (Campbell). terior pillars of the fauces. The anterior pillars of the fauces are formed by the palatoglossus muscles and the posterior pillars by the palatopharyngeus mus- cles (Fig. 25). Externally, the tonsil is in relation 92 THE TONSILS AND THE MOUTH 93 with the superior constrictor muscle of the pharynx, which separates it from the internal carotid artery. This artery has been wounded in operations on the tonsil. Superior longitudinal sinu ferior longitudinal sinus Falx cerebri Temporosphenoid lobe Posterior part of orbit Temporal muscle Z\goma External pterygoiu Ramub of mandible Soft palate Uvula External pterygoid Palatopharyugeus Palatoglossus Hyoid bone Thyrohyoid muscle Thyroid cartilage Omohyoid Sternocleidomastoid Cricoid cartilage Fig. 25. — Vertical transverse section of a frozen head (after Cryer). The ascending pharyngeal artery is more likely to be injected, but is a much smaller vessel, and is not likely to give rise to serious hemorrhage if divided. The tonsil is 94 APPLIED ANATOMY composed of lymphoid tissue arranged in follicles. It is covered with stratified squamous epithelium. On the proximal surface of the tonsil are several depressions or crypts, lined with squamous epithelium, into which open a number of mucous glands. These crypts some- times become clogged by secretion, giving rise to inflam- mation of the tonsil. The blood-supply of the tonsils is derived from the tonsillar and ascending palatine branches of the facial artery, the descending palatine branch of the internal maxillary artery, and the ascending pharyngeal artery. The functions of the tonsils are obscure. The fact that they atrophy about puberty unless diseased shows some connection with the growth of the individual. They are believed to act as filters which prevent the absorption of disease germs through the throat. On the other hand, there is abundant evidence to show that many diseases gain entrance through the tonsils. In addition to the faucial tonsils, there are other masses of lymphoid .tissue known as the lingual and pharyngeal tonsils. The Mouth The oral cavity consists of a roof, a floor, lateral walls, vestibule, an inlet, and an outlet. The Yoo] of the mouth is formed by the hard palate in front and the soft palate behind. " The hard and soft palates should be described as extending from the anterior teeth backward and slightly down in a concave line to near the postpharyngeal wall, leaving scarcely any space. In the normal living sub- ject, when the mouth is closed, the soft palate, the THE TONSILS AND THE MOUTH 95 posterior border of the tongue, and the epiglottis are all in close proximity to the post-pharyngeal wall " (Cryer) (Fig. 14). The floor of the mouth is composed of the two mylo- hyoid muscles, which join in the median line to form a raphe. Above the mylohyoid muscle is the sublingual gland, while below it is the submaxillary gland. Pos- teriorly is the base of the tongue, and anteriorly are the alveolar process and the lower anterior teeth. The mouth is bounded laterally by the cheeks. The vestibule of the mouth is the pocket between the outer side of the alveolar processes and teeth and the inner surface of the cheek. The i}ilet of the mouth is surrounded by the orbicu- laris oris muscle, forming the lips. Just within this are the upper and lower anterior teeth. The outlet of the mouth is bounded above by the uvula and posterior edge of the soft palate, laterally by the pillars of the fauces and the tonsils, and below by the dorsum of the tongue. Review Questions Give the structure, position, relation, blood supply, and functions of the faucial tonsil. What other tonsils are there? Describe the roof of the oral cavity. Describe the floor oi the mouth, giving the structures in close rela- tion to it. What structures form the outlet of the mouth? PART II ORAL SURGERY General Considerations CHAPTER IX ABNORMAL CONDITIONS OF THE CIRCULATION AND COMPOSITION OF THE BLOOD By hyperemia, or congestion, is meant an excessive sup- ply of blood in a part. It may be active, in which case there is an increase in the moving blood, due to dilatation of arterioles and capillaries, or passive, in which the blood is stagnant, due to venous obstruction. In hyperemia the elements of the blood remain within the vessels, as distinguished from the further process of inflammation. By anemia is meant a deficient supply of blood to a part, or a defect in the composition of the blood. The degree of anemia is measured by the percentage of hemoglobin as compared with that of normal blood, and by the number of red corpuscles (erythrocytes) in a given quantity of blood as compared to the normal blood. In normal blood the percentage of hemoglobin is taken as loo, and the number of red cells as 5,000,000 per cubic milHmeter. Various grades of anemia are recog- 7 97 98 ORAL SURGERY nized by comparison with these standards, and by change in the ratio borne by the percentage of hemoglobin to the number of red cells. Severe anemias are also characterized by alterations in size and shape of the red corpuscles (poikilocy tosis) , and by the appearance of nucleated red cells and granular degeneration of the cells. Two general classes of anemia are recognized, primary and secondary. Secondary anemia may be due to hemorrhage, various poisons, as lead, phosphorus, etc., wasting diseases, as syphilis, tuberculosis, cancer, and other conditions, as intestinal parasites. Primary anemia is regarded as a disease originating in the blood itself or in the blood-forming organs, though it is probable that ultimate causes will be found for this class also. The leukocytes, or white blood-corpuscles, are nor- mally found in the proportion of about 8000 to the cubic millimeter. An increase in their number is known as leukocytosis, which occurs in ordinary acute inflam- mation, sometimes amounting to 15,000, 20,000, or 50,000. In inflammatory leukocytosis the increase is chiefly in the polymorphonuclear leukocytes. Certain diseases of the blood and blood-forming organs known as leu- kemias, are also characterized by a tremendous increase in the number of certain varieties of leukocytes, and the appearance in the blood of new forms. Active h5^eremia is the result of mild irritation of some sort. When irritation is more severe or is kept up, a condition of inflammation is induced. Review Question Define hyperemia, anemia, leukocytosis, leukemia. CHAPTER X INFLAMMATION It is impossible to adequately define the term inflam- mation in a short sentence, owing to the complex nature of the process, and the following definitions are neces- sarily imperfect. Inflammation is an expression of the effort on the part of a living tissue to rid itself of or render inert noxious irritants, arising from within or introduced from without. It is the sum of the pathologic changes taking place in a part as the result of injury, and characterized by heat, pain, redness, swelling, and disturbance of function. Inflammation is a succession of local adaptive changes in a part resulting from direct or referred injury (Adami). Etiology. — Anything that causes local injury to the tissues is a cause of inflammation. These causes are: (a) Mechanical — trauma, (b) Chemical, (c) Physical — heat, cold, electricity, (d) MetaboHc — gout, etc. (e) Bacterial. The presence of bacteria is not essential for inflam- mation. There are two grades of inflammation, the acute, running a rapid course, characterized by the classic symptoms, and generally due to microbic invasion, and the chronic, slow in development and progress, in which cardinal symptoms may be lacking. All grades occur between these two extremes. 1)9 lOO OUAL SURGERY Tissue Changes Occurring in Acute Inflammation. — These may be studied under the microscope in the web of the living frog's foot or mesentery, and also by pre- paring sections of tissue in different stages of inflamma- tion. What knowledge we have has been gained by a combination of these methods. These changes may be summed up as follows: 1. Primary contraction of blood-vessels, and increase in rapidity of the current. 2. Dilatation of the vessels and gradual slowing of the current. 3. Temporary or permanent arrest of the blood cur- rent (stasis). 4. Emigration of leukocytes through the vessel- walls into the surrounding tissues. 5. Exudation of blood-serum, and diapedesis of red blood-corpuscles. There is a primary contraction of the blood-vessels, due to the irritation. This causes a temporary increase in the velocity of the blood-current. The vessels now gradually dilate, and the current becomes slower and slower until it is almost entirely arrested. These phenomena are observed solely in the veins and capil- laries. The slowing of the current is believed to be due to changes in the endothelia of the veins. While the current is flowing rapidly, the individual cells of the blood cannot be distinguished, but as it slows down, the leukocytes are observed to accumulate in the outer zone of the current, along the walls of the veins, some of them becoming fixed there. The leukocytes also show a tendency to cling to the walls of the capillaries (mar- gination of leukocytes). After a time the leukocytes IN FLA MM A TION I o I are observed to be making their way through the vessel walls. The first indication of this is the appearance of a small portion of the cell on the outer side of the vessel- wall, gradually followed by the whole cell. This passage of the leukocytes through the walls of the veins and capillaries is known as emigration. The white blood- cells are beheved to pass through spaces or stomata between the endothelial plates lining the vessel-walls. The leukocytes which have left the vessels may pass through the tissue spaces to the seat of the irritation, or may reenter their circulation through the lymph vessels. While the emigration of leukocytes is going on, red cells and blood-serum find their way into the sur- rounding tissues, principally through the walls of the capillaries. The extravasation of red cells is known as diapedesis. The serum extravasated differs somewhat in composition from normal blood plasma, being richer in proteins. Inflammation may terminate in resolution without pus formation, or suppuration may supervene before resolution. In the inflammatory process the leukocytes pass to the point of irritation, which is generally due to bacteria, gather around the infected area, and attempt to neutral- ize the action of the bacteria and their products. This action of the leukocytes is called phagocytosis. The leukocytes can be shown to absorb the bacteria into themselves and digest them. Other body cells and tis- sues form substances that neutralize the toxic effects of the bacteria and prepare them for ingestion by the leukocytes. In primary resolution after inflammation there is no death of tissue, which returns to a normal I02 ORAL SURGERY condition by absorption into the circulation of the inflam- matory exudates. Sometimes the resistive powers of the body are not sufficiently powerful to overcome the bacteria, which continue to grow and send out their products, resulting in liquefaction and death of the tissue-cells and leuko- cytes. This process is known as suppuration. Sooner or later, as a rule, the suppurative process becomes localized or walled in by leukocytes. The liquefied necrotic area is known as an abscess, and the material contained in it is called pus. Pus is, therefore, com- posed of fluid containing broken-down leukocytes and tissue-cells, fat globules, albuminous granules, and bac- teria. Pus is not, as a rule, absorbed, but gradually makes its way in the direction of least resistance, toward the surface of the tissue and is expelled. The communi- cation of an abscess cavity or area of necrotic tissue with the surface of the body is known as a sinus. This term should not be confused with ^^/w/a, which is a pathologic communication of a normal cavity or hollow viscus with the body surface, or with some other hollow viscus. After evacuation of an abscess, resolution takes place, new tissue being formed to make up for that lost by suppuration. The process of repair of tissues will be considered under Wounds. Symptoms of Inflammation. — The cardinal or clas- sical symptoms of inflammation are heat (calor), pain (dolor), redness (rubor), swelling (tumor), and disturbed function (functio laesa). These symptoms can all be explained by the pathologic changes which occur in an inflamed tissue. Heat. — An inflamed part is usually both subjectively INFLAMMATION IO3 and objectively warmer than the surrounding tissues. The temperature, however, is, in reality, no higher than that of the blood. The local sensation of warmth is due to the increased blood-supply and to chemical action. Pain is due to irritation of sensory nerve-endings by the toxins produced. That it is not caused by pressure of the exudate is borne out by the anesthesia produced by injection of subcutaneous tissues with physiologic salt solution. Redness is due to distention of the capillaries of the inflamed part with blood. Swelling is caused in part by the increased amount of blood in the vessels, but is chiefly due to exudation of blood-serum into the tissues. Disturbed Function. — This naturally results from the swelHng and pain. In addition to the classical symptoms, other signs are noted in the various stages of inflammation. Some are purely local, while others are an expression of a general poisoning of the system by absorption of toxins into the circulation. Edema, or pitting on pressure of the skin over the inflamed part, is usually present in microbic inflammation of subcutaneous tissues. It is due to the presence of inflammatory exudate. Fluctuation is a sign of a localized collection of pus or abscess. Fever, or elevation of temperature, is present in all microbic infections in which the products of bacterial growth are absorbed into the general circulation. It is due to increased heat production from the breaking down of tissues by bacterial toxins. The rise of temper- ature is always accompanied by increased pulse-rate. 104 ORAL SURGERY A chill often precedes the formation of pus. Leukocytosis is found in nearly all acute inflammatory conditions, the increase being chiefly in the polymorpho- nuclear leukocytosis. Besides these symptoms, we may have muscular weak- ness, anorexia or distaste for food, headache, delirium, and other disturbances of the nervous system. The liver, kidneys, and other excretory organs may be affected. Treatment of Inflammation. — The general principles of treatment of inflammation consist in removal of the cause, putting the parts at rest, and the application of cold and pressure. When pus forms, it must be evacuated. Cellulitis. — When the leukocytes fail to build a lim- iting wall to the area of infection, the bacteria spread in the tissue-spaces and along the lymph-channels of the subcutaneous tissues. This process is known as cellulitis. It may result in diffuse suppuration, or, in more severe cases, where there is extensive tissue destruction, in phlegmonous or gangrenous inflammation. In the re- gion of the jaws cellulitis may be caused by an infected tooth, from stomatitis, from infection of the salivary glands, or from an impacted third molar. The cellu- litis from an abscessed tooth may spread down the neck between the layers of the deep fascia. Where it is caused by an impacted third molar, the inflammation generally passes upward to the temporomandibular ar- ticulation, causing acute ankylosis. Ulceration An inflammatory ulcer is the result of suppuration and tissue destruction in close connection with an epidermal INFLAMMA TION I O 5 or mucous surface, causing loss of these layers. The process is identical with that of abscess formation, and repair takes place in the same way. Tissue surface may be lost by injury of some kind, resulting in the formation of a traumatic ulcer. The surface may also break down from lack of nutrition by cutting off of the blood-supply, forming trophic ulcer. Gangrene Gangrene is necrosis or death en masse of soft tissue. It is caused by interference with the blood-supply of the part affected, and may be due to virulent microbic infection. It is also seen in disorders of nutrition, in which the arterial supply is gradually shut off. This variety, known as dry gangrene, is characterized by a shriveHng up of the part affected, which turns black and finally drops off if not previously removed by the sur- geon. In moist gangrene there is also obstruction to the veins; the part becomes swollen by distention of the tissues with exudation from the vessels, putrefaction sets in, giving rise to a very foul odor, and the patient may die from absorption of the products of putrefaction. Necrosis The term necrosis means death en masse of any tissue, but is usually applied to death of bone. It is pro- duced in the same way as gangrene of the soft tissues, by any agent that destroys its blood-supply, either through the internal portion of the bone or the perios- teum covering the bone. It may thus follow trauma, I06 ORAL SURGERY chemic action, as seen in poisoning of various kinds, and microbic invasion of the bone-marrow (osteomyel- itis), or of the periosteum (periostitis). By caries of bone is meant a slow molecular disinteg- ration of the bone. Bacteria Commonly Associated with Surgical Affections In the following brief account only the more important of the micro-organisms will be mentioned, and there will be no consideration of the purely bacteriologic side of the subject, which can be obtained in text-books. The commonest organisms met with are the pyo- genic cocci. These include the staphylococcus aureus, staphylococcus albus, staphylococcus citreus, and the streptococcus pyogenes. The staphylococcus aureus is associated with practic- ally all circumscribed local suppurations, such as abscesses, boils, etc. The staphylococcus albus is present normally in the skin, and is found in suppurative lesions of the skin, such as acne. This organism is responsible for stitch abscesses after operations. The staphylococcus citreus is less common than the foregoing. The streptococcus pyogenes is the commonest cause of spreading infections, cellulitis, erysipelas, etc. It is more liable to cause systemic disturbance than the staphylococci, resulting in grave septicemia. INFLAMMA TION 1 0/ Other organisms capable of producing pus under favorable conditions are the gonococcus, pneumococcus, bacillus typhosus, bacillus coli communis, bacillus pyocyaneus. The gonococcus is the specific cause of gonorrhea. In addition to infection of the urethra, it may cause in- fection of the conjunctiva, lymphatic glands, joints, and serous membranes. The pneumococcus is at times responsible for suppu- rative lesions of joints and other tissues. The typhoid bacillus may cause suppuration of joints, glands, and other tissues. Abscess of the parotid gland is a frequent sequel of typhoid fever. The colon bacillus is frequently responsible for in- fections connected with the alimentary and genito- urinary tracts. The bacillus pyocyaneus, or green-pus bacillus, often becomes ingrafted on another infection, particularly in connection with the alimentary canal. The bacillus tuberculosis is of surgical interest by reason of the lesions it causes in bones, joints, and lymphatic glands. The bacillus mallei is the cause of glanders. The bacillus anthracis is the cause of anthrax or malignant pustule, a disease seen in wool-sorters or men engaged in the handling of hides. The tetanus bacillus is the cause of tetanus or lock-jaw. It is especially found in soil, dust, and in sweepings of stables. The organism is anaerobic, and, therefore, deep or punctured wounds are more liable to become infected by it than open ones. I08 ORAL SURGERY The spirochetcB pallida, or, more correctly, the trep- onema paHidum, is the cause of syphilis. The actinomyces, or ray-fungus, is the cause of actino- mycosis. The diphtheria bacillus is occasionally associated with surgical conditions. The bacillus aerogenes capsulatus is found in cases of emphysematous gangrene. Review Questions Define inflammation. Give tiie etiology of inflammation. Describe the tissue changes taking place in acute inflammation. What may be the terminations of inflammation? Define the terms stasis, diapedesis, phagocytosis, abscess, sinus, fistula. Give the five cardinal symptoms of inflammation, with the explana- tion of each. What other symptoms may be present in inflammation? What are the principles of treatment of inflammation? Explain the terms cellulitis, ulcer, gangrene, necrosis. Name and describe briefly the principal micro-organisms associated with surgical affections. CHAPTER XI CONTUSIONS AND WOUNDS Contusions A contusion is an injury to an organ or to the sub- cutaneous tissues, due to a blunt force, in which the surface remains intact, such as falls, kicks, blows, etc. Pathology.— The tissue structure is torn, blood-vessels are ruptured, and there is an effusion of blood and lymph. If a large vessel is ruptured, there may be a considerable extravasation of blood into the tissues (ecchymosis), or there may be a distinct cavity in the tissue, containing a collection of blood {hematoma). This is usually gradually absorbed, but may undergo suppuration. A petechia is a small ecchymosis. As blood is absorbed it undergoes chemic changes, giving rise to a succession of colors, the part being first red, then in turn purple, black, green, and yellow. Symptoms of contusion are swelling, pain, tenderness, and numbness. Swelling, due to rupture of a blood- vessel, appears very quickly after the injury, while later swelling is due to the exudation of lymph. Dis- coloration of the skin appears early in superficial con- tusions, late in deep ones. A hematoma fluctuates at first, later becomes hard, due to coagulation of the blood. Secondary softening is usually due to suppuration, and is accompanied by the symptoms of inflammation. 109 no ORAL SURGERY Treatment. — This in most cases consists in rest, com- pression, and application of cold to the part. If the swelling increases, due to rupture of a large vessel, an incision must be made, and the vessel sought for and ligated. The only other indications for incision are persistence of the swelUng for some weeks, infection, and gangrene. "Wounds A wound is an injury involving a breach in the surface. Wounds are divided into incised, lacerated, contused, and punctured. An incised wound is a clean cut, made by a sharp- edged instrument, with loss of only a thin film of tissue. A lacerated wound is one in which the tissues and skin- edges are torn, made by a dull instrument. A contused wound is one in which the tissues are crushed, made by a blunt instrument. A -punctured wound is one of varying depth, made by a pointed instrument. When it communicates with a cavity, it is known as a ■penetrating wound. Gunshot wounds may be lacerated, contused, punc- tured, or penetrating. Any of these varieties may be complicated by the presence of bacteria, resulting in an injected wound. Hemorrhage is a symptom of all wounds. Fain is, as a rule, not so severe after incised wounds as after other varieties. In an incised wound the skin-edges gape less if the cut be parallel to the fibers of the underlying muscle. If the muscle-fibers be cut across, the edges usually gape CONTUSIONS AND WOUNDS III widely, resulting in a broader scar, and also in greater functional disturbance after healing has taken place. This point should be borne in mind in making incisions at operations. General Principles of Treatment of Wounds. — i. Arrest hemorrhage. 2. Remove foreign bodies. 3. Render aseptic. 4. Drain, and bring edges together. 5. Secure rest. 1. Any but the smallest bleeding vessels are grasped with hemostatic forceps and secured by ligatures. Capillary oozing may be controlled by hot applications or by compression. Bleeding from small vessels in the skin is often arrested by the sutures which bring the edges together, 2. All visible foreign bodies, such as bits of glass, clothing, etc., should be removed with forceps. Devit- alized tissue should be trimmed away. 3. To thoroughly cleanse a wound, shave any hair from the immediately surrounding skin, wash the skin with tincture of green soap, followed by alcohol and 5 per cent, solution of iodin. Any wound other than that made by the surgeon should be swabbed out with the last solution. If dirt be ground into a wound, wash first with turpentine, followed by soap and germicidal solution. 4. In superficial wounds, suture the edges together without drainage. Deep wounds require drainage by strands of silkworm-gut, catgut, rubber tubing, or gauze. Bring together divided muscle-fibers or tendons with deep sutures of chn^micized catgut. Bring the skin- edges together with interrupted sutures of catgut, silk- worm-gut, or horsehair, leaving space for the drain. In- fected wounds must invariably be drained. Arrange the drainage material loosely, so that it will not dam back 112 ORAL SURGERY the fluid. Strips of rubber dam may be used to drain small wounds. Drainage should be employed for at least twenty-four hours. After that time the appearance of the wound is a guide as to drainage. Apply a wet dressing of gauze saturated with equal parts of i : looo bichlorid solution and alcohol over all infected wounds, or those in which infection is suspected. This stimulates phagocytosis and feels more comfortable than a dry dressing. Cover the wet dressing with waxed paper to retain the moisture as long as possible, or pour on fresh solution from time to time. In badly infected wounds it is well to arrange to keep a constant drip of fresh bichlorid solution, i : 10,000, on the dressing, by means of a vessel suspended above the part with a piece of gauze hanging over the side. An infected wound is redressed at least every twenty-four hours. An aseptic wound should be inspected in two days. Skin stitches may be removed from superficial wounds in four or five days. An aseptic wound may be sealed with White- head's varnish after closure with a continuous suture. This is particularly useful in parts of the body which are liable to become bathed with secretions, such as the region of the mouth. It is made up as follows: Iodo- form, I ounce; compound ethereal solution of benzoin, 5 ounces. 5. Rest. Immobilize the parts by bandaging and splints if necessary. In punctured wounds where there is a possibility of infection by the tetanus bacillus, the parts are cauter- ized with pure carbolic acid, followed by the applica- tion of alcohol, and a prophylactic dose of 1500 units of tetanus antitoxin should be administered subcutan- eously. CONTUSIONS AND WOUNDS II3 Wounds of mucous membranes such as the mouth are always infected, but, as a rule, heal remarkably well. In a wound of the mouth the hemorrhage should first of all be arrested, after which steps should be taken to reduce the amount of infection as much as possible. Deposits of decomposing food and tartar should be re- moved from the teeth, all useless roots extracted, and carious teeth treated. An antiseptic mouth- wash should be employed at frequent intervals. Small wounds of the mouth require no suture, but the edges of large lacerated or incised wounds should be brought together with cat- gut, which does not have to be removed, or horsehair, which must be taken out after four or five days. If made by the surgeon in the course of an operation, under approximately aseptic conditions, small incised wounds of the mouth may be closed without drainage, interrupted horsehair sutures being employed. In lacer- ated or contused wounds, or incisions made in connection with large areas of infection, the raw surfaces should be painted with tincture of iodin, after which partial closure may be made with catgut or horsehair, but an opening should be left for drainage with a strip of rubber dam. Repair of Tissue After a wound, there is an exudation of lymph, fibrin, and white blood-corpuscles. The corpuscles become changed into fixed connective-tissue cells, and other connective-tissue cells are formed by proliferation from surrounding tissues. From the walls of neighboring capillaries plugs of endothelial cells, known as fibro- blasts, are thrown out, which unite with similar out- growths from the opposite side of the wound. These R 114 ORAL SURGERY plugs are at first solid, but later become hollowed out, forming new capillaries. The connective-tissue cells elongate until they take on the character of white fibrous tissue. This reparative tissue is known as granu- lation tissue. In incised wounds whose edges have been brought together, healing by primary union or first intention takes place. This means that, as there is no loss of substance to be made up, only a thin layer of granulation tissue is formed between the two sides of the wound, leaving a linear scar. In larger wounds, where a considerable amount of tissue has been lost, healing takes place by second in- tention. Here the space between the edges of the wound is filled in with granulation tissue, and proHferation of epithelium from the edges gradually covers over the surface: What is known as healing by third intention is some- times brought about by approximation of two granu- lating surfaces. Repair of soft tissues after inflammation takes place in the same way as after wounds. In the case of bones, the lost tissue is replaced by fibrous connective tissue into which lime salts are de- posited by the osteoblasts, forming new bone. Review Questions What is a contusion? Give its symptoms and treatment. Define the terms ecchymosis, petechia, hematoma. Define the term wound. Give the varieties, symptoms, and general principles of treatment of wounds. Describe healing by first and second intention. How are bones repaired? CHAPTER XII SURGICAL FEVER Aseptic surgical fever, first described by Billroth, is the almost invariable sequel of a surgical operation or severe injury, in the absence of infection, and is believed to be due to the absorption of fibrin ferment from the seat of injury. There is no evidence of infection of the wound, and the patient feels well. There is an eleva- tion of temperature, sometimes to 103° F., beginning on the evening of the operation, and lasting for twenty- four or forty-eight hours. Aseptic surgical fever requires no treatment. The symptoms of septicemia should be carefully watched for, and the bowels opened with a purge. The wound should not be disturbed. Septic Surgical Fever Under this general heading are included three condi- tions due to the entrance into the system of micro- organisms or their products through a wound or breach of surface. 1. Sapremia is a constitutional disorder due to chemic poisoning by the products of bacteria, these products having been absorbed from the wound. It is usually the result of putrefaction. 2. Septicemia is a disorder caused by the action of the products of living micro-organisms that have gained 115 Il6 ORAL SURGERY entrance into the body, and are undergoing growth and multiplication there. It differs from sapremia in that the poison is being continually produced within the body, while in sapremia the poison is produced in the wound, that is, outside the body. 3. Pyemia is a disease produced by the absorption of pyogenic organisms into the blood, and character- ized, in addition to other symptoms, by the formation of abscesses in various tissues of the body. Sapremia This is usually seen in connection with a putrefying mass of material in a wound, such as a blood-clot. A common cause of sapremia is retention of blood-clot and fetal membranes in the uterus after delivery. Symptoms. — These usually come on suddenly and early in the case. The temperature rises to 103° or 104° F., and is sometimes associated with a rigor. The skin is flushed, hot, and dry, and the patient complains of headache and thirst. The tongue is coated and persistent vomiting may occur. The pulse is rapid and full, the respirations hurried. Inspection of the wound reveals a foul-smelling discharge. The diagnosis from septicemia depends chiefly on rapid recovery after removal of the putrefying material. Prognosis. — Very favorable if the cause is removed early. Treatment. — Clean out the putrefying blood-clot or other material, taking care to injure the surrounding parts as Httle as possible. Do not use strong germicidal solutions. In severe cases stimulation may be advisable in the form of alcohol, such as whisky, half an ounce SURGICAL FEVER 117 every four hours by mouth, or strychnin hypodermic- ally. Subcutaneous infusion of normal saline solution, half a pint every three hours, dilutes the poison in the blood. Persistent vomiting is best treated by washing out the stomach. The diet, while marked symptoms persist, should be hquid, in the form of milk or albumin water. Septicemia The organisms usually associated with this disease are the pyogenic cocci, which are absorbed from a wound into the surrounding tissues or into the blood, where they grow and liberate their toxins. Symptoms. — As in sapremia, these come on early. There is a rapid rise of temperature to 103° or 105° F., which remains high and is usually associated with rigors. The pulse is rapid, and in severe cases may be weak and irregular. Respiration is rapid and there may be dyspnea or cyanosis. Vomiting is not so marked as in sapremia. Headache and, later, delirium are usually present. Examination of the blood shows leukocytosis. Locally, the tissues surrounding the wound (which may be a very small one) become swollen, reddened, and tender, showing the signs of inflammation, and later there may be suppuration. The neighboring lymphatic glands are enlarged and tender and may suppurate. Prognosis. — This is very grave. The disease is often fatal and recovery is generally very slow. Treatment. — The wound should be thoroughly cleaned out and cauterized with pure carbolic acid if possible. The same general treatment is indicated as in sapremia, but must be given more vigorously, and continued Il8 ORAL SURGERY for a longer time. Tincture of the chlorid of iron in doses of 15 minims four times a day is especially effica- cious in septicemia. If the micro-organism causing the disease can be isolated, an antitoxin may be given. Pyemia The micro-organism usually present in pyemia is the streptococcus pyogenes, though the micrococcus aureus has also been known to cause it. The constitutional effects are due to the action of the toxins of these bacteria in the blood-stream. The secondary abscesses are formed by the micrococci becoming lodged in the walls of the veins (suppurative phlebitis) and septic thrombi becoming detached from these, and being carried to various organs. Pyemia is frequently a sequel of acute suppurative osteomyelitis. A case of osteomyelitis of the mandible, for instance, may be followed by pyemia, with secondary foci in the lungs, peritoneum, brain, and joints. Symptoms. — Pyemia does not, as a rule, begin as early as the other two forms of surgical fever. Local signs of inflammation appear in the wound, associated with phlebitis of the veins of the region under the red and tender skin. The general symptoms begin with a chill and rapid rise of the temperature to 104° or 105° F. This is followed by profuse sweating and a fall of the temperature two or three degrees. The chills, fever, and sweats occur irregularly throughout the course of the disease. The other general symptoms resemble those of septicemia, but are more severe. The second- ary abscesses appear from the sixth to the tenth day, and may be located in the lungs, spleen, kidneys, brain, SURGICAL FEVER 119 peritoneum, and joints, giving rise to special symptoms according to the organ affected. Prognosis. — Recovery from pyemia is extremely rare. Treatment. — The wound or primary seat of the infec- tion must be thoroughly cleaned and drained. Cold sponging may control the fever. Tincture of the chlorid of iron and quinin should be given, and the patient should be stimulated as in septicemia. Morphin may be required to relieve pain. Secondary abscesses, if accessible, must be opened and drained. Review Questions Define surgical fever, and give its varieties. Give the symptoms and differential diagnosis of sapremia, septi- cemia, and pyemia. Give the prognosis and treatment of each. CHAPTER XIII SYNCOPE, SHOCK, COLLAPSE Shock is that state of prostration which may follow any excessive disturbance of the nervous mechanism, as in those who have been severely injured, or whose minds have been shaken by intense emotion (Brodie). Collapse is a condition similar to shock, differing in its mode of causation and rate of onset. The main symptoms are the same. Syncope J or fainting, is a mild degree of shock, produced by a temporary anemia of the brain. It is of sudden onset and short duration. The face suddenly becomes blanched, the pulse small and rapid, and the individual sinks to the ground unconscious for a few moments. Etiology. — Shock is usually caused by severe bodily injury, following operation, or associated with intense pain or emotional disturbance. It sometimes follows prolonged anesthesia. Collapse is caused by severe external or internal hemorrhage and loss of body fluid, as through persistent vomiting or diarrhea. Pathology. — Shock is due to a depression of function of cerebral nerve-centers, particularly of the vasomotor centers, resulting in dilatation of the splanchnic area and a lowering of blood-pressure. Collapse is brought about by a primary loss of body fluid, resulting in cerebral anemia and consequent de- 120 SYNCOPE, SHOCK, COLLAPSE 12 1 pression of the higher nerve-centers, with lowering of blood-pressure. Symptoms.— 5//ocA^ usually comes on suddenly. The skin is pale, cold, and moist. The muscles are relaxed. The patient is apparently unconscious, but can be aroused and will reply to questions. The temperature is sub- normal, the pulse weak and rapid, and the respirations shallow. The pupils are dilated. The sensibiUty is dulled. In collapse the onset is gradual, and the symptoms, which are the same as those of shock, grow progressively worse. Treatment.— 5y«co/?e.— Loosen the clothing about the neck, place the patient in a recumbent position, or thrust the head down between the knees, douche the head with cold water, and allow the patient to inhale aromatic spirits of ammonia. As the patient recovers consciousness administer one dram of aromatic spirits of ammonia in a little water by the mouth. Shock. --Kamove the exciting cause if it is still present, and then restore the circulatory function. Place the patient in the recumbent position, elevating the foot of the bed to assist the return of blood from the lower extremities. This is often aided by bandaging the lower extremities. Administration of saline solution increases the volume of circulating blood. Where a rapid effect is desired, from one to two pints of normal saline solution (a teaspoonful of common salt to a pint of sterile water), at a temperature of 104° to 112° F., may be injected directly into a vein. In less urgent cases the saline solution may be given through the rectum fenteroclysis) or subcutaneously (hypodermo- 122 ORAL SURGERY clysis). To prevent loss of body heat the patient is wrapped in hot blankets, surrounded by hot- water bottles. A pint of hot coffee may be given by the rectum. Where the shock is due to pain, give morphin, \ grain, with sulphate of atropin, -^^-^ grain hypodermic- ally, and repeat if necessary. Other valuable stimu- lants are aromatic spirits of ammonia, 30 minims, camphor in olive oil (camphor, i grain, olive oil, 5 min- ims) in 15-minimdoses, strychnin, 215" grain, atropin, y^o" grain, administered hjrpodermically, and repeated every three hours if necessary. The most rapid effects are produced by the camphorated oil and the ammonia. AdrenaUn chlorid is recommended by some, but its effects are only transitory. CriWs Method. — In cases of sudden heart failure during anesthesia or following injury Crile injects normal saline solution containing adrenalin directly into the common carotid artery toward the heart, com- bining this with massage of the heart. The abdomen is opened through the left rectus, and the heart massaged through the diaphragm. Cases have been literally brought back to life by this method. In collapse, caused primarily by loss of body fluids, the administration of saline solution by the mouth or by injection is especially valuable, though the general principles of treatment are the same as for shock. Hemorrhage Hemorrhage is the escape of blood from the blood- vessels. It may be either spontaneous or due to trau- matism. The blood may either escape from the surface of the body, or into the tissues surrounding the blood- HEMORRHA GE 1 2 3 vessels, when it is known as extravasation. A circum- scribed collection of extravasated blood is known as a hematoma. A hemorrhage is known as internal when it escapes into one of the body cavities, such as the peri- toneal cavity, but is not met with in the region of the body with which we have to deal. There are three anatomic varieties of hemorrhage — arterial, venous, and capillary. 1. Arterial hemorrhage is caused by section or rupture of an artery. There is a flow of bright-red blood, which occurs in spurts coincident with the heart-beat. 2. Venous hemorrhage is caused by injury to a vein. There is a continuous flow of dark colored blood. 3. Capillary hemorrhage is characterized by a steady oozing of blood from a wound. The clinical varieties of hemorrhage are primary, intermediate, and secondary. 1. Primary hemorrhage occurs immediately after the division of a blood-vessel. 2. Intermediate hemorrhage occurs after the reaction from shock, due to disturbance of the temporary blood- clot by increased vigor of the circulation. It occurs within twenty-four hours after the injury. 3. Secondary hemorrhage occurs after the first twenty- four hours. It may be due to sloughing of the end of the vessel, traumatism, or infection. Certain condi- tions predispose to it, such as arteriosclerosis and hemo- philia. Certain terms are also used in connection with hemor- rhage from particular regions. Thus, epistaxis refers to nose-bleed; hemoptysis, the coughing up of blood; hematemesis, the vomiting of blood; hematuria, blood in the urine. 124 ORAL SURGERY Constitutional Effects of Hemorrhage. — When a con- siderable amount of blood has been lost, the pulse becomes rapid and feeble, the respirations gasping. There is a sense of suffocation or air hunger and intense thirst. The skin is cold, pale, and moist. Delirium may be present. Spontaneous Arrest of Hemorrhage. — When an artery is divided, the inner and middle coats curl up within the lumen and occlude the cut end. The blood clots above this in the case of a small vessel and hemorrhage ceases spontaneously. The escaped blood also clots around the cut end of the vessel. Later the clot becomes converted into fibrous tissue by the process of repair. Methods of .Arresting Hemorrhage. — Arterial hemor- rhage is arrested by grasping the bleeding artery with a pair of hemostatic forceps. In the case of a small artery the crushing together of the coats of the vessel by the forceps is often sufficient to stop the bleeding if the forceps are allowed to remain for a few minutes. Before removing the forceps the vessel may be twisted with them. In the case of larger arteries a catgut Hga- ture is tied around the vessel before removing the for- ceps. Sometimes it is necessary to tie both ends of the cut vessel. Venous Hemorrhage. — Bleeding from large veins is arrested in the same way as arterial hemorrhage. Mod- erate and slight venous oozing can generally be controlled by gauze packing or compression. Bleeding from a small incised wound is generally stopped after the skin sutures are tied, if they are placed deeply enough to compress the bleeding points. Capillary hemorrhage may be checked by the applica- HEMORRHA GE 1 2 5 tion of hot water to the wound, followed by compression with gauze. Hemorrhage Following Tooth Extraction. — Considering the large number of teeth extracted, this is not a very fre- quent complication, but it may be a very serious and even fatal one. If undue hemorrhage occurs, the alveolus is to be syringed out with warm water to dislodge any clots. In most cases a little tannic acid on cotton packed into the socket will usually stop the bleeding. If this does not sufhcc, the socket should be tightly packed with gauze covered with tannic acid. A pad of gauze is now laid over the plug, and the teeth of the two jaws are brought together. The jaws are held together with Barton's bandage. In most cases the packing should not be disturbed for twenty-four hours. The gauze packing in the tooth socket may be held in place by a crossed ligature passed over the socket and secured to teeth on either side of it. Sometimes it is advisable to replace the extracted tooth in the alveolus and allow it to remain for several hours. In severe cases it may become necessary to ligate the external carotid artery. Persistent capillary hemorrhage is frequently due to a deficiency of substances which bring about coagulation of the blood. These substances may be supplied to a patient in whom bleeding from a tooth socket persists by the injection hypodermically of normal blood-serum. Normal horse-serum may be obtained in convenient syringes for this purpose, and is given in doses of lo to 20 c.c, which may be repeated in twenty-four hours or less if necessary. Where the normal horse-serum is unobtainable in emergencies, diphtheria antitoxin may be used. Normal serum has also been successfully em- 126 ORAL HEMORRHAGE ployed locally to check hemorrhage, and may be used on the cotton packing in the tooth socket instead of tannic acid. Constitutional Treatment Following Hemorrhage. — The patient is to be placed in the recumbent position, with the head lowered, and kept perfectly quiet. This is secured, if necessary, with a hypodermic injection of \ grain of morphin. The lost blood is replaced with intravenous injection of one to two pints of normal salt solution, and circulatory stimulation is carried out by hypodermic injections of strychnin, atropin, and camphorated oil, in the doses given in the treatment of shock. If the site of the hemorrhage is not absolutely secured from further bleeding, judgment must be exer- cised in stimulating the circulation on account of the danger of setting up fresh hemorrhage from increased arterial pressure. The thirst present in these cases is relieved by water, either by the mouth or by the bowel. The anemia following severe hemorrhage is to be treated later by tonics, particularly iron. In some cases the only hope of improvement is by direct transfusion of blood from another person, pre- ferably a blood relation of the patient. Hemophilia Hemophilia (hemorrhagic diathesis) is a congenital tendency to spontaneous hemorrhage and immoderate hemorrhage after injury. The disease is restricted to the male sex, and is usually hereditary in character, being nearly always transmitted through the female sex. Etiology and Pathology. — The blood in these cases is found to have a subnormal number of leukocytes, par- HEMOPHILIA 1 27 ticularly of the polymorphonuclear leukocytes. It is now recognized that the disease is due to a defect in the coagulating power of the blood. Symptoms. — The diathesis shows itself in subcutaneous hemorrhages, hemorrhage into joints, and immoderate spontaneous bleeding from mucous membranes, for example, from the nose and gums. Moreover, severe bleeding follows the slightest injury, and can be arrested only with great difficulty. Death has frequently fol- lowed extraction of a tooth in one of these cases, and as extensive dental caries is very often associated with hemophilia, this becomes a serious complication. There is a noticeable tendency for the hemorrhage to come on at night. It may not be severe immediately after in- fliction of the wound, but will break out again after the patient goes to sleep. Prognosis. — This is especially unfavorable in infancy, but the coagulability of the blood increases as age advances, and while the outlook is never good so far as the traumatic hemorrhages are concerned, yet the patient, as he grows older, becomes careful not to incur these, and the tendency to spontaneous hemorrhage usually is overcome. Treatment. — From the surgical standpoint the chief consideration is the prevention and arrest of traumatic and postoperative hemorrhage. The following measures are on the lines laid down by Sir A. E. Wright. Prophylaxis. In a patient known to be a bleeder it is well to avoid performing any operations, if possible. If an operation, such as extraction of a tooth, becomes imperative, some attempt may be made to increase the coagulability of the blood by the administration of 128 ORAL SURGERY drugs by the mouth. The defect in nucleo-albumin may be supplied by the administration of extract of thymus gland, in doses of 5 grains three times a day. The remedies used to increase coagulability are the salts of calcium and magnesium. A mixture of calcium chlorid or lactate and magnesium carbonate may be given in doses of 5 grains of each three times a day. These measures should be carried out for several days preceding the operation. If, in spite of these precautions, or if bleeding occurs in an unsuspected case of hemophilia, the remedies must be given in larger doses — 20 grains three times a day of the thymus extract may be given. An initial dose of I dram of calcium chlorid or lactate, or a mixture of equal parts of calcium chlorid and magnesium carbon- ate, may be given to an adult, followed by 30 grains daily to keep up the effects. The injection of normal blood-serum in suitable doses, repeated if necessary, is indicated in hemophilic bleed- ing, as well as a prophylactic, just as in ordinary capillary hemorrhage. Direct blood transfusion may also give suc- cessful results. Local Treatment. — This consists in the application of physiologic styptics, which exert their effect by accelerating the coagulation of the blood on the bleeding surface. Wright finds that with such a styptic he can arrest hemorrhage from the cut femoral artery of a dog, provided the artery be compressed for a minute or two to allow consoUdation of the clot. This styptic is made from the thymus gland of a calf or lamb. The gland is chopped up finely and placed in a jar with normal salt solution in the proportion of one part of gland to ten HEMOPHILTA 1 29 parts of the solution. The extract is filtered off, and 0.5 per cent, of calcium chlorid added to the filtrate with i per cent, of carboHc acid. The wound is plugged with cotton or Hnt soaked in the styptic. Review Questions Define shock, collapse, syncope. Give the etiology, symptoms, and treatment of shock. Define and give the anatomic and clinical varieties of hemorrhage. Give the constitutional effects or symptoms of hemorrhage. How is spontaneous arrest of hemorrhage brought about? Give the methods for controlling arterial, venous, and capillary hemorrhage, respectively. Give the methods of arresting hemorrhage following tooth extraction. What is the constitutional treatment of hemorrhage? Define hemophilia. Give its etiology, pathology, symptoms, prog- nosis, and treatment. CHAPTER XIV ANESTHESIA Three methods of inducing anesthesia are employed at the present time for the performance of surgical operations. The three forms are spinal, local, and general. Spinal anesthesia, so successfully employed by Jon- nesco, of Bucharest, has not met with universal favor in this country, and a limited number of surgeons employ it in operations on the lower extremities and lower part of the trunk. The anesthesia is induced by paral- yzing the sensory spinal nerve-roots by injection of a solution of stovain into the spinal canal in the lumbar region. This method is not, as a rule, applicable to operations on the head and neck, so it is only briefly mentioned in passing. Local Anesthesia. — By this is meant the induction of loss of sensibility in a part by the local application or injection of certain drugs. Superficial local anesthesia may be induced by the application of a volatile fluid, such as ethyl chlorid. This is applied in the form of a spray, and by its evaporation abstracts heat from the part. The ethyl chlorid spray is suitable for opening small abscesses. Various substances are used to paralyze sensory nerve-endings by injection into the skin. Cocain hydrochlorid, beta-eucain hydrochlorid, and novocain are the most commonly used, in solutions ranging from I to 5 per cent. Novocain is just as efficient as cocain, 130 ANESTHESIA I3I and is practically never followed by toxic effects. More- over, the novocain solution can be sterilized by boiling, which is not true of cocain without interference with its anesthetic properties. For most practical purposes a I per cent, novocain solution will answer. With this is combined adrenalin chlorid in the proportion of i part in 10,000. The adrenalin enhances the anesthetic effect, constricts the blood-vessels of the part, thus less- ening hemorrhage, and retards absorption of the anes- thetic. This form of local anesthesia is applicable for the removal of small growths from the skin, foregin bodies, etc. It should not be used where there is in- fection, and extreme care should be employed in thorough sterilization of the needle and the parts to be operated upon. The needle is introduced into, not beneath, the skin, at one end of the prospective incision, and a drop of the solution injected. The needle is then pushed a little further along the hne of incision and another drop injected. This is continued until the whole line of inci- sion is infiltrated by the anesthetic. Before proceeding with the operation, it is well to wait two or three min- utes for the anesthetic to take effect. Local Anesthesia Jor Extraction of Teeth and Operations About the Jaw Bones. — With improvements in technic and the substitution of novocain for cocain, what was formerly condemned as dangerous and unsatisfactory, has in the last few years come to be regarded as one of the most valuable aids in dental and oral surgery. The essen- tials of success in the employment of local anesthetics are a thorough knowledge of the anatomy of the parts, proper technic, the selection of suitable cases, and, above all, the observance of absolute asepsis. It is dangerous to inject 132 ORAL SURGERY a local anesthetic into acutely inflamed tissues about a tooth, as the introduction of any fluid under pressure in these circumstances may result in spreading the infection or sloughing of the tissues. The anesthetic effect, too, is not nearly so powerful when the tissues are inflamed. Again, certain people of nervous temperament are not suitable subjects for local anesthesia, their nervous con- dition causing them to flinch at the sight of instruments, the prick of the needle, etc. This apphes also to young children, in whom general anesthesia is more satisfactory. For details of the technic of injection, etc., the reader is referred to special works on this subject, such as those of Fisher-Riethmuller, Thoma, and Allen. General Anesthesia. — General anesthesia is the arti- ficial production of loss of consciousness by the action following inhalation of certain drugs upon the sensory nerve-centers in the brain. In a general way the cranial nerves are affected by general anesthetics in their regular order, beginning with the olfactory. The general anesthetics in common use are ether, chloroform, and nitrous oxid. Ethyl chlorid is occasion- ally used. The choice of an anesthetic depends upon several factors, such as the length of anesthesia required, the nature of the operation, and the condition of the patient. For prolonged anesthesia, ether and chloroform are used. For the vast majority of cases ether should be selected, as it is very much less dangerous than chloro- form. The number of deaths following the inhalation of chloroform is about i in 4000, while the number from ether is about i in 16,000. Chloroform is more danger- ous than ether because it acts more strongly and quickly ANESTHESIA 1 33 upon the circulation and respiration than ether. In its administration there is a progressive fall of blood- pressure. The comparative infrequency, too, with which chloroform is given by anesthetists in this country undoubtedly contributes to the danger. Chloroform is much more pleasant to take than ether, produces less excitement, less irritation of the respiratory passages, its effects are much more quickly produced than those^ of ether, while there is usually less nausea and vomiting following its administration. All these advantages, however, are counterbalanced by the danger of chloro- form and the comparative safety of ether, and there are only a few cases in which the latter is not to be preferred. In chronic bronchitis, asthma, and phthisis pulmonalis, chloroform is preferable to ether, as the latter is a power- ful irritant to the respiratory passages. In case of war, chloroform is less bulky, and the patients can be anes- thetized much more rapidly, and thus there is the possi- biUty of attending to a greater number of wounded. The secondary effects of chloroform on the tissues are more serious than those of ether. Ether is said to be unsatisfactory in tropical countries, owing to its great volatility, but it is used here with success in the hottest weather. It is also said that ether is less suitable for children than chloroform, but practical experience shows that it can be employed just as satisfactorily in the case of children as of adults. Ether Narcosis Ether anesthesia may be divided into four stages, as follows : I. Stage of primary anesthesia. 134 ORAL SURGERY 2. Stage of excitement. 3. Stage of relaxation. 4. Stage of collapse. First Stage. — On first inhalation of ether there are burning in the throat and a feeling of strangulation, due to local irritation of the ether. In a short time sensi- bility becomes distinctly lessened, and the patient becomes semiunconscious. In this stage minor opera- tions, such as extraction of a tooth or opening an abscess, can be performed without pain. Second Stage. — The first stage is soon succeeded by the stage of excitement. The patient becomes delirious and often violent. The muscles are rigid; the respira- tions are rapid, though they may cease through spasm of the glottis; the face is flushed and moist. Reflexes are present and may be exaggerated. The pulse is rapid and full. The pupils are dilated. Third Stage. — In this stage the patient becomes quiet. The muscles are relaxed; the corneal and other reflexes are lost. The pupil is contracted. The breath- ing is slow, deep, and regular. The pulse is full, strong, and slow. The skin is flushed, warm, and moist. This is the stage during which surgical operations are per- formed. Production of complete surgical anesthesia requires, as a rule, from ten to fifteen minutes. Fourth Stage. — If anesthesia be carried beyond the third stage, the patient's life is in danger from collapse. The breathing becomes stertorous from paralysis of the muscles of the palate. The respirations then become shallow and irregular, or may cease altogether. The pupil dilates, and will not respond to light. The pulse becomes rapid and weak. The skin is cold, moist, and ANESTHESIA 1 35 dusky. Ether usually produces death by asphyxia, due to depression of the respiratory centers, but may also act fatally by depressing the heart. On the nervous system ether acts as a depressant, first on the cerebrum, then the sensory side, and finally the motor side, of the spinal cord. The first action of ether upon the circula- tion is as a stimulant to the heart and vasomotor centers, but it finally depresses the heart and vascular system. Extraction of a tooth, or opening of an abscess, can often be performed during the first stage of ether anes- thesia. In these cases little or no previous preparation of the patient is necessary, and they can be done with the patient in the sitting posture. The best way of giving the ether in these cases is by means of a towel folded into the shape of a cone, in which a sponge moistened with warm water is inserted. A considerable quantity of ether is poured on the sponge, and the face of the patient gradually approached with the cone. The patient is instructed to take full breaths and to hold up one arm. In a few minutes the arm drops and the tooth is extracted without pain. Before the administration of ether for complete anesthesia, the following precautions are to be taken: No food should be taken by the patient for at least ten or twelve hours before the administration of the ether where a long operation is to be performed. If this precaution be not observed, vomiting is Hable to occur, with danger of suffocation and aspiration pneumonia. The bowels should be emptied by a dose of magnesium sulphate the evening before the operation. The patient's heart and lungs should be carefully examined. It is important to know the condition of the kidneys, both as 136 ORAL SURGERY to presence in the urine of albumin and casts and the quantity excreted. Ether is a powerful irritant to the kidneys, and the minimum amount must be used in the presence of nephritis. Just before administration of the anesthetic all foreign bodies, such as removable artificial teeth, should be taken from the mouth. The clothing about the neck and chest must be loosened. The horizontal position is preferred in administration of the anesthetic, but the patient can later be placed in any more convenient position for the performance of the operation. In giving the anesthetic it is not necessary to remove the pillow from beneath the patient's head, as is so often done. Respiration is usually much less embarrassed with the pillow. The lips and nostrils of the patient should be anointed with vaseHn before giving the ether. Some anesthetists precede the administration of ether by nitrous oxid, and by this means shorten the induction of complete anesthesia. The method is undoubtedly also more agreeable to the patient, and the after-effects are said to be less noticeable. But in the experience of the writer, for prolonged operations, where complete relaxation is necessary, it is best to commence with ether. Patients throughout the operation do not seem to lose the cyanosing effects of the nitrous oxid, thus masking possible cyanosis from the ether, and complete relaxation is not so easily attained. If the ether be given slowly, it is seldom objected to by the patient. I have seen one anesthesia death following the combina- nation of nitrous oxid and ether, probably caused by mistaking the results of too much ether for nitrous oxid cyanosis. ANESTHESIA 137 The best way of administering the ether is with the ordinary wire mask (Fig. 26) usually employed in giving chloroform. It is easily handled and removed when necessary in operations about the face, and has the especial advantage that plenty of air is admitted with the ether. This latter is the most important point in ether administration. About four layers of gauze are placed on the mask and a few drops of ether allowed to fall on them. The mask is held at first at some little distance from the patient's face, and gradually made to come nearer, until finally the fumes become tolerable and it can be laid directly in contact with the face. After this the ether can be given more rapidly, but still drop by drop, and, if necessary, a few more layers of gauze tem- porarily applied, which can be removed when anesthesia is complete. By this open method, with slow adminis- tration of the ether and allowing admixture of plenty of air, a longer time is required for anesthesia than by giving the ether in larger quantities and excluding the air, but relaxation becomes more complete, and the general conditiun of the patient is much better through- out the operation. The patient is instructed to breathe deeply and regularly, but forcible respiration is to be avoided. Any cessation of the respiration dur- Fig. 26. — Wire frame for hold- ing gauze in ether anesthesia. 138 ORAL SURGERY ing the early stages is due to local irritation or spasm of the glottis. A full breath of air, followed by an in- crease in the amount of the anesthetic, is generally suc- cessful in restoring natural respiration. The lower jaw should be kept forward by pressure of the fingers behind the angle. This prevents the tongue from falling back and obstructing the glottis. During the stage of excite- ment the patient may become so violent as to require assistants to hold him. When the patient is quietly resting upon the operating table, the arms should be secured to the sides by a towel passed under the body, the ends being fastened to the wrists with safety-pins. This prevents the arms from hanging over the sides of the table, and consequent risk of musculospiral paralysis from pressure on the nerve by the edge of the table. The indications that anesthesia is complete are relaxation of the muscles and absence of the corneal reflex. During the operation the anesthetist must from time to time note the condition of the pulse, and report it to the operator. The pulsation of the temporal artery can be conveniently felt immediately in front of the ear. He should remove any mucus which may have collected in the throat by means of a gauze sponge. Respiration may be aided by inserting a mouth-gag, drawing the tongue forward, and holding it with a small piece of gauze in the fingers. This is preferable to the tongue forceps, which crush and wound the tongue un- necessarily. During the operation the patient is kept under with the minimum amount of ether, continually administered drop by drop. The best guide to the depth of anesthesia is the respiration of the patient. A slight break in the regularity of the breathing is an ANESTHESIA 1 39 indication, as a rule, that the patient is coming out, and to push the anesthetic a little. During deep anesthesia the pupil is contracted. As it becomes less profound the pupil dilates, but will respond to light. When the ether is pushed too far, the pupil also dilates, but does not respond to light. The depressant effects of the ether also show themselves in a duskiness of the skin, due to sluggish circulation. This is well seen in the lobe of the ear. Pressure causes the cyanosis to disappear, and it returns slowly when the pressure is released. Cyanosis is accompanied by a gradual acceleration in the pulse- rate and a decrease in its volume. These signs call for stimulation and a termination of the operation in as short a time as possible. Strychnin sulphate, -j\j grain, and atropin sulphate, yj^ grain, and tincture of digitalis, lo minims, may be given hypodermically, and the first repeated if necessary. In more extreme cases, with the pulse at i6o or higher, especially when the patient has lost a considerable quantity of blood, intravenous infusion of a pint or more of normal saline solution is indicated. Vomiting during the operation is usually a sign that the anesthesia is not sufficiently deep. Its onset is heralded by retching, and it can often be averted by pushing the ether. If vomiting does occur, remove the mask and turn the head of the patient to one side to prevent inspiration of the vomited material. As soon as possible after the throat has been cleared the administration of the anesthetic is continued. In case of respiratory failure, remove the anesthetic at once, see that the tongue has not fallen back to ob- struct the glottis, and attempt to set up respiratory 140 ORAL SURGERY movements by pressure on the chest. A piece of gauze saturated with aromatic spirits of ammonia placed over the nostrils will often be of assistance. If these fail, regular artificial respiratory movements should be tried. Administration of oxygen with the ether in all cases that show a tendency to respiratory embarrassment should be a regular procedure. Sudden heart failure calls for cardiac massage and Crile's method of saline infusion into the carotid artery (see section on Shock). The anesthetic may be withdrawn several minutes, as a rule, before the operation is completed, and may be replaced with oxygen or aromatic spirits of ammonia. Careful watch should be kept over the patient recovering from the anesthetic, as vomiting almost invariably occurs, and the respiratory passages must be kept clear of vomited material. Ether vapor is heavier than air, and consequently the fumes during its administration tend to settle in the lower part of the room. As ether is very inflammable, all gas, candle, or lamp lights should be well above the level of the patient. The thermocautery should not be used near the anesthetic. The fact that ether vapor is heavier than air also renders anesthesia most rapid when the mask is held vertically above the face of the patient. For operations within the mouth various forms of apparatus have been devised for introducing the anes- thetic into the respiratory passages without interrupting the operation. The ether may be given in the form of vapor by means of catheters passed into the pharynx through the nose, or directly into the trachea through ANESTHESIA 14I the mouth (intratracheal insufflation). In all these methods the ether is vaporized, mixed with air, and pumped in by means of an electric motor, a foot bellows, or a hand bulb. Nitrous Oxid For short operations, such as the extraction of teeth, opening abscesses, etc., nitrous oxid gas (N2O) is a suit- able anesthetic, though in the practice of the writer its use has become considerably replaced by local anes- thetics. It is best given combined with oxygen. Nitrous oxid has the following advantages over other general anesthetics: 1. It is the safest anesthetic known. 2. It requires very little previous preparation of the patient. 3. The patient can be anesthetized either in a recum- bent or a sitting posture. 4. The patient is rapidly anesthetized. 5. Ill after-effects are seldom produced by nitrous oxid. The disadvantages of nitrous oxid are: (i) The appliance required for its administration is very heavy and cumbersome. • (2) Its effects pass off very rapidly, and it is, therefore, not suitable for operations in the mouth that require more than a few seconds. By the use of oxygen with the nitrous oxid the period of anesthesia can be lengthened, though the effects pass off as rapidly as with nitrous oxid alone, and with the introduction of the nasal inhaler prolonged opera- tions within the mouth may be successfully undertaken. 142 ORAL SURGERY The writer, however, reserves nitrous oxid and oxygen for cases in which local anesthesia is contraindicated and unsuitable, and where the operation is not of suffi- cient consequence to require hospital facilities. But in operations on other parts of the body the combination of oxygen and nitrous oxid is very useful in cases where other anesthetics, such as ether or chloroform, are contra- indicated. The writer has had experience with it in operations lasting nearly an hour. By this method the cyanosis induced by nitrous oxid alone is eliminated, and after-effects are more rarely seen. Perfect relax- ation of the muscles can be obtained. The time re- quired to anesthetize a patient by this method is rather longer than by nitrous oxid alone. The operator must judge of the amount of oxygen required by watching the face of the patient for cyanosis. The amount of oxygen used ranges from 4 to lo per cent. Before administering nitrous oxid, the clothing about the neck of the patient should be loosened, and removable artificial teeth or other foreign bodies taken from the mouth. A cork or rubber prop should be placed between the teeth on the side opposite to that upon which the operation is to be performed. The patient is instructed to take slow full breaths, and is made to go through several respirations of this character with the hood over the face and the air- valve open. When proper breathing has been established, the gas is turned on and air excluded. The time for anesthesia to become complete varies, but averages about a minute and a half. The indica- tions of the onset of the anesthesia are a tremor or shaking of the body, stertorous breathing, and cyanosis. The tremor generally appears first, followed by cyanosis ANESTHESIA 1 43 and stertorous breathing. Stertorous breathing is the surest sign of complete anesthesia, and calls for with- drawal of the anesthetic. The operator usually in- structs the patient to hold up one arm, and as soon as this falls to the side, anesthesia is regarded as complete. The effects last about a minute or a minute an a half. After this period has passed the patient gradually regains consciousness, the return often being accompanied by laughing, weeping, and sometimes violence. Conscious- ness returns in about two minutes, after which no ill effects are felt by the patient, as a rule. The anesthetic effect of nitrous oxid is in part due to deprivation of oxygen, but chiefly to the inherent action of the gas upon the sensory centers. It is unsafe to continue administra- tion of the gas after anesthesia has been induced, and it is, therefore, not available for prolonged operations unless combined with oxygen. The operator must judge of the amount of oxygen required by watching the face of the patient. He can start anesthesia with pure nitrous oxid, and then add oxygen, gradually increasing the percentage as cyanosis appears, just giving enough to eliminate the cyanosis, and yet not enough to coun- teract the effect of the nitrous oxid. Ethyl Chlorid Ethyl chlorid, under the names of somnoform, nar- cotile, etc., is used to a considerable extent for the extraction of teeth and other minor operations. It resembles nitrous oxid in the rapidity of its action and fugaciousness, but several deaths have been reported from its use, so that it is not to be recommended for ordinary practice. 144 ORAL SURGERY Tracheotomy This procedure consists in making an artificial open- ing in the wall of the trachea to enable respiration to be carried on after obstruction of the larynx. The indication for its performance is occlusion of the res- piratory tract above the trachea by inflammation (diph- theria, laryngitis, tuberculosis, etc.), edema of the glottis, tumors, and foreign bodies. Fig. 27. — Cohen's tracheotomy tubes: i, Outside tube and obturator; 2, obtu- rator; 3, inside tube; a, cross-section of the tube (Fowler). The operation is performed as follows: The shoulders are raised and the head thrown back as far as possible, which gives increased room for the operation, brings the trachea near the surface, and puts it on the stretch, thus making it less mobile. A median incision, 3 inches long, is made from the cricoid cartilage downward. The sternohyoid muscles are pulled to either side with re- tractors, exposing the isthmus of the thyroid gland, which usually lies over the second, third, and fourth ANESTHESIA 1 45 rings of the trachea. Cutting the isthmus should be avoided if possible, owing to its vascularity. The open- ing in the trachea is made preferably above the isthmus, the latter being pushed down. The trachea is opened by a longitudinal incision large enough to admit the silver tracheotomy tube (Fig. 27), w^hich is then inserted and secured in place. Hemorrhage may occur from division of the inferior thyroid veins, which should be controlled by ligation. Ligation of Common Carotid Artery and External Carotid Artery One of these procedures is carried out as a prelimin- ary to operations on the head and neck w'here a large portion of tissue is to be removed, as a precaution for the control of hemorrhage, for example, before removal of the upper jaw for sarcoma. It is also done in the treatment of aneurysm of one of these arteries and for arresting hemorrhage which cannot be stopped by the usual methods. The common carotid artery is ligated in the superior carotid triangle, just before its bifurca- tion at the level of the upper border of the thyroid cartilage. An incision 2 inches long is made over the anterior edge of the sternocleidomastoid muscle, through the skin, superficial fascia, platysma myoides, and deep fascia. The pulsation of the artery is now felt for and the carotid sheath opened. The artery lies to the inner side of the internal jugular vein, with the pneumo- gastric nerve between and behind the vessels. To avoid wounding the vein, the ligature Csilk) is passed by means of an aneurysm needle around the artery 10 146 01? AL SURGERY from the outer side, care also being taken not to include the pneumogastric nerve in the ligature. If the artery is to be severed, it must be tied in two places and cut between the ligatures. The external carotid artery is also ligated in the supe- rior carotid triangle, just above the level of the upper edge of the thyroid cartilage. After bifurcation of the common carotid, the external carotid lies at first nearer the median Hne than the internal carotid, for which it must not be mistaken. The branches of the external carotid artery may also be ligated in the superior carotid triangle. Review Questions Define local anesthesia. Give some of the local anesthetics in common use, with indications for and mode of administration. What are the dangers of the hypodermic use of cocain as a local anes- thetic in the region of the jaws? Define general anesthesia. Name the three commonest general anesthetics in their order of safety of administration. Discuss the points to be considered in the selection of ether or chloro- form as a general anesthetic. Describe the stages of ether narcosis. Give the preliminary measures to be carried out before the adminis- tration of ether. Describe the method of inducing primary ether anesthesia for the extraction of a tooth. Describe the method of inducing complete ether anesthesia. What are the most reliable signs that anesthesia is complete? What are the signs that the patient is coming out of the anesthesia? What are the signs that the patient is getting too much ether? What treatment is called for when the depressant effects of the anes- thetic begin to show themselves? What is the treatment of respiratory failure during ether anesthesia? What is the treatment for sudden heart failure during ether anesthesia? Give the treatment of vomiting during ether administration. ANESTHESIA 1 47 Is ether vapor heavier or lighter than air? What is the importance of knowing this? Give the advantages and disadvantages of nitrous oxid as a general anesthetic. Give the advantages of the use of oxygen in conjunction with nitrous oxid in anesthesia. What are the indications for the performance of tracheotomy? Des- cribe the operation. What are the indications for hgating the common carotid or the external carotid artery? Describe the operation. CHAPTER XV PREPARATION FOR OPERATION Operations about the face and jaws should be per- formed under as aseptic conditions as possible, that is, bacteria should be removed from the field of operation and excluded from it after the operation. In external operations on the face and neck this can be successfully carried out, but within the mouth asepsis is impossible, though even here a satisfactory degree of cleanliness can be approached by removing diseased roots, tartar, etc., and by the use of antiseptic mouth- washes before operation. The skin is prepared by washing with soap and sterile water, followed by alcohol and a i : 2000 solution of bichlorid of mercury. A piece of sterile gauze is now applied, and nothing allowed to touch the part until time for the operation. At this time the region of incision may be painted with a 5 per cent, solution of iodin, which destroys any bacteria in the deeper layers of the skin which may have escaped the preliminary cleansing. The hands of the operator and of his assistant, and of any one else who is to handle instruments or dressings that will touch the wound, are sterilized by scrubbing for ten minutes with soap and water, followed by alcohol and the bichlorid solution. The surgeon should preferably wear sterile rubber gloves. It is hardly necessary to add that the instruments, dressings, towels, and, in fact, everything that comes in contact with the wound must be sterile. For opera- 148 PREPARATION FOR OPERATION 149 tions within the mouth, these precautions are all carried out, except, of course, that the mouth cavity cannot be rendered sterile. Some degree of asepsis, however, can be attained by painting the mucous membrane in the field of operation with tincture of iodin just before mak- ing the incision. Instruments Commonly Required in Operations Knives. — A scalpel (Fig. 28) is a broad-bladed knife for making incisions through the skin and tissues. Fig. 28. — I, Scalpel; 2, bistoury (Gibbon). A bistoury (Fig. 28) is a narrow^ sharp-pointed knife for opening abscesses and making small incisions. Fig. 2g. — A, S( issors curvcJ on the flat; B, straight scissors; C, angular scissors (Fowler). Scissors (Fig. 29), which may be straight or curved, are used ior cutting tissue, sutures, ligatures., dressings, etc. 150 ORAL SURGERY Dressing forceps are used to grasp the tissue while dis- secting it during the operation, to handle dressings, etc. Hemostatic forceps (Fig. 30) are instruments used to clamp blood-vessels to arrest hemorrhage. Fig. 30. — Hemostatic forceps (de Nancrede). A grooved director (Fig. 31) is a long, probe-like instru- ment, which is grooved on one side to act as a guide for the knife-blade. Probes are usually made of silver, and have a ball-like end, which permits them to easily follow the course of sinuses and spaces within the tissue. r. — Grooved director (Fowler). Allis' forceps (Fig. 32) are long toothed forceps which can be clamped, and are useful as retractors and for grasping tissue during dissection. A blunt dissector is a dull-bladed instrument used in dissecting tissues without cutting them. An osteotome is a chisel-shaped instrument used in conjunction with a mallet for cutting bone. Retractors are instruments used to draw back the PREPARATION FOR OPE RATIO A' 151 skin and other tissues to give a better view of the field of operation. tig. 32. — Allis' forceps (GibbonJ. The instruments required in an ordinary operation are: Knife, scissors, dressing forceps, several pairs of Fit;. 33. — Rack-anfl-pinion mouth-Rag (Fowler). hemostatic forceps, grooved director, j^robe, and re- tractors. 152 ORAL SURGERY For operations within the mouth a mouth-mirror, mouth-gag (Fig. 33), and tongue depressor (Fig. 34) are required in addition to the other instruments. In operations on the jaw bone the surgical engine and various burs, drills, etc., are required. For the extrac- tion of teeth dental forceps (Fig. 35) and elevators (Fig. 36) are used. Fig. 34. — Bosworth's tongue depressor (Keen's Surgery). The surgical engine designed by Cryer (Fig. 37) is indispensable for operations about the jaws, and is to be preferred to the chisel and mallet in general bone surgery. It is adaptable for trephining and osteoplastic operations in brain surgery, drilling holes in the operative treatment of fractures, removal of bone in osteomyelitis, and, in fact, for all the uses to which ordinary bone PREPARATION FOR OPERATION 153 instruments are put. The engine is modeled after the cord dental engine, but is larger, and the hand-piece and Fig. 35.— A, Lower molar forceps; B, Universal upper forceps (Cryer); C, Universal lower forceps (Cryer). Fig. 36. — No. 3 elevator. accessories are fitted for heavier work than the dental engine. Saws, trephines, drills, and burs, of various 154 ORAL SURGERY sizes and shapes, may be obtained to fit the hand-piece. The engine may be driven by hand or by an electric motor. f^/sactuaZ. size,) Fig- 37- — Cryer's surgical engine, spiral osteotome, drill, and bur. The spiral osteotome is a useful instrument used for cutting bone with the surgical engine. For brain surgery it is furnished with a special guard, to protect PRE PAR A TIOX FOR OPERA TION \ 5 5 the dura and cerebrum from its point. With this instrument the bone cutting necessary for an osteoplastic flap can be cut in the skull in less than two minutes. Ligatures. Sutures, Etc. A ligature is a thread used to tie around a blood-ves- sel after the latter has been secured with hemostatic forceps, and also to tie around pedunculated growths. Ligatures are nearly always composed of catgut (No. I, plain) or silk. In tying ligatures a double square knot should always be used. In the case of a large vessel it is better to secure this with a third knot. A suture is a thread used with a needle to close a wound. J\lany materials are used for sutures, the com- monest being catgut, plain and chromicized, silk, silkworm-gut, horsehair, and silver wire. Sutures may be continuous, a single thread being used to close the wound from one end to the other, or interrupted, in which case a series of threads is used at intervals. Catgut is absorbed by the tissues, and sutures of this material do not have to be removed by the surgeon. Plain catgut usually is absorbed in three or four days, while chromicized catgut remains from ten to twenty days. All other suture materials are non-absorbable. and, therefore, surface sutures of these require removal. In wounds of the skin of the face, where there is little tension, sutures of fine silk or horsehair are least liable to leave a scar. Horsehair is also the least irritating in the mucous membrane of the mouth, and does not swell from absorption of fluid. In larger wounds, where there is considerable tension, interrupted sutures of silkworm- gut are the most satisfactory. 156 ORAL SURGERY In using non-absorbable material it is better to make interrupted sutures, as it is easier and less painful to remove them, especially in children. Many varieties of needles are employed for inserting sutures. For the skin a needle with a cutting-edge is necessary. When possible, it is better to use a straight needle than a curved one, as this does away with the necessity for a needle- holder. A pair of hemostatic forceps makes a conveni- ent needle-holder, but in time this spoils it for any other purpose. Sutures should be tied firmly, but not too tightly. Undue tension causes sloughing of the tissue and cutting out of the sutures. The edges of the tissue should be approximated and not made to overlap or fold in. The suture is tied with a double square knot, with the exception of silkworm-gut, which may be tied with a single surgeon's knot. Silver wire sutures are used in some cleft-palate operations to hold the two halves of the palate in apposition. Drainage Materials Glass and rubber tubing, rubber dam, gauze, and strands of catgut or silkworm-gut are used among other materials for this purpose. Glass tubes are used prac- tically only after abdominal operations. Rubber tubing may be used to drain abscess cavities in which the discharge is very free. Holes should be cut in the rubber tube at intervals. It may be sutured to the edge of the wound with silkworm-gut or a safety- pin may be put through it at each end to prevent it from slipping out of the wound. Strips of gauze may be employed for drainage. They should be packed in lightly, and drainage is considerably PREPARATION FOR OPERATION- 'S? aided by previously moistening the gauze. It is not necessary to use iodoform gauze about the face. Strips of rubber dam cut with serrated edges are useful for providing drainage, and have the advantage over gauze that that they do not become clogged with secretions from the wound and act as plugs. Strands of catgut and silkworm-gut are sometimes tied together and used for draining superficial wounds. Dressings for wounds consist of pads of sterile gauze, secured in place by means of adhesive plaster and I-'ig. 38.— Barton's bandage (Fowler). bandages. Zinc oxid adhesive plaster should always be used in contact with the skin. Bandages are made of muslin or of gauze. Gauze is, as a rule, satisfactory for holding ordinary dressings 158 ORAL SURGERY in place, but where considerable support and firmness are required, as in the case of fractures, the musHn bandage is preferable. The Barton bandage (Fig. 38), or one of its modi- fications, is the most useful about the head. For this bandage muslin or gauze 2 inches in width is used, and is apphed as follows: Starting at the occiput, the bandage is carried to the vertex, then beneath the chin, to the vertex, to the occiput, around the jront of the chin, ending at the occiput. These turns should be repeated three times. When additional stability is required, this may be secured by ending with a turn or two around the forehead. The direction in which the turns are made may vary with the individual case. The Barton bandage is used in dressing fractures of the jaws, and in some cases alone suffices to maintain im- mobility. In cases of fracture of the angle or ramus the turn in front of the chin would tend to pull the jaw too far back. A modification of the Barton bandage is used in these cases, the bandage passing from the occiput to the vertex, under the chin, to the vertex, to the occiput, under the chin, to the vertex, to the occiput, under the chin, to the vertex, ending at the occiput. This modification is also useful in holding dressings to the jaw for any purpose. Review Questions Describe the measures for sterilization to be carried out before per- forming an operation. Define the following: Grooved director, osteotome, ligature, suture. Give the suture materials in common use, and the indications for each. Describe the Barton bandage. Special Surgery CHAPTER XVI HYPERTROPHY By the term hypertrophy is meant an overgrowth of tissue in which the individual cells maintain their normal physiologic functions. The overgrowth may be due either to an increase in the size of the individual cells, or to an increase in their number (hyperplasia), or both. The term hyperplasia is not confined to hypertrophic conditions alone, but is applied to any increase in number of cellular elements, such as that seen in inflammatory conditions and in neoplasms. Hypertrophy may be inherited or acquired. In inherited hypertrophy, certain portions of the body may be the seat of the overgrowth, e. g., the gums and alveolar process. In cases of this kind the gum tissues may be so redundant as to completely hide the teeth. The lips bulge out, giving the patient the appearance of a receding chin (Figs. 39, 40). Acquired h>^ertroph'y may be the result of increased demand for work on the tissue, mild irritation continued over a long period of time, overnutrition, and other factors. Acquired hypertrophy of the gums is caused by irritation of various kinds. A badly fitting plate may cause the gum tissue in the anterior part of the 159 l6o SPECIAL SURGERY mouth to grow down between the plate and the front of the bony ridge, giving the appearance known as ''double lip." In the roof of the mouth a deep vacuum chamber with sharp edges will often cause hypertrophy. A badly fitting crown or clasp" may set up irritation about the neck of a tooth, thus causing hypertrophy of the Fig. 39. — From photograph of a lad sufifering from hypertrophy of the gums and alveolar process (after Cryer). gum. In the same way a cavity in a tooth often becomes filled with hyper trophied gum tissue. Treatment. — In inherited hypertrophy this consists in removal of the excess of gum tissue by operation. To do this it may be necessary to enlarge the opening of the lips by an incision on the face. Where the teeth are embedded in the hypertrophied tissue, they often have to be removed. When the parts have healed, // yPER TROPHY 1 6 1 an artificial denture may be put in to replace the lost teeth. In acquired hypertrophy of the gums the first thing to do is to remove the cause, whether it be a badly fitting plate, vacuum chamber, or crown. An over- growth of gum tissue in a tooth cavity may be removed after cauterizing with trichloracetic acid. In the case Fig. 40. — Tissue removed from upper jaw of patient shown in Fig. 39 (after Cryer). of "double lip" under local anesthesia the hypertrophied tissue can be cut away with gum scissors, the base of the growth having been previously ligated, if necessary, to control hemorrhage. If the growth is pedunculated, it can be ligated and cut off. Where the hypertrophy is only slight, removal of the cause and painting the parts with astringents, such as glycerol of tannic acid, will generally be sufficient treatment. 11 l62 SPECIAL SURGERY Neoplasms or Tumors A neoplasm or tumor is a new-growth of cells, resemb- ling in structure, as a rule, the organ or tissue from which it arises, but having an atypical arrangement of cells and no useful function. Etiology.— Certain facts are known as to the etiology of tumors, but we are still in the dark, to large extent, and can only resort to theory — and none of these theories is adequate to explain all tumors. Cohnhehn's Theory. — According to this theory, cer- tain cells which, in the course of development, have been displaced from their normal relationship or have failed to grow with the rest of the body, retain their embryonic properties, and later on in life take on renewed growth, resulting in tumor formation. This theory can be applied in part to certain forms of tumors, particularly teratomata and some new-growths of malignant type, but cell displacement cannot account for all tumors. The microhic theory might suffice to explain the cause of cancer, but not of other tumors. It has not yet been found that certain micro-organisms set up certain forms of new-growth. All that we can say at present is that there is a change in the biologic properties of cells giving origin to tumors, and can only theorize on what brings about this change. External stimulus may favor this change, and it is well known that certain forms of tumor are especially apt to follow trauma or irritation, but this factor is not essential. Heredity, age, and sex seem to act as predisposing factors in the causation of certain kinds of tumors. TUMORS 163 Classification. — Tumors, as a rule, are classified in accordance with their resemblance to normal tissues. Inasmuch as all tissues have a framework of connec- tive tissue holding the cell^ proper in place, tumors of epithehal type are not composed of epithelial tissue alone, but contain connective tissue as well, though the essential nature of the tumor lies in the epithelial ele- ments. Three great types of tumors are, therefore, recognized, according to the tissues from which they are derived: I. Epithelial type. ' Papilloma (warts). Adenoma (glandular tissue). Neuroma (nerve tissue). Carcinoma (embryonic epithelial tissue). Epithelioma (embryonic squamous celled epithelial tissue. Subvariety of car- cinoma). Fibroma (fibrous tissue), ^lyoma (muscular tissue). Chondroma (cartilaginous). Osteoma (bony). Angioma (vascular). Lymphoma (lymphatic tissue). Lymphangioma (lymphatic vessel tissue). Myxoma (mucous connective tissue). Lipoma (fatty tissue). Sarcoma (embryonic connective tissue). Myeloma (bone-marrow). IIL Mixed ty,.e, composed | ^^^^^^^^ (j.^j^^id cyst, odontoma). of both tissues • IL Connective-tissue type. Two varieties may be combined, giving rise to com- pound tumors, such as fibromyoma, adenofibroma, osteo- chondroma, angiofibroma, osteosarcoma, myelosarcoma, etc. There are also many sub varieties of the different types. 164 SPECIAL SURGERY A cyst is a hollow tumor, usually lined with epithe- lium, and with fluid or semifluid contents. Clinical Classification of Tumors. — Clinically, tumors are divided into two types, benign and malignant. An intermediate class exists, having some of the properties of each. Benign tumors are characterized by their slow growth, the fact that they are usually circumscribed and encap- sulated, do not have a deleterious effect on the organism at large, and do not tend to recur after removal. They closely resemble in structure the adult tissues from which they spring, and do not infiltrate surrounding tissues. Malignant tumors are, as a rule, not encapsulated or circumscribed. They rapidly infiltrate the surrounding tissues, are accompanied by pain, have a deleterious effect on the general system, tend to form metastases in other parts of the body, and tend to recur after re- moval. They resemble embryonic tissue in their struc- ture. Examples of this type are carcinoma and sarcoma. Most of the other tumors are benign, though they may cause ill effects or even death by pressure on vital structures. To the intermediate type belong certain forms of tumors microscopically malignant that infiltrate sur- rounding tissues very slowly, do not form metastases, and do not tend to recur after removal. Benign growths that tend to undergo malignant change may also be placed in this group. Carcinomata, which are composed of epithehal cells of embryonic type embedded in a stroma of connective tissue, are divided into — (i) scirrhus, or hard cancer, and (2) medullary, encephaloid, or soft cancer, according TUMORS 165 as the connective tissue or the epitheHal tissue prepon- derates. Thus a tumor composed of much connective- tissue stroma with few epithelial cells would be scirrhous, while one containing many epithelial cells and but Httle stroma would be medullary. Another variety of car- cinoma, composed of flat or squamous epithelium, is known as epithelioma. The more cells, in proportion to the connective tissue, the more malignant the tumor. Sarcomata are divided into several varieties according to the types of cells of which they are composed. Thus we have small round-celled sarcoma, large round-celled sarcoma, spindle-celled sarcoma, giant-celled sarcoma, etc. The smaller the cells, as a rule, the more malig- nant the growth. Thus, small round-celled sarcoma is very malignant, while giant-celled Sarcoma has compara- tively little malignancy. DIFFERENTIAL DIAGNOSIS BETWEEN CARCINOMA AND SARCOMA. Carcinoma. Sarcoma. Occurs late in life. Occurs at any age, most commonly early in life. Not encapsulated. May be encapsulated and circum- scribed. Grows less rapidly. Grows more rapidly. Adjacent lymphatics involved. Lymphatics, as a rule, not involved. Forms metastases through the Forms metastases through the lymphatics. blood-vessels. More ajjt to form metastases. Less apt to form metastases. Tendency to ulceration. Does not tend to ulcerate. Positive diagnosis can generally be made by removing a portion of the growth and examining under the micro- scope. I. Epithelial type. II. Connective-tissue type. 1 66 SPECIAL SURGERY NEW-GROWTHS COMMONLY ASSOCIATED WITH THE FACE AND JAWS. Papilloma (warts). Adenoma (salivary glands) . Carcinoma (epithelioma). Sebaceous cysts. Fibroma (in subcutaneous tissue). Lipoma (in subcutaneous tissue). Angioma (of skin or gum). Chondroma. Osteoma. Osteosarcoma. Sarcoma. ^ Giant-cell myeloma. HI. Mixed type / ^^'^^^ ^^^^^'^ °^ P"''^^^^ S^^^^" I Odontoma. Carcinoma may affect the lip, tongue, cheek, or sali- vary glands, particularly the parotid. It usually takes the form of epithelioma, and occurs in greatly varying degrees of malignancy (Fig. 41). In some cases it is found as a deep-seated, slowly spreading ulceration of the cheek (rodent ulcer), having apparently no general ill effects, while in others it may rapidly infiltrate the floor of the mouth, the tongue, cervical lymphatics, pharynx, and larynx, resulting shortly in death. The treatment for carcinoma is removal if seen early enough. The entire growth and some healthy tissue beyond the apparent limits of the disease should be removed. This includes bone and cervical lymphatics if they are involved. Secondary operations sometimes have to be performed to make flaps to cover denuded areas, and prosthetic appliances may be used to replace lost tissue. TUMORS 167 Fig. 41. — Rodent cancer of the face (Fowler). Fig. 42. — Osteosarcoma of the lower jaw (after Cryei;. An osteoma i.s a simple benign tumor of l)one, and is rare in this region of the body. Removal of the growth 1 68 SPECIAL SURGERY will not be followed by recurrence. Bony tumors of the jaws are usually malignant, osteosarcoma (Fig. 42), and are to be treated as such — i. e., by removal of the whole of the growth and some of the surrounding healthy tissue. Sarcoma frequently affects the -upper jaw, involving the maxillary sinus. Fig. 43.— Epulis (after Cryer). Epulis is a clinical term applied to the commonest group of tumors in the mouth. From the derivation of the word, it is any growth on the gum, but the name is usually applied to a circumscribed connective- tissue growth from the alveolar ridge, attached with a broad or narrow pedicle, and covered over by normal mucous TUMORS 169 membrane, except as the latter may undergo secondary ulceration due to pressure necrosis, infection, etc. From both the cHnical and pathologic standpoints several varieties are described. Fibrous epuHs is hard, grows slowly, gradually displacing teeth in its neighborhood, and microscopically is a fibroma. A second variety is Fig. 44. — Malignant epulis (Binnie). the angiofibroma, in which the microscope shows numer- ous distorted capillary channels running through the fibrous tissue. This form of epuUs presents a bright red, spongy appearance and bleeds easily. The third com- mon variety of epulis is the giant-cell myeloma, which consists of a stroma of fibrocellular tissue, with numerous giant-cells scattered throughout. These growths arc 170 SPECIAL SURGERY dusky red in color and grow with comparative rapidity. All forms of epulis spring from the periosteum or from the bone itself, and, therefore, to prevent recurrence it is im- portant in the treatment not only to remove the apparent growth itself, but also to curet the point of origin or bur away some of the bone from which it arises. Teeth in- volved in the growth should be extracted. If left they may invite recurrence by interfering with complete re- moval of the tumor. The use of the actual cautery is an efficient means of controlHng the hemorrhage when operating on such vas- cular structures. An odontoma or odontome is a tumor derived from the special cells concerned in tooth development (James). In general, odontomas may be classified into two great groups, the solid and the cystic. The commonest form of the solid group is the calcified composite odontoma, which consists of a conglomerate mass of tooth struc- ture formed of the various component tissues of a tooth massed together without any definite arrangement. It usually takes the place of one of the natural teeth, and in a case of this kind one of the normal teeth is missing from the arch. There is usually a swelling of the jaw in the region involved which may cause no discomfort un- less infection takes place. If the latter occurs, the swell- ing becomes painful, and there may be a discharge of pus either within the mouth or externally through sinuses leading down to the diseased tooth tissue. The x-ray is useful in distinguishing a growth of this kind from necro- sis of the jaw bone. The treatment consists in removal of the abnormal tooth structure. TUMORS 171 The principal forms of cystic odontomas are (i) fol- licular and (2) radicular. (i) The follicular cyst or odontocele is a sac lined with epithelium, filled with fluid, and containing an unerupted normal or abnormal tooth. It is caused by an abnormal- ity in development of the dental follicle. The accumula- tion of fluid causes a distention of the jaw bone, the bone oftentimes becoming so thin as to give a crackhng, parch- ment-like sensation. The fluid is usually clear and straw colored, but may be converted into pus by infection. The treatment consists in removal of the encysted tooth, evacuation of the fluid, and removal of the epithelial lining of the cavity. This epithelium secretes the fluid, and if not throughly removed the operation may be foflowed by recurrence. (2) The dental root cyst is a growth arising about the apex of an erupted tooth that has usually been devital- ized, and is probably the result of infection, whereby the epithelial cells normally found in the peridental mem- brane are stimulated to grow and secrete fluid. The fluid causes a destruction and sometimes distention of the jaw bone, as in the case of the follicular cyst. Here, too, the fluid is normally clear, but may be converted into pus by secondary infection. The treatment consists usually in removal of the affected tooth, evacuation of the cyst contents, and removal of the lining membrane by curet- ment. Mixed tumors of the parotid arc composed of various tissues, sometimes even containing cartilage and bone. 1/2 SPECIAL SURGERY Leukoplakia Leukoplakia consists of white, slightly raised patches, varying in size and irregular in shape, situated on the mucous membrane of the tongue, cheek, lips, and palate. They are especially apt to be found on the part of the cheek corresponding to the line of occlusion of the molar and premolar teeth. The patches consist of dead epi- thelium that has not been cast off from the mucous membrane. Etiology. — The cause is not known, but leukoplakia is frequently found in persons with unclean mouths, those who use tobacco and alcohol to excess, or who are fond of hot condiments, pepper, pickles, etc. In some cases the disease apparently has a syphihtic origin. Symptoms. — In addition to the description already given, the patches may be painful, particularly when anything irritating is taken into the mouth. They cannot be scraped off without leaving an ulcerated, bleeding surface. Prognosis. — If all irritation be discontinued after treatment of early cases, the condition is not likely to return. If allowed to continue without treatment, leukoplakia has a tendency to develop into epithelioma. Treatment. — This consists in removal of the patches, either with the knife or, preferably, with the actual cautery. The parts are then to be kept clean. Chemic caustics are not to be used, as they only cause irritation and tend to aggravate the condition. TUMORS 173 Review Questions Define hNpertrophy, hyperplasia, neoplasm. Give the etiology, symptoms, and treatment of the various forms of hypertrophy of the gums. Discuss the etiology of tumors. " Give a classification of tumors. Give the clinical classification of tumors, and two examples of each variety. Give the varieties of carcinoma. Give the varieties of sarcoma. Give the differential diagnosis between carcinoma and sarcoma. Name several of the commoner tumors of the face and jaws, giving the tissue from which they spring. Give the symptoms and treatment of carcinoma of the lower jaw. Give the pathology, symptoms, and treatment of epulis. What is an odontoma? Give treatment. Give the etiology, symptoms, prognosis, and treatment of leukoplakia, CHAPTER XVII SYPHILIS OR LUES The recognition of this disease by the dentist is very important, as he is at any time liable to meet with its oral manifestations, some of which are among the most contagious lesions of the disease. Etiology. — Infection occurs through some break in the surface of the skin or mucous membrane. It may be of genital or of extragenital origin. The common- est mode of infection is through sexual intercourse, but the disease may be acquired innocently through infected drinking-cups or other utensils, a razor, kissing, etc. Surgeons have become infected by wounding their fingers while operating on syphilitic patients. Infec- tion may be transmitted from one patient to another by unclean surgical or dental instruments. The infecting organism is the spirochceta pallida or, more correctly, the treponema paUidum, discovered by Schaudinn about 1905. The organism can be found in lesions of all stages of syphilis. It is a pale, spiral organism, with from ten to twenty turns, a fiagellum at either end, and is endowed with active motility. It can only be stained by special methods. It is taught that the ter- tiary stage of syphilis is not contagious. In this stage probably the spirochetse, though they are present, have lost their virulence. Syphilis is divided into the primary, secondary, and tertiary stages, (i) Primary Stage. — The typical lesion is the chancre, which appears at the point of infection about three 174 SYPHILIS OR LUES 1 75 weeks after exposure. It begins as a small, slightly raised papule, which slowly grows larger, and finally breaks down, discharging purulent material, leaving a crater-like ulcer, the size of a twenty-five-cent piece, with raised edges and indurated base. The chancre is very rarely painful. At the same time there is an enlargement of the lymphatic glands of the region, which do not coalesce and are not painful. (2) Secondary Stage. — The symptoms of this stage begin to appear about six weeks after the chancre. There is a general adenopathy or lymphatic enlargement, particularly of the postcervical and epitrochlear glands, anemia, slight fever, headache, joint pains, shedding of the hair, iritis, and deafness. The principal secondary symptom is the skin eruption. This begins as the roseolar or macular eruption, which progressively be- comes papular, pustular, and even ulcerative. Examples of all these lesions may be found at the same time. They occur symmetrically on the two sides of the body, vary from a pin-head to a split-pea in size, and do not itch. The tubercular syphilid is a large pustule of the secondary stage occurring in severe cases. Mucous patches are papules occurring on moist skin surfaces or on mucous membranes. They are found on the genitalia, under the breasts of women, and on the mucous membrane of the mouth. In the mouth they usually appear first on the tonsils, then at the sides of the tongue, and the inner surface of the cheek and lips. Mucous patches are oval, grayish-white, slightly raised, and moist, and leave a raw, bleeding surface when scraped away. The lesions in the mouth are accompanied by sore throat and hoarseness. 176 SPECIAL SURGERY After the secondary stage, if the case has been treated properly, we may have no further symptoms. Other- wise there is an intermediate period of eighteen months to three years, followed by the tertiary stage. (3) Tertiary Stage. — Tertiary symptoms manifest themselves in the skin as deep-seated ulcers known as rupia, which ara less numerous than the secondary eruption and are not symmetric. In other tissues the typical tertiary lesion is known as the gumma, which is a deep-seated localized softening, which becomes ne- crotic, and may Kquefy and find its way to the surface of the body, discharging a dirty brown fluid. Gummata may be found in any tissue of the body, muscle, bone, liver, and other abdominal organs, tongue, palate, and brain. When they break down, they cause great loss of tissue, which is not repaired. Oral Manifestations of the Different Stages of Syph- ilis, and the Diagnosis from Other Lesions. — ^The initial lesion of syphilis in rare cases may occur on the lip, tongue, palate, or tonsil. This is associated with early enlargement of the submaxillary lymphatic glands. Chancre of the lip is to be diagnosed from epithelioma by the following points: Chancre. Epithelioma. May occur at any age after puberty. Occurs in middle age, as a rule. Is not painful. May be very painful. Early enlargement of submaxillary Late enlargement of submaxillary glands. glands. Some induration at base. Wide-spread induration. Followed by secondary eruption. Not followed by skin eruption. Improves on antisyphilitic treat- Not improved by medicinal treat ment. ment. Develops rapidly. Develops slowly. Spirochete present. Microscope reveals cancer tissue. SYPHILIS OR LUES 177 In the secondary stage we find mucous patches, and the patient complains of sore throat. The postcervical lymphatic glands are enlarged. jMucous patches are to be differentiated from leuko- plakia and from simple ulcers. Mucous Patches. May occur at any age. History of chancre and other le- sions of s>'philis. Glandular involvement. Easily scraped off. Painless. Spirochaeta pallida present. Responds to treatment by mercury. Leukoplakia. Usually occur in middle life. History of excessive smoking or other irritation in the mouth. No glandular involvement. Scraped off with difficulty. Painful. No spirocheta. Does not respond to mercury. Simple ulcers are rounded instead of oval, with reddish borders, are painful, and there are no other lesions of syphilis present. In the tertiary stage we may find a gumma of the tongue, lip, cheek, soft palate, or hard palate, or its sequel, necrosis of the bones of the roof of the mouth, and cleft palate (Fig. 45). A gumma of the tongue is differentiated from car- cinoma of the tongue as follows: CiUNLMA. Not painful. Develops more ra[)idly. V^ery little induration. History and other signs of s>q)hili^ Carcinoma. Painful. Develops more slowly. Great induration. Microscope reveals nature of the growth. Syphilitic ulcer is to be differentiated from tuber- culous ulcer. 12 178 SPECIAL SURGERY Syphilitic Ulcer. Not painful. Rough, undermined edges. Spirochetae may be found. History and other lesions of syph- ilis. Tuberculous Ulcer. Painful. Pale, with smooth edges. Tubercle bacilli found. Other lesions of tuberculosis. The oral manifestations of hereditary syphiHs are: Hutchinson's teeth, which are typically seen in the per- manent central incisors, though the lateral incisors Fig. 45. — Nasal deformity due to syphilis. In this case the cartilaginous and bony septum was completely destroyed, allowing the nose to fall in and the two nostrils to become fused into one opening. There is scarcely any trace of the alae nasi (Eisendrath). and other teeth may be poorly developed. The teeth are barrel shaped, with a semilunar notch on the cutting- edge. Cracks or fissures (rhagades) around the mouth SYPHILIS OR LUES 1 79 are common in infants with hereditary syphilis, which later in life leave radiating linear scars. The ordinary secondary and tertiary symptoms — mucous patches, glandular enlargement, gumma, necrosis, cleft-palate, etc. — are found just as in acquired syphilis. Newer Methods of Diagnosis and Treatment. — Within the last ten years our ideas as to the diagnosis and treat- ment of syphilis have been revolutionized by three great advances: (i) The estabhshment of the Treponema palli- dum as the cause of syphilis; (2) the apphcation of the serum complement-fixation test or Wassermann reaction; (3) chemotherapy by means of organic arsenical com- pounds (salvarsan, etc.). (i) By 'means of the dark field illuminator micro- scopic diagnosis may be made early in a large proportion of cases by finding the treponema in the exudate from the primary lesion, where formerly it was frequently neces- sary to wait until secondary symptoms appeared before a diagnosis of syphilis could be made. We are now in a position, therefore, to commence treatment several weeks earlier in the disease than formerly, and conse- quently with a greater chance of cure. (2) The Wassermann reaction consists in the detection in the blood of a syphilitic individual of certain sub- stances produced through the action of the Treponema pallidum. It is out of the question to attempt a descrip- tion of the test here, and the reader is referred to works on immunology and laboratory diagnosis. Of far greater importance to the chnician is the method of obtaining the specimen of blood from the patient and the signifi- cance of the reaction. At least 2 c.c. of blood should be obtained from the l80 SPECIAL SURGERY patient either by puncturing the end of the finger or by withdrawing it from a vein at the bend of the elbow with a hypodermic syringe. The blood should be placed in a sterile tube and sent to the laboratory as soon as possible for examination. The patient whose blood is to be tested should not have had any antisyphilitic treatment for at least three weeks prior to the removal of the blood. Otherwise a negative reaction may be obtained in a case that should be positive. Alcohol taken within the pre- vious twenty-four hours may have the same effect. A positive Wassermann reaction means the presence of living spirochetes in the body. As a rule the test does not become positive until at least two weeks after the appearance of the chancre, so for positive diagnosis earHer than this we resort to microscopic examination for the Spirochaeta pallida in the exudate. The Wassermann reaction is strongly positive in practically every case of secondary syphilis, while in tertiary syphilis it is positive in from 80 to 90 per cent, of cases. It may also be posi- tive in cases of latent syphihs presenting no active symp- toms. A single negative Wassermann reaction does not rule out syphihs. A strongly positive reaction practically always means syphihs. (3) For the past five years a synthetic arsenical com- pound discovered by Ehrlich, dioxydiamidoarsenobenzol, known under the trade name salvarsan, and popularly as "606," has been extensively used in the treatment of S5^hilis, and has resulted in immense improvement over our old methods. Treatment. — The treatment of syphilis should not be commenced until the diagnosis of the primary lesion is certain. This may be made in the great majority of SYPHILIS OR LUES l8l cases, especially if no local treatment has been applied, by microscopic examination of the exudate from the chancre for the Treponema pallidum (Spirochaeta pallida). Later a positive Wassermann reaction will be obtained. In cases seen early, therefore, it is seldom necessary to wait until secondary symptoms appear before beginning treatment. It is now recognized that vigorous early treatment with modern remedies will frequently result in a rapid cure, even in the prevention of secondaries or of a positive Wassermann reaction. Before commencing antis^phiUtic treatment the mouth and teeth should be got into the best possible condition. Tartar should be removed, cavities filled, and all useless and unhealthy teeth and roots extracted. The patient should diligently use the tooth-brush and a mouth-wash during the entire period of treatment. Danger of saHvation by mercury is thus lessened. Mucous patches may be painted with a solution of chromic acid, 4 grains to the ounce of water. The most efhcient treatment for syphilis consists in the intravenous administration of salvarsan, the average dose being 0.6 gram. One injection frequently suffices to make all symptoms disappear in a very short time, though not permanently. But in the majority of cases two or three injections at intervals of a week or ten days are necessary. The salvarsan should be followed by mer- cury, for example, i to 3 grains of the protiodid per day by mouth for several weeks. The course of treatment should be guided by the Wassermann reaction. A reac- tion still positive after a full course of treatment, even in the absence of symptoms, calls for more salvarsan and mercury. After cessation of treatment the serum should 1 82 SPECIAL SURGERY be tested every three months or oftener for at least two years, and should be returned negative for this period before the patient may with safety be pronounced cured. As a rule, the later in the course of syphilis that treatment is begun the more difficult it will be to effect a cure, as evidenced by disappearance of symptoms and perma- nently negative Wassermann reaction. If seen in the early stages we are justified in regarding syphilis as a curable disease. Mercury may also be given in the form of mercurial ointment as inunctions in the skin, dose, i dram daily, or hypodermically in the form of the bichlorid, 2*4 grain daily. In late cases of syphilis mixed treatment should be given, i. e., potassium iodid is added to the mercury. It is given in beginning doses of 10 grains, increased up to i dram three times a day. The potassium iodid is best given in milk after meals. Review Questions Give the etiology of sjT)hilis. Give the period of incubation and the various stages of syphilis, with the duration of each. Give the principal lesions of the three stages of syphilis. Describe the oral manifestations of the three stages of syphilis, acquired and hereditary. Give the differential diagnosis of chancre and epithelioma of the lip. Give the differential diagnosis of mucous patches and leukoplakia. Give the differential diagnosis of gumma of the tongue and carcinoma. What do you know of the serum diagnosis of syphilis? What is the prophylactic mouth treatment in syphilis? Give the principal reason for carrying it out. Give the constitutional treatment of syphilis. Discuss the " salvarsan " treatment of syphilis. CHAPTER XVIII STOMATITIS Stomatitis is inflammation of the mucous membrane of the mouth. There are many varieties of stomatitis— almost as many as the causes that produce it: 1. Simple stomatitis. 2. Aphthous stomatitis. 3. Ulcerative stomatitis. 4. Gangrenous stomatitis. 5. Parasitic stomatitis (thrush). 6. Toxic stomatitis (mercurial, arsenical, etc.). 1. Simple or catarrhal stomatitis is usually seen in children, and is caused by digestive disturbances, par- ticularly in warm weather, and bad hygienic surround- ings. The symptoms are heat and tenderness in the mouth, redness of the mucous membrane, fetor of the breath, and fever. Treatment.-— Reguhte the bowels, and keep the mouth clean with a solution of boric acid. 2. Aphthous stomatitis presents the symptoms of catarrhal stomatitis, with the addition of numerous small, round, yellowish-white vesicles on the lips, cheek, and tongue. These soon break, and leave small shallow ulcers with a red areola. The cause of aphthous stomatitis has not been defin- itely settled. Aphthae are liable to appear in the mouths 183 184 SPECIAL SURGERY of children during the digestive disturbance at the time of teething. The general opinion now tends to the belief that the lesions are not bacterial in origin, but have something to do with nervous derangement. The treatment is the same as for catarrhal stomatitis. 3. Ulcerative stomatitis occurs both in children and in adults, and is usually the result of bad hygienic surroundings. It sometimes occurs in epidemics. Symptoms. — The mucous membrane of the mouth is very much inflamed, breaks down, and leaves shallow ulcers covered with yellowish exudation. The breath is extremely fetid, and there is excessive flow of saliva. The infection may spread to the sockets of the teeth, causing the latter to loosen and drop out. Fever and digestive disturbances are often associated conditions. Treatment — The internal administration of potassium chlorate in 5-grain doses is beneficial, combined with a mouth-wash of potassium chlorate in the proportion of 10 grains to the ounce of water. The teeth should be cleaned, all cavities filled, and decayed roots removed. The ulcers may be touched with silver nitrate, pure carbolic acid, or trichloracetic acid. The application of powdered subnitrate of bismuth to the ulcers is often soothing. 4. Gangrenous stomatitis is a further stage of ulcera- tive stomatitis in which the destruction of tissue extends beneath the mucous membrane. Causes. — It is seen in persons whose vitality has been much lowered, as through alcoholism, and who live in poor hygienic surroundings. These factors, in conjunc- tion with lack of attention to cleanliness of the mouth and teeth, are responsible for the disease. STOMATITIS 185 Symptoms. — The disease starts as an ulcer, usually in the vestibule of the mouth, which becomes larger, the inflammation spreading to the deeper tissues, which slough, forming a foul, yellow, stringy mass. The teeth become very loose and may be lost. The flow of saliva is increased, and the swelling interferes with speech and mastication. Marked constitutional symp- toms sometimes are present, the result of absorption of toxic matter from the mouth. The temperature may be as high as 103° F., and the pulse weak and rapid. The gangrenous process may spread through the cheek, or the infection may pass into the deep cellular tissue of the neck and about the glottis, suffocating the patient. The prognosis is unfavorable, probably about 50 per cent, of the cases being fatal. Treatment. — Local measures consist in keeping. the mouth as clean as possible. The stringy necrotic tis- sue should be trimmed away with scissors once a day, and after swabbing the surface with cotton soaked in dioxid of hydrogen, it should be touched with pure nitric acid, care being taken not to allow the acid to touch other than the parts desired. The patient should be given a mouth-wash of potassium permanganate I : 2000, which should be used frequently throughout the day. General Treatment. — Where constitutional symptoms are marked, the patient should have rest in bed. Stim- ulants and tonics are indicated. The bowels should be freely opened with calomel in repeated doses of \ grain every hour for four doses, followed by half an ounce of magnesium sulphate, if necessary. Ten or fifteen drops of tincture of the chlorid of iron and sV grain of strychnin 1 86 SPECIAL SURGERY four times a day are usually sufficient in the way of stimulation. Half an ounce of whisky four times a day is often beneficial, particularly in alcoholic subjects. The diet should be liquid at first, until the patient can chew and swallow solid food. As soon as possible the patient should be allowed to sit up, as the danger of pneumonia is thereby lessened. Noma, or cancrum oris (Fig. 46), is a form of gangren- ous stomatitis occurring in infants, sometimes in epi- Fig. 46. — Noma (after Schamberg). demic form. It occasionally follows infectious diseases, such as measles or whooping-cough, and occurs in badly nourished children in poor hygienic surroundings. Various forms of bacteria have been isolated from cases of the disease, and the spirillum and fusiform bacillus described by Vincent have been found. Symptoms. — The disease commences as a swelling of the cheek, with fetor of the breath and salivation. This is followed by a small ulcer at the buccal margin of the STOMATITIS 187 gum, which rapidly spreads to the cheek and alveolar process. The tissue of the cheek becomes black, and finally sloughs away, exposing the mouth. The disease is, as a rule, unilateral. The efTects on the general system are very marked. The temperature is high, the pulse weak and rapid, and the child lies in a semi- comatose condition. Prognosis. — Nearly all cases are fatal. Treatment. — The ulcer should be cauterized with nitric acid on an orange-wood stick, or with the actual cautery. The parts should be frequently washed with a I : 4000 solution of potassium permanganate. The gangrenous tissue of the cheek must be removed. If the patient survives, the resulting disfigurement may be corrected, to some extent, by plastic operations. The general condition of the patient requires stimulation in the form of strychnin and brandy. The latter may be given in doses of five to ten drops every three or four hours. 5. Parasitic Stomatitis. — The commonest form of stomatitis parasitica is known as thrush, and is due to a fungus — the saccharomyces albicans. The disease oc- curs in children and is usually associated with gastro- enteritis. The mouth presents numerous small white elevations which, on removal, leave a raw surface, with slight bleeding. The disease affects the tongue, cheeks, lips, and hard and soft palate. Treatment consists in removal of the patches by wiping out the mouth with cotton soaked in a solution of boric acid do grains to the ounce) every two hours. Attention should also be given to the general condition of the j)atient. 1 88 SPECIAL SURGERY Vincent's angina is an exudative inflammation of the pharynx and the tonsils which occasionally affects the mouth. It is characterized by the formation of a false membrane resembling that of diphtheria. The disease is associated with the presence of a spirillum and a fusiform bacillus, described by Vincent, which are readily stained in smears. In the mouth the grayish-white patches may appear on the gums about the necks of the decayed teeth. They are easily removed, leaving an eroded surface. Sometimes deeper ulceration occurs. The treatment is the same as for thrush and for ulcera- tive ■ stomatitis. The local application of salvarsan powder is said to be specific. Syphilitic stomatitis is described under that disease. 6. Toxic Stomatitis. — Mercurial stomatitis is an in- flammation of the mouth due to the continued adminis- tration of small doses or the ingestion of large doses of mercury. It is also seen in artisans who work in mercury. The inflammation is not produced by the direct action of the mercury itself upon the oral mucous membrane, but the drug lowers general vital resistance, thus per- mitting the growth of pathogenic bacteria within the mouth. Patients taking mercury whose mouths have been previously put in hygienic condition and are kept clean very rarely get mercurial stomatitis. Symptoms. — The disease starts with tenderness of the gums and pain on bringing the upper and lower teeth together. The gums around the necks of the teeth are reddened. There is a metallic taste in the mouth and an increase in saliva (ptyahsm). Later, the sahvation becomes profuse, there is intense fetor of the breath, and the gums become much swollen and of a purple STOMATITIS 189 color. The teeth loosen and may be lost. In severe cases ulceration of the gums and necrosis of the alveolar process may result. Treatment. — The condition can practically always be prevented by appropriate prophylactic treatment before putting a patient on a course of mercury and by careful watch for the earliest signs of the onset of the disease. Before administering mercury, when the drug is to be given for any length of time, the mouth should be brought into a thoroughly hygienic condition. All deposits should be removed from the teeth, cavities filled, and useless roots extracted. During the entire course of treatment by the mercur}- a mouth-wash should be used, and the teeth kept thoroughly clean. If the slightest tenderness of the teeth on bringing them to- gether occurs, reduce the dose of mercury to one-half, and if the s}Tnptoms do not subside, discontinue the mercury altogether for a time. The mouth must be thoroughly cleaned, as in the case of prophylactic treat- ment. The inflamed gums may be touched once daily with tincture of iodin. The best mouth-wash is a i : 2000 solution of potassium permanganate, used every few hours. A I : 6000 solution of bichlorid of mercury some- times acts well, tending to show that it is not the local action of mercury that causes the stomatitis. Potassium chlorate, 10 grains to the ounce of water, may also be used as a mouth- wash. Potassium iodid in lo-grain doses may be given internally. Arsenic may cause a localized inflammation of the gum about a tooth from carelessness in its use in devital- ization of the dental pulp. The inflammation may spread to the deeper tissues and cause necrosis of the bone. IQO SPECIAL SURGERY The treatment consists in the immediate appHcation of the antidote — dialyzed iron — ^if arsenic is accidentally allowed to touch the gum. If inflammation occurs, the gum may be painted with tincture of iodin. Lead-poisoning does not cause stomatitis, but is often manifested in the mouth by a blue line at the margin of the gums around the necks of the teeth. This is due to a deposit of sulphid of lead in the gum tissue, and not on the teeth. Consequently, it cannot be scraped off. The gums are not inflamed. Other symptoms of lead-poisoning are present, including colic, constipation, wrist-drop, etc. Review Questions What is meant by stomatitis? Give the etiology, symptoms, and treatment of ulcerative stomatitis. Give the etiology, symptoms, and treatment of gangrenous stomatitis. What is noma? Give the etiology, symptoms, prognosis, and treat- ment. What is Vincent's angina? Give the etiology, symptoms, and treatment of mercurial stomatitis. What are the oral manifestations of lead-poisoning? How would you diagnose the condition? CHAPTER XIX ALVEOLAR ABSCESS; OSTEOMYELITIS; NECROSIS j ACTINOMYCOSIS Treatment of Alveolar Abscess The treatment of acute alveolar abscesses differs in de- tails, but not in principle, according as to whether the offending tooth is to be saved or not. The technic of treat- ment for preservation of the tooth is discussed fully in works on operative dentistry. While it is possible to pre- serve and render useful many teeth which have caused al- veolar abscesses, it is also undoubtedly true that too many of these teeth are retained and remain as sources of irritation for years. There is also a general hesitancy about extracting a badly decayed tooth that is causing an alveolar abscess. The patient is told to wait until the ab- scess subsides, as extraction might cause the abscess to spread. The patient consults the family physician, who refers him back to the dentist, and thus the abscess often does "spread," extending to the bone, setting up osteo- myehtis and necrosis. The treatment of an alveolar abscess caused by a tooth too badly decayed to be preserved is extraction of the tooth as soon as possible. Frequently this will be all the treatment necessary, as the pus will be evacuated through the socket. In other cases the pus must be allowed to escape through an incision made in the gum 191 192 SPECIAL SURGERY over the swelling. Where there is too much swelling to render an attempt to extract the tooth certainly successful, this should be first reduced by letting out the pus, but the tooth should be removed as soon as possible. Dioxid of hydrogen should never be used in these cases, either in cleaning out the root-canal when the tooth is to be preserved, or in the abscess cavity. An attempt should always be made to prevent the pus from an alveolar abscess from pointing externally on the face or neck. This may be attained by early incision within the mouth, by the avoidance of hot poultices or hot-water bags on the face, and by the application of cold and pressure externally. Chronic abscesses in which there is necrosis of the end of the root of the tooth are sometimes cured by so-called amputation of the root, but frequently do not heal until the tooth is ex- tracted. It is unwise to attempt to save teeth that have been the cause of abscesses opening into the maxillary sinus or externally on the face or neck. They should be extracted. Osteomyelitis and Necrosis of the Jaw bones Osteomyelitis is an inflammation of the marrow of bone. Etiology. — General diseases, such as syphilis, tubercu- losis, and infectious fevers, interfere with the nourish- ment of bone, giving opportunity for the entrance and growth of pyogenic micro-organisms. Local infections following alveolar abscess, stomatitis, or fracture of the jaw bone may set up osteomyelitis. The use of dioxid of hydrogen about an infected area OSTEOMYELITIS AND NECROSIS 1 93 communicating with the bone is one of the commonest causes of osteomyelitis. When this drug comes in con- tact with organic material free oxygen is given off, and in an inclosed space, such as an alveolar abscess with a small opening, it produces a species of explosion, driv- ing the infected material before it through the cancel- lated tissue of the bone. The hypodermic injection of cocain or any drug into inflamed tissues to produce anes- thesia for the extraction of a tooth may act in a similar manner by carrying infection from around the tooth or from the gum surface into the surrounding tissues and thence to the bone. Osteomyelitis may thus occur quite independently of the toxic action of the drug itself. Poisons, such as mercury, arsenic, cocain, and phos- phorus, cause osteomyehtis either by their direct action or by so lowering the resistance of the tissues that pyo- genic bacteria gain entrance. Mercury may cause osteomyelitis in those who work with the metal, or the disease may be a late stage of the stomatitis that follows overdosage of the drug. Arsenic and cocain may cause a direct poisoning of the tissues when applied locally as therapeutic agents. Phosphorus causes osteomyelitis of the jaws in workers at match-making who pay little or no attention to hygiene of the mouth. The phosphorus in solid form or by its fumes probably gains entrance to the jaw bone through devitalized carious teeth, or through an inflamed peri- dental membrane. The white or yellow phosphorus is the poisonous form. The red, amorphous variety is non-poisonous. Since the passage of prohibitive legis- lation against the use of white phosphorus in match 13 194 SPECIAL SURGERY manufacture necrosis from this source has been elim- inated. Osteomyelitis from any of the foregoing causes usually ends in necrosis or death of a portion of the bone en masse. Necrosis may also be caused by trau- matism, whereby a portion of the bone is cut off from its blood-supply. Bones are nourished through blood- vessels derived from the marrow and from the perios- teum, so that necrosis is essentially the result of star- vation from interference with either of these sources by inflammation or injury, or by derangement of the trophic nerves, which govern the nutrition of the bone. When necrosis occurs, the dead bone becomes sepa- rated in the form of a sequestrum. The periosteum, if not destroyed, forms a shell of new bone about the sequestrum, known as the involucrum. Between the two the inflammatory process goes on, forming pus, which makes its escape through openings on the surface of the bone. Symptoms. — In osteomyelitis the usual signs of inflammation are present. There are deep-seated pain and tenderness over the bone affected. In the case of the mandible, the side of the face affected becomes greatly swollen. The general symptoms — fever and prostration — are usually greater than those caused by an ordinary alveolar abscess. Grave septicemia and even pyemia, with metastatic abscesses of other parts of the body, may result. The pus eventually makes its way to the surface of the bone, and is evacuated in the mouth or points on the neck, leaving sinuses. When necrosis occurs, the sequestrum can be felt by passing a probe up the sinus. In the mouth, the appearance OSTEOMYELITIS AND NECROSIS I95 of a red papilla through which pus exudes is an indica- tion of dead bone underneath. In the early stages of necrosis the sequestrum is not separated from the rest of the bone, but later it becomes quite loose and maybe thrown off spontaneously. The different causes of necrosis may give rise to variations in the character of the sequestrum. In syphilis, the dead bone is usually black and soft. In tuberculosis it is commonly white and soft. In phos- phorus poisoning it is white, hard, and brittle, giving rise to the term "pumice-stone " necrosis. The necrosis may be slight in extent, or it may involve the entire bone. In the mandible, providing the perios- teum is not destroyed, an entire shell of new bone may be formed. Regeneration of bone after necrosis in the upper jaw is rare. The x-ray is a valuable guide in ascertaining the condition of the bone and the extent of the sequestrum. Treatment. — If a cause be present, such as a devital- ized tooth, it should be removed. An ice-cap applied to the side of the face will often give relief. When there are indications that pus is present, it should be evacuated, through the mouth if possible, and if not, by as small an external opening as is necessary to give drainage. When dead bone is felt, the surgeon must be guided by the indications of the individual case and by experi- ence whether to remove it or wait until separation of the sequestrum occurs. It is better to remove small portions from time to time than to do a radical operation too early. In this way the osteogenic cells are more likely to be preserved for the formation of new bone, and less 196 SPECIAL SURGERY disfigurement results. If new bone is formed coinci- dentally with destruction of the old bone, the continuity of the jaw is preserved, and pathologic separation or fracture through the diseased area is not so liable to occur. Some cases, however, on account of. the effects on the general system, demand early and thorough eradication of the necrotic area. A cardinal rule is to remove sequestra from within the mouth when possible, thereby avoiding scars on the face and neck. Loose sequestra should, of course, be removed at once. After scraping away dead bone the walls of the cavity left may be smoothed by the surgical engine. When a loose sequestrum has been taken out, the walls of the cavity will have a smooth and velvety feeUng to the finger. After the operation the parts may be lightly packed with a strip of gauze to control any oozing; this should be removed on the following day, and the mouth syringed out with a solution of boric acid several times a day. Dioxid of hydrogen should never be used to irrigate these cases. Sinuses on the neck will close almost immediately if all the dead bone has been removed. They should not be packed with gauze. If some dead bone remains, suppuration will still go on through the sinus, in which case a small gauze or rubber drain may be inserted and covered with a sterile gauze pad held in place by a modified Barton bandage. The general condition of the patient in osteomyelitis and necrosis of the jaws requires careful attention. If there is much fever, the patient should be kept in bed, on liquid diet, and stimulation given if required. actinomycosis or streptotrichosis 1 97 Actinomycosis or Streptotrichosis This is a chronic infective disease occurring in cattle, and rarely in man. It is usually due to the actinomyces or ray fungus, but the same symptoms may be caused by other allied organisms belonging to the general streptothrix group, so that the term streptotrichosis is preferable. The appearance of the lesion varies according to the part affected, and the presence or absence of pyogenic organisms. The head and neck are involved in more than half of the cases. Frequent involvement of the jaw gives rise to the name " lumpy jaw." Etiology.— The ray-fungus, or streptothrix bovis, is the usual cause of the disease. It appears under the microscope as a mass of radiating threads with clubbed ends. Other forms are found, consisting of branching threads, and sometimes with spores. The organism is believed to gain entrance into the body by grain or straw, causing a lesion of the mucous membrane of the digestive or respiratory tract or the skin. The tonsils or carious teeth may be points of entrance. Thus the disease is particularly apt to occur in persons residing in the country. The disease spreads in the body by a gradual invasion of the tissues surrounding the point of inoculation. It spreads both by continuity and contiguity of tissue— that is, it passes onward without regard to anatomic boun- daries. The lymphatics are not apt to be involved except when the disease is associated with an infection by pyogenic organisms. Metastases may take place through the veins. Symptoms. In cases of superficial infection the dis- ease begins as a small, soft, and tender nodule which 198 SPECIAL SURGERY slowly spreads, giving to the skin a purplish mottling. The nodules break down, forming sinuses which discharge a thick pus in which the typical " sulphur granules " are found. These granules are composed of masses of the fungi, which can be demonstrated under the micro- scope. It is practically impossible to make the diagnosis without the microscopic demonstration of the organism. The lesions show a tendency to heal in one portion and to break down in another. In healing, much cica- tricial tissue is formed. The lesions are tender, but are not, as a rule, accompanied by great pain. The chronic cases rarely present constitutional symptoms. In acute cases complicated by infection with pyogenic organisms, or by the formation of metastases, symptoms of septi- cemia or of pyemia may be present. The prognosis of chronic and localized cases depends on the situation of the disease. Where vital organs are not involved, the chances for recovery are good. The principal danger of the disease lies in the intro- duction of pyogenic organisms into the lesions, result- ing in septicemia or pyemia The formation of metas- tases also renders the prognosis unfavorable. The mortality of superficial lesions is about 10 per cent., and of the deeper tissues about the jaws, 30 per cent. Treatment. — The most successful forms of treatment are the internal administration of potassium iodid, and total excision of the part affected. Potassium iodid may be given in doses of 15 to 60 grains a day. Opera- tive interference, in which all the diseased tissue could not be removed, has been followed by rapid metastases. Tincture of iodin locally may have a beneficial effect. ACTINOMYCOSIS OR STREPTOTRICHOSIS I99 Injection of killed cultures of the organism has met with some success. Review Questions What is the treatment of an abscess caused by a decayed tooth, opening into the maxillary sinus, or externally? Define osteomyelitis. Give etiology. What is necrosis? What are the essential factors in its production? Define sequestrum, involucrum. Give the symptoms of osteomj^elitis and necrosis of the mandible. Give the treatment of osteomyelitis and necrosis. Give the etiology, symptoms, prognosis, and treatment of actinomy- cosis. CHAPTER XX DISEASES OF THE MAXILLARY SINUS The maxillary sinus or antrum of Highmore may be the seat of catarrhal inflammation, empyema or sup- purative inflammation, impacted teeth, tumors, and polypi. Catarrhal inflammation is usually the result of exten- sion of catarrh from the nose and associated air-cells. The inflammation extends from the middle meatus of the nose, by way of the hiatus semilunaris and the ostium maxillare. The mucous membrane becomes swollen and secretes mucus. The swelling of the mucous membrane in the region of the ostium maxillare sometimes shuts off that opening, and the accumula- tion of mucus gives rise to pain from pressure. In simple acute catarrhal inflammation of the antrum it is not, as a rule, necessary to open into the sinus. The inflammation usually subsides by spraying and applica- tions through the nose. Suppurative inflammation or empyema of the maxil- lary sinus may be caused by infection extending from the nose and associated air-cells, or from penetration of bacteria and their products through the floor of the antrum from the teeth. The latter is not so common as might be supposed, because when a tooth becomes diseased, and an abscess from its root threatens to break into the antrum, the floor of that cavity over the 200 DISEASES OF THE MAXILLARY SINUS 2OI particular root becomes thickened by hyperplasia of the bone tissue, thus protecting the antrum from in- fection. There are also more cases in which teeth are lost through diseases of the antrum than cases in which the teeth are primarily diseased and cause infection of the antrum. Foreign bodies, such as rubber drainage- tubes, may become lodged within the maxillary sinus and keep up chronic suppuration. The symptoms of acute empyema of the maxillary sinus are pain, swelHng, and tenderness over the affected side of the face. There may be a history of a diseased tooth on the affected side and examination may reveal it. Breathing through the nose on that side may be impaired or completely obstructed. A flow of pus from the nostril can usually be obtained by holding the head down and forward with the affected side uppermost. Transil- lumination, by placing a small electric light in the mouth, may show a dark area on the affected side, but the small size of the antrum may make this sign of little value. The .T-ray is a valuable aid in diagnosis, a cloudiness of one side of the face often indicating maxillary sinus disease. The x-ray in a great many cases shows exactly which tooth is involved. Chronic suppuration of the maxillary sinus may be accompanied by little or no pain or swelling, and the only symptom may be a flow of pus from the nostril or an opening into the mouth. A" badly decayed tooth may be present, the a^-ray showing its root discharging into the sinus. Suppuration of the maxillary sinus may be complicated by infection of the frontal and sphenoid sinuses and the ethmoid cells. If the frontal sinus be involved, the patient 202 SPECIAL SURGERY complains of pain in the supra-orbital region, and there will often be a flow of pus from above into the anterior portion of the nose. When the sphenoid and ethmoid cells are affected, the pus passes backward and collects on the posterior wall of the pharynx. Treatment. — This consists in making an opening into the maxillary sinus and draining it. If an abscess from a diseased tooth has opened into the antrum, the tooth should be extracted at once. Conservative treatment of the tooth should not be attempted, as sufl&cient drainage cannot be obtained through the root. After extraction of the tooth, usually a bicuspid or molar, the opening into the antrum may be made larger by drilling through the socket with the surgical engine. Selection of the Place of Opening the Maxillary Sinus when No Tooth-socket is Available. — There are three places to be considered: (a) Through the canine fossa. (b) Through the nose, (c) Through the alveolar process just above the second bicuspid tooth. (a) In a great many cases an opening through the canine fossa will give the best access to the antrum, but we often cannot be sure that an opening at this point will not enter the nose instead of the maxillary sinus. The opening through the canine fossa also may not enter the lowest point of the sinus, and drainage will be imperfect. (b) Drainage through the nose is also often imperfect, and in making an opening in this region we are working in the dark, to a large extent. (c) The alveolar process over the second bicuspid tooth, or the same region if the tooth has been previously lost, is for most cases the best point to open the antrum, DISEASES OF THE MAXILLARY SINUS 203 as we are generally sure to reach the antrum from this position, and drainage is more perfect as the cavity is opened at its lowest point. The bone also is usually thin in this region. Sometimes a counter-opening from the nose is advisable for freer washing out of the cavity. After the antrum has been opened, it is washed out several times with warm antiseptic solution. The fluid should be forced through the antrum untils it runs out from the nostril. This is done every day and kept up until all odor and discharge disappear. Drainage-tubes should not be placed in the opening. If this threatens to close too early, a small plug of cotton may be inserted daily. If the discharge is slow in clearing up, tincture of iodin, a few drops to half a glass of water, may be used in flushing out the cavity. If dead bone is felt, it must be removed, and necrotic mucous membrane must also be scraped away. Impacted teeth are sometimes lodged in the wall of the maxillary sinus. Their position is well shown by the a*-ray. Treatment consists in removal. Tumors of various kinds — carcinoma, sarcoma, osteo- sarcoma, etc. — may involve the antrum. Their treat- ment is by early operation, just as in the case of malig- nant growths of other regions. Polypi are pedunculated growths covered by mucous membrane. They are an overgrowth of the submucous tissue and contain cystic areas filled with mucus. They usually follow chronic inflammatory conditions. Another form of polyp is fibrous in character, springing from the periosteum. Polypi are felt as soft, semisolid masses that bleed easily. Treatment is by enlarging the opening into the antrum 204 SPECIAL SURGERY from the mouth if one aheady exists; if not, make a new opening with the surgical engine, grasping the polypi with special long-beaked forceps, and twisting or tearing them out. Bleeding after removal is controlled by packing the antrum with gauze, which is changed in twenty-four hours, for three or four days, after which the opening may be allowed to close. Review Questions Name the principal diseases of the antrum of Highmore. Give etiology, symptoms, and treatment of empyema of the antrum of Highmore. What factors should guide the operator in selecting a place for opening a diseased maxillary sinus when no tooth socket is available? Give the diagnosis and treatment of polypi of the maxillary sinus. CHAPTER XXI DISEASES OF THE SALIVARY GLANDS AND THEIR DUCTS The salivary glands are subject to inflammation and tumors, while their ducts may be obstructed by in- flammation, tumors, calculus, or foreign bodies. Inflammation. — The parotid gland is subject to epidemic parotitis or mumps, a specific inflammation, the nature of which is not known, and infection by various bacteria. Typhoid fever is sometimes followed by suppuration of the parotid gland. Tumors. — The most common tumors of the parotid gland are the so-called mixed tumors, or teratomata, which consist of several varieties of tissue, including fat, fibrous tissue, muscle, glandular tissue, and car- tikge. Carcinoma of the parotid gland sometimes occurs, but is rare. A swelling over the region that may be mistaken for a tumor of the parotid gland is sometimes caused by enlargement of the lymph-node which lies over the gland. Swelling of the parotid gland, whether due to inflam- mation or neoplasm, is generally associated with false ankylosis of the temporomandibular joint. The patient has pain and difficulty in opening the mouth. There is also nearly always some facial paralysis on the affected 205 206 SPECIAL SURGERY side, due to pressure on the filaments of the seventh nerve as they pass through the parotid gland. The submaxillary gland may also be affected by in- flammation of tumors. These give rise to a swelling in the submaxillary triangle. Stenson's duct, the outlet of the parotid gland, some- times becomes obstructed by an extension of inflamma- Fig. 47. — Ranula. Note the prominent tumor on right side of floor of the mouth, pushing the tongue upward (Eisendrath). tion from the mucous membrane of the mouth. It may be relieved by probing. Ranula. — Obstruction of the ducts of the submaxillary, sublingual, or mucous glands gives rise to a swelling in the floor of the mouth caused by retention of the secretion of these glands, known as ranula (Fig. 47). A ranula is, therefore, a retention cyst. DISEASES OF SALIVARY GLANDS AND DUCTS 20/ Etiology. — The obstruction may be caused by sali- vary calculus or a foreign body, such as a tooth-brush bristle, within one of the ducts, or by inflammation or a tumor involving or causing pressure upon the ducts. The encysted material may be mucus, cheesy matter, or hard calculus. Symptoms. — The floor of the mouth presents a smooth sweUing, usually soft, of a grayish color, which pushes the tongue up and interferes with eating and speech. The tongue may protrude from the mouth. There is, as a rule, very little pain associated with the swelling, which slowly increases in size. Puncture of the swelHng is followed by a flow of thick mucus, the retained secre- tion of the gland involved. When the swelling contains calculus, it is hard. Treatment. — This consists in attempting to open the duct of the gland by dislodging the cause of the obstruc- tion and evacuating the fluid. If this cannot be done, a new outlet is to be made. This, in some cases, may be brought about by means of a " seton," which is a piece of silk ligature passed through the mucous membrane near the duct with a curved needle and tied in place. The silk sloughs off in a few days, leaving a new opening. In other cases a V-shaped flap is cut in the mucous mem- brane over the swelling, turned in, and sutured. Some- times the entire sac must be dissected out. Salivary fistula is a communication of one of the salivary glands, usually the parotid, with the surface of the face, through which the saliva is discharged. Saliv- ary fistula is caused by obstruction or injury to Stenson's duct, which may be due to traumatism, such as a gun- shot-wound, carelessness or unavoidable injury in opera- 2o8 SPECIAL SURGERY tions in the region of the duct, obstruction of the duct from calculus or inflammation, or ulceration following malignant disease. The opening on the face is just beneath the zygoma, and is usually very resistant to treatment, owing to retraction of the scar tissue and the constant escape of saliva. Treatment. — Any obstruction to the normal outlet of saliva into the mouth must be first removed, if possible, or a new connection made between the duct and the mouth. After this has been, done, the opening on the face must be closed by cutting the scar tissue away from the bone, to which it may be very adherent, freshening the edges of the opening, and bringing them together with sutures. Sometimes, when a large space is to be filled, it is necessary to close the opening with a flap of skin turned up from the neck. Ludwig's Angina. — Ludwig's angina is the name given to a rapidly spreading celluhtis of the tissue beneath the floor of the mouth. Etiology and Pathology. — The infection gains entrance through the roots of decayed teeth, through peridental inflammation, through the tonsils, or through the ducts of the submaxillary glands. The invading organism in the majority of cases is the Streptococcus pyogenes. The inflammation first involves the submaxillary lymphatics, and spreads thence into the surrounding cellular tissue, passing sometimes into the region of the glottis. Symptoms. — The disease begins as a swelhng in the floor of the mouth, accompanied by pain and increased flow of sahva. Later, the submaxillary region becomes indurated, swollen, and tender. The rapid increase in DISEASES OF SALIVARY GLANDS AND DUCTS 2O9 the swelling and in the other symptoms is character- istic of the disease, its entire course sometimes not occu- pying more than twenty-four or forty-eight hours. The mucous membrane of the floor of the mouth may be pushed up to the level of the tops of the lower incisor teeth. The tongue is forced up, causing the mouth to be held open. The disease usually commences on one side, but not infrequently both sides soon become in- volved. The local symptoms are often accompanied by high temperature and rapid pulse, and the patient may be prostrated by absorption of the toxic products of the infection. The cellulitis may rapidly spread to the glottis, causing suffocation of the patient. Prognosis. — If the case is seen very soon after its onset and proper treatment instituted, recovery gener- ally follows. Cases seen late, or allowed to go without proper treatment, are usually rapidly fatal. Treatment. — This consists in free external incision and drainage as soon as possible after the diagnosis has been made. Incision in the floor of the mouth is not sufficient. Two openings should preferably be made, one in the median line of the neck, just beneath the chin, and the other laterally, in the submaxillary triangle. The incisions must be carried beneath the deep fascia, for this is where the inflammation is taking place. The two openings should be connected by passing hemostatic forceps from one to the other, and a rubber drainage-tube inserted between them. Pus usually is not obtained in early cases, but this incision almost invariably checks the spread of the inflammation The incision in the median line may be carried up to, but should not pass through, the mucous membrane of the mouth. At this 14 210 SPECIAL SURGERY point, as in the case of all median raphes, no blood-vessels are apt to be wounded. These incisions are usually followed by subsidence of the swelHng within a few hours, accompanied by a fall of temperature and general im- provement in the patient's condition. The opposite state of affairs has been seen so often to follow postpone- ment of free incision that delay is to be severely con- demned. If the case is seen late, when the process has begun to occlude the glottis, tracheotomy in addition to the other measures offers the only hope of recovery. The general condition of the patient requires hquid diet and stimulants Review Questions Give several causes and the effects of swelling of the parotid gland. Give the etiology, varieties, symptoms, and treatment of ranula. Give the etiology and treatment of salivary fistula. Define and give the etiology, pathology, symptoms, prognosis, and treatment of Ludwig's angina. CHAPTER XXII DISEASES OF THE TONSILS AND OF THE LYMPHATIC GLANDS The tonsils normally undergo atrophy as age advances, but may become hyper tropied, in which case they are subject to attacks of inflammation, form points of entrance for pathogenic bacteria into the system, and give rise to various pathologic conditions. In hypertrophy of the tonsils the organs are enlarged, and either project toward the median line, narrowing the lumen of the oropharynx, or are buried behind the pillars of the fauces. While the former give rise to excessive mouth-breathing and its sequels, it is the latter that act as a constant menace to the health of the indi- vidual from the absorption of pathogenic bacteria. It is doubtful whether hypertrophy of the tonsils causes a narrowing of the bony palatal arch. It cer- tainly narrows the lumen of the oropharynx, thus in- creasing the mouth-breathing, which is normal in all cases, to a certain extent. In this way irregularity of the teeth may result, because the normal hammering action of the mandible is absent (Fig. 48). The treatment of hypertrophy of the tonsils consists in removal of the organs. This is best done by enuclea- tion by blunt dissection, followed by the use of a snare. It is impossible to completely remove the buried variety of hypertrophied tonsil by cutting with the ordinary tonsillotome, and this is the variety that demands removal most frequently. In operations on the tonsil 211 212 SPECIAL SURGERY care must be taken not to wound the internal carotid artery, which Hes externally to it, being separated from the tonsil by the superior constrictor muscle of the phar- ynx. The ascending pharyngeal artery is more likely to be wounded, but is a much smaller vessel, and is not apt to give rise to serious hemorrhage if divided. Fig. 48. — Facial expression in hypertrophied tonsils and adenoids (St. Clair Thomson). Tonsillitis. — The tonsils are subject to several varieties of inflammation, which will only be mentioned briefly. The two commonest forms are follicular tonsillitis and suppurative tonsillitis, or quinsy, A convenient method of removing pus from the region of the tonsil and without danger of causing undue hemorrhage is by thrusting the end of a grooved director into the abscess. The tonsils are the most frequent seats of diphtheric infection. This produces a grayish-white membrane of DISEASES OF TONSILS AND L YMPHA TIC GLANDS 2 I 3 necrotic tissue over the tonsil. Smears and cultures made from this membrane contain diphtheria bacilli. The secretion of the tonsillar crypts often collects behind the anterior pillar of the fauces, giving a foul odor to the breath. Many of these cases come with the idea that the odor is due to decay of the teeth. Examina- tion reveals no cavities in the teeth, but small, cheesy masses of the tonsillar secretion are found behind the anterior pillar of the fauces, and the removal of this by wiping with cotton gives immediate relief. Adenoids. — Adenoid growths are hypertrophy of the lymphoid tissue which normally lies beneath the mucous membrane of the nasopharynx. These growlhs obstruct the posterior nares, preventing nasal breathing, thus giving the mouth abnormal respiratory work to do, and causing in this way the same conditions as hypertrophy of the tonsils. Deafness may also result from occlusion of the Eustachian tube. Adenoids are felt by passing the finger up behind the soft palate. The treatment consists in removal of the growths by a special curet. The Lymphatic Glands The lymphatics most frequently affected by lesions of the mouth and jaws are the submaxillary group. When enlarged, the.se are felt immediately beneath the lower border of the mandible, in the submaxillary triangle of the neck. These glands may be enlarged from inflam- mation or malignant disease of the region. Inflammation. — The most common inflammatory con- ditions causing enlargement of the submaxillary lymph- glands are inflammation of the tonsils, inflammation 214 SPECIAL SURGERY about the roots of teeth, and osteomyelitis of the mandible. These structures must, therefore, be examined in search- ing for a cause of the swelling. The glands are also subject to tuberculous infection. Inflammation of the submaxillary lymph-glands (lymphadenitis) may be acute or chronic. In the acute form there is a painful tender swelling beneath the lower border of the jaw, which may go on to suppuration. The treatment consists in removal of the cause, application of cold or soothing ointment, such as ichthyol, and pressure. If pus forms, the neck must be opened and drained. Chronic lymphadenitis is characterized by nodular swellings in the submaxillary region, which may or may not be tender. The swellings tend to remain about the same size for a long period. The treatment is to remove the cause if it can be found-, and if this is not followed by subsidence of the swelling, the glands should be dis- sected out. Malignant Disease. — Carcinoma of the tongue, floor of the mouth, or of the mandible is usually accompanied sooner or later by enlargement of the submaxillary lymphatic glands. This enlargement may at first be due to absorption of infectious material from ulceration of the tumor, but is also caused by a growth of tumor- cells in the glands. Hence the glands, if involved, should always be removed at the time of operation on the primary focus. Review Questions What pathologic conditions may be caused by hypertrophied tonsils? What are adenoid growths? Give the symptoms, diagnosis, patho- logic effects, and treatment. What conditions may cause swelling of the submaxillary lymph- glands? CHAPTER XXIII INJURIES AND DISEASES OF THE TEMPOROMANDIB- ULAR ARTICULATION Dislocation By dislocation or luxation (Fig. 49) is meant an alteration in the relation of the bony surfaces composing a joint. One or both temporomandibular joints may be affected, double luxation being more frequent. The dislocation may be complete or incomplete. Displacement.— The condyle of the mandible is always carried forward. It is prevented from passing back- ward by the tympanic plate of the temporal bone. Hence, posterior dislocation is unknown unless accom- panied by fracture of this plate of bone. In complete dislocation the condyle of the mandible passes out of the glenoid fossa, under the eminentia articularis into the zygomatic fossa, accompanied by the interarticular fibrocartilage, and is held there by contraction of the temporal and masseter muscles. The capsular ligament of the joint is torn and other ligaments are put upon the stretch. In incomplete dislocation or subluxation the condyle of the mandible rests on the eminentia articularis. Etiology.— Dislocation of the jaw is caused by any force which produces an overopening of the mouth. A blow on the chin while the mouth is open, undue 215 2l6 SPECIAL SURGERY forcing open the mouth in the extraction of a tooth, and yawning are among the numerous causes of dislocation. Some individuals have the power of producing a dis- articulation at will, and in them the luxation gives rise to little or no discomfort. Fig. 49.— Dislocation of temporomandibular joint. Symptoms. — In double luxation the mouth is held wide open and cannot be closed, interfering with mastica- tion and speech. The chin is protruded beyond the normal. There are hollow spaces in front of the ears, where the condyles ought to be. Considerable pain is complained of. In dislocation of one joint only, the chin is protruded and deflected toward the sound side, and there is a THE TEMPOROMANDIBULAR ARTICULATION 2 1/ hollow space in front of the ear on the affected side. Single luxation is not so common as double. Treatment. — When seen early, a case of dislocation of the temporomandibular joint may be difficult to reduce, owing to the rigidity of the temporal and masseter muscles, but in an hour or two, when the muscles have relaxed, the condyle usually slips back into place easily. It may be necessary to anesthetize the patient. Reduc- tion is brought about by covering the thumbs with a towel, and placing them one on each side of the mouth, to the outer side of the molar teeth. The other fingers are placed under the chin. By downward pressure of the thumbs and lifting the chin with the fingers, the condyle is carried under the eminentia articularis into the glenoid fossa. After reduction of the dislocation the Barton bandage should be applied and worn for two weeks. After this time massage and passive motion may be begun. Old dislocations that resist all attempts at reduction require osteotomy at the angle of the mandible. Ankylosis By the term ankylosis is meant partial or total im- mobility of a joint. The following varieties of ankylosis of the temporo- mandibular joint arc found: {a) True Ankylosis. — Immobility due to disease within the joint itself. This is usually complete, owing to a deposit of bone in and around the joint. Ossification may be preceded by fibrous or cartilaginous change in the joint, in which case the ankylosis would be in- complete. 2l8 SPECIAL SURGERY Etiology. — True ankylosis of the temporomandibular joint is usually found in osteoarthritis, a chronic disease, in which all the joints of the body are progressively affected by ossification of the joint structures. Bony union of the joint surfaces and surrounding parts also occurs after traumatism. After prolonged ankylosis characteristic changes take place in the shape of the mandible. The condyloid process is shortened. This causes an apparent elongation of the coronoid process. The angle of the mandible is elongated, so that it forms a projecting point, and the base of the bone under the mental foramen is thickened. The mental process is much diminished in size by recession. The base of the bone, between the angle and a point vertically under the canine tooth, is deeply concave in outline. The cause of these changes lies in the activity of the muscles that depress the jaw. The muscles of mastica- tion — I. e., those which elevate the lower jaw — are in- active, while those which assist in depressing the man- dible become more and more active in their work in an endeavor to overcome the fixation of the temporo- mandibular articulation. By their action the lower jaw, from the symphysis to the angle, becomes modified in proportion to the contraction of the depressing muscles of the lower jaw. Anteriorly, there are the geniohyo- glossus, the sternohyoid, the sternothyroid, the digastric, the omohyoid, and the platysma myoides, all of which are abnormally active. Their action without the com- pensating factor of the mandibular motion brings about the changes noted ^ (Figs. 50 and 51). {h) False ankylosis is partial immobility, due to changes ' Cryer, " Studies in the Internal Anatomy of the Face. " THE TEMPOROMAXDIBULAR ARTICULATIOy 219 in structures outside the joint. It may be — (i) chronic, (2) acute. Chronic false ankylosis of the temporomandibular joint may be due to (a) trauma, resulting in thickening of the ligaments, or formation of scar tissue from a wound in the region of the joint. Fig. so. — .\rikyi(^.^i.^ o( jaw (allcr L rycry (b) Inflammatory conditions, followed by organiza- tion of exudate or formation of scar tissue about the joint. ic) Cicatricial tissue following sloughing within the mouth in the course of acute exanthemata (scarlet fever, etc.). 220 SPECIAL SURGERY The changes in the shape of the mandible following prolonged ankylosis of this character are similar to those seen in acute ankylosis. L- Fig. 51. — Radiograph of ankylosis of temporomandibular joint, showing under- development of mandible and impaction of teeth (after Cryer). Acute false ankylosis is inability to move the jaw, owing to an acute inflammatory exudate in the region of the joint. This is often seen in connection with mumps and other inflammations of the parotid gland. An impacted THE TEMPOROMANDIBULAR ARTICULATION 221 third molar tooth or an abscess from a tooth often causes celluhtis, which extends up to the region of the joint. Symptoms. — Complete True Ankylosis. — Complete im- mobility of the temporomandibular joint is rare. There is absolute inabihty to open the mouth. After a time the chin recedes, the angle of the jaw becomes obtuse, and the muscles below the jaw have the appearance of being tense. If ankylosis dates from childhood, the teeth are found to be irregular and some of them im- pacted, owing to lack of space for eruption. The x-rays are of great value in these cases in ascertaining the condition of the joint, and also because inability to open the mouth makes examination by the ordinary methods difficult or impossible. True ankylosis that has not become complete and chronic false ankylosis present symptoms that vary only in degree. Here the jaws can be separated to a slight extent. There is no pain, except when force is used to open the mouth. The secondary changes, recession of the chin, impaction of teeth, etc., are found as in the case of bony ankylosis. Acute False Ankylosis. — Here we have the symptoms of acute inflammation — heat, pain, redness, swelHng, and disturbed function — in the region of the joint. The motion of the lower jaw is limited owing to the pain and exudation, and the patient has difficulty in opening the mouth. The local signs may be accompanied by fever and other general symptoms. In inflammations of the parotid gland the swelling is triangular in shape, behind the ramus of the jaw and in front of the ear. The limitation of jaw movement in these cases is due largely 222 SPECIAL SURGERY to inflammation of the process of parotid gland that is found in the glenoid fossa, though it is also brought about by the general swelling behind the ramus. This form of ankylosis often gives rise to great alarm on the part of the patient and family, who fear the onset of tetanus. Prognosis and Treatment. — In true ankylosis of the temporomandibular joint the prognosis is unfavorable. Where bony union of the parts has taken place, it is never possible to restore the function of the joint. In this case the only hope of improvement is by making a false joint (pseudo-arthrosis) . It is best to do this by removing a wedge-shaped piece of bone at the angle of the mandible, rather than section at the neck of the condyle. This may be done by making a section at the neck of the condyle, or by removing a wedge-shaped piece of bone at the angle of the mandible. A flap of soft tissue is interposed between the cut ends of bone, and after the operation motion is begun early to prevent the formation of new bone at the point of section. In incomplete ankylosis, whether true or false, the prognosis is more favorable, and great improvement can sometimes be brought about. Cicatricial tissue or fibrous bands which restrict the movement of the jaw may be cut away by operation, and the jaws gradually spread apart by a special appliance, or they may be gradually stretched without operation. A special wedge is made, the jaws of which are spread wider apart little by little each day. Wedge-shaped pieces of box-wood or ivory may also be introduced between the upper and lower teeth, and the patient instructed to work the jaws with the wedge in position. In this way great progress may be made, the final result obtained depending on the severity of the case. THE TEMPOROMANDIBULAR ARTICULATION 22 3 In acute ankylosis the prognosis is good, and the treat- ment consists in removal of the cause. If it be an im- pacted or abscessed tooth, this should be removed. Anes- thesia is often necessary to get the mouth open. The inflammation is treated by rest, cold, soothing lotions, incision, etc. Differential Diagnosis of Tetanus and Acute Ankylosis. — The muscles of the jaw are those earliest affected in tetanus (lockjaw), and this fact often leads to alarm on the part of the patient suffering from acute ankylosis that he has an attack of lock-jaw. There is no necessity, however, for the surgeon to confuse the two. In the trismus of tetanus or lock-jaw the inability to open the mouth is purely due to muscular spasm, and is not in- flammatory, consequently there is no swelling in the re- gion of the temporomandibular joint. The muscular contractions are intermittent. The convulsions are not confined to the muscles of the jaw- , except in the earliest stages, but are general; there are severe constitutional symptoms, and the patient is very much prostrated. Spasm of the muscles of the back causes a marked arch- ing (opisthotonos), so that the patient may be supported by his head and heels. In tetanus there is generally a history of a punctured wound, such as that made by a rusty nail in the foot, a gun-shot w^ound, etc. Review Questions Give the displacement, etiology. symi)toms, and treatment of luxation of the temporomandibular joint. What is meant by ankylosis? Give the varieties of anl^ylosis of the temporomandibular articulation and the causes of each. (iive the symjitoms of the fh'ffcrent varieties of anl