'tMMM, •M^'i'^'tM ff- ^cfjool of Hcntal anb (!^ral Purser? LIBRARY OF Dr. carl F. W. BODECKER 1846-1912 The gift of Dr. Henry and Dr. Charles Bodecker 1929 ^pV^i "V ■_ \\'',-/-v-i<^ fM^k^Ss^M 'v^MM ''MM Digitized by the Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/oralpathologypraOObarr Oral Pathology and Practice. A Text-Book for the Use of Students in Dental Colleges and a Hand-Book for Dental Practitioners. By W. C. BARRETT, M.D., D.D.S., M.D.S. Professor of Oral Pathology in the University of Buffalo Medical Department Professor of Dental Anatomy and Pathology in the Chicago College of Dental Surgery; Professor of the Principles and Practice of Dentistry and Oral Pathology in the University of Buffalo Dental Department ; Oral Surgeon to the Buffalo General Hospital, etc, etc. PHILADELPHIA: THE S. S. WHITE DENTAL MFG. CO. 1898. V^x' Copyright, 1898, by W. C. Barrett. TO My beloved Associates in College "Work, AND TO My Boys, THE MEMBERS OF THE VARIOUS CLASSES WHO HAVE BEEN UNDER MY INSTRUCTION, AND WHOM I HAVE SOUGHT TO SERVE, THIS WORK IS AFFECTIONATELY INSCRIBED. PREFACE. This book is not a treatise, and surgical or operative pro- cedures form no part of its scheme. In writing it the first object has been to condense, not to ampHfy, that it may be published at as low a price as possible. With this end in view, cuts have been excluded, desirable as they might in some instances be. The work has thus been kept within the limits of a manual. It has been the aim of the author to consider as succinctly as is consistent with clearness the functional derangements of all the oral tissues that properly fall within the compass of a broad dental practice. In addition to this there are certain constitutional dis- orders, the effects of which may be observed in and about the oral cavity, which have not as yet been incorporated into our specialty, and perhaps never will be, yet of which it is essential that the dentist should have sufficient knowledge to enable him to make a clear diagnosis, even if he should not purpose active remedial measures. Such disorders as facial paralysis, syphilis, and tumors have therefore been given a general consideration, but practitioners who wish to make a more exhaustive study of those subjects are referred to special works upon them. It should not be expected that a writer would blindly and unreservedly follow even accepted practice when in his opinion it is founded in error: such a course would make of him a mere echo, and would inhibit originality and progress. If, therefore, the author has advanced his own ideas upon subjects concerning which there is a difference of opinion, he believes them entitled to candid consideration in the light in which they are presented. If not found in harmony with clinical experience and observation, they disprove themselves. It is only within a few years that Pathology as a separate study has been made a distinct part of the curriculum of our colleges. The treatment of a few of the more pronounced pathological condi- tions has always Ijecn included in the course of lectures upon VI PREFACE. Operative Dentistry, or in that of Materia Medica and Therapeu- tics, but the subject has been made rather incidental than founda- tional. With the growth of dental practice and the expansion of the course of instruction in our colleges, a more extended con- sideration of the treatment of complications naturally attendant upon dental degenerations becomes a necessity in our best schools. Dentists are reasonably plentiful, and the multiplication of institu- tions devoted to their training is believed to promise an even more abundant supply. The complaint that the profession is getting uncomfortably crowded arises from the old graduates, as well as from those who have been deprived of the advantages of scholastic training. The remedy for these conditions can only be found in the deepening of the stream — in the enlarging of the field of practice by incorporating with the methods of the past (the mechanical and operative procedures which have already been carried to such a high state of perfection) the treatment of the diseases that prop- erly fall within the province of the oral physician, and the making of Oral Practice a true specialty of medicine. For some years the author has annually delivered before his classes in dental colleges from fifty to sixty lectures upon patho- logical and morbid functional and structural conditions in the oral cavity and the tissues immediately connected with it, in which there has been attempted nothing of instruction in constructive, opera- tive, or manipulative dental work. This has tended to open for students a field insufficiently cultivated by dentists. It has en- larged their opportunities, added to their emoluments, and given to them a better professional status. But in this line of teaching he has been seriously handicapped by the absence of proper text-books. ExceUent treatises were in existence, but none of them was exclusively devoted to the every- day work of either student or practitioner. They included other branches of dental science, and while, as works of reference and as text-books for advanced members of the profession who desired to make special studies in scientific fields, they were much better adapted than a work of this kind can possibly be, yet as hand- books for students in colleges and as everyday manuals for those who sought help in the hourly recurring complications of office life they were too voluminous. In the time of Hippocrates it was possible to comprise in one PREFACE. Vll volume all that was known of medicine. Many of our older practitioners can call to mind the days when the whole art of den- tistry was imparted by a preceptor in a few easy lessons. One man might then be universally recognized as the highest authority in the whole field. Now, a complete knowledge of any one of the distinct branches of medicine demands a post-graduate course after four years of general study, while three years in a dental college are scarce sufficient to enable the student to master the basal principles of our greatly extended oral practice. Not alone medi- cine, but dentistry is divided into specialties, and already there are among us those who give their exclusive attention to Operative or to Prosthetic work, to Oral Surgery, to Odontothorsis or to Odontotherapy. The tendency seems to be toward the teaching of each branch in separate classes, with distinct text-books for the several departments. The present work grew out of that seeming drift, and the germ of its existence lay in tlie notes of lectures upon the subjects considered. The book could easily have been expanded into greater dimen- sions, but that would have limited its usefulness among those for whom it was specially prepared. Extended abstracts of the writ- ings of others might have been included with profit, but that would have swollen the volume beyond the limits set for it, and have added to its cost. Besides, a book should have a distinctive indi- viduality, a personality as pronounced as that of the successful teacher, and without this it is usually as insipid as is the man who possesses no distinguishing peculiarities. So it is perhaps better that it should be marred by some of the many faults of its author rather than be without any special traits at all. W. C B. 208 Franklin St., Buffalo, N. Y., June, 1S9S. CONTENTS. CHAPTER I. PAGE General Considerations i CHAPTER II. Bacteriology : Classification 3 CHAPTER III. Fermentation 7 CHAPTER IV. Bacteriological Pathology 11 CHAPTER V. Septic and Aseptic Conditions 14 CHAPTER VI. Inflammation: Its General Characteristics 19 CHAPTER VII. Changes Attending the Inflammatory Condition 23 CHAPTER VIII. Further Degenerative Changes 27 CHAPTER IX. The Products of Inflammation 30 CHAPTER X. General Tre.\tment of Inflammation 35 CHAPTER XL Diseases of the Gums 39 CHAPTER XII. Stomatitis 42 CHAPTER XIII. Treatment of Stomatitis .45 CHAPTER XIV. Piinryngitis and Tonsillitis 49 ix X CONTENTS. CHAPTER XV. PAGE Diseases of the Tongue 52 CHAPTER XVI. Diseases of Dentition : General Considerations 54 CHAPTER XVIL The So-called Diseases of Dentition 58 CHAPTER XVIII. Treatment of the So-called Diseases of Dentition 64 CHAPTER XIX. Real Diseases of Dentition 67 CHAPTER XX. Dental Caries 70 CHAPTER XXI. Dental Caries (Continued) y;^ CHAPTER XXII. The Medicinal Treatment of Dental Caries yy CHAPTER XXIII. Pulpitis — Inflammation of the Dental Pulp 80 CHAPTER XXIV. Treatment of Inflammatory Conditions of the Dental Pulp 84 CHAPTER XXV. Pericementitis — Inflammation of the Peridental Membrane 88 CHAPTER XXVI. Alveolar Abscess 92 CHAPTER XXVII. Symptomatology and Treatment of Alveolar Abscess 97 CHAPTER XXVIII. Depo'sits upon the Teeth 103 CHAPTER XXIX. Pyo ?.rhea Alveolaris 107 CHAPTER XXX. Pyorrhea Alveolaris (Continued) 109 CHAPTER XXXI. Facial Neuralgias 115 CHAPTER XXXII. Facial Paralysis . . . ' 1 19 CONTENTS. XI CHAPTER XXXIII. p^^^ Sympathetic Disturbanxes 122 CHAPTER XXXIV. Diseases of the Maxillary Sinus 125 CHAPTER XXXV. Treatment of Diseases of the Maxillary Sinus 130 CHAPTER XXXVI. DisE.\SES OF THE Froxtal Sinus 135 CHAPTER XXXVII. Cysts and Their Treatment 137 CHAPTER XXXVIII. Tumors and Neoplasms 141 CHAPTER XXXIX. Tumors and Neoplasms (Continued) 144 CHAPTER XL. Osteitis 148 CHAPTER XLI. C.A.RIES OF Bone 151 CHAPTER XLII. Necrosis 155 CHAPTER XLIII. Treatment of Necrosis 158 CHAPTER XLIV. Hypersensitive Dentin 161 CHAPTER XLV. Treatment of Hypersensitive Dentin 165 CHAPTER XLVI. Secondary Dentin, Pulp Nodules, and Calcific.\tions 171 CHAPTER XLVII. Hypercementosis 174 CHAPTER XLVIII. Discolored Teeth 175 CHAPTER XLIX. Abrasions; Pitted and Furrowed Teeth 177 CHAPTER L. Replantation; Transplantation; Implantation 181 Xll CONTENTS, CHAPTER LI. Syphilis : The Primary Stage i86 CHAPTER LH. Syphilis (Continued) : The Secondary Stage 189 CHAPTER LHI. Tertiary and Hereditary Syphilis 192 CHAPTER LIV. Syphilis of the Mouth and Tongue 194 CHAPTER LV. Physical Diagnosis: The Pulse 196 CHAPTER LVI. Physical Diagnosis (Continued): The Respiration 201 CHAPTER LVII. The Oral Tissues in Diagnosis 205 CHAPTER LVIII. Wounds and Injuries 208 CHAPTER LIX. Treatment of Wounds 2x1 CHAPTER LX. Excessive Bleeding 216 CHAPTER LXI. Fractures and Their Treatment 218 CHAPTER LXII. Special Cases of Fracture 222 CHAPTER LXIII. Dislocations and Sprains 225 CHAPTER LXIV. Shock — Collapse 22S CHAPTER LXV. Treatment of Shock 232 ORAL PATHOLOGY AND PRACTICE. CHAPTER I. GENERAL CONSIDERATIONS. The study of disturbed, as well as of normal systemic condi- tions, necessarily commences with the consideration of Function. Health and sickness (ease and dis-ease) are dependent upon the ac- tivities of the organs of the body. In the former condition all are harmoniously working together, each accomplishing its proper task in the best manner and at the right moment. In the latter there is a disturbance of the harmonious bodily relations through the inaction or the mal-action of some organ or set of organs, in- duced by malnutrition, by unsanitary conditions, or by external in- terference. Function is the action of an organ, or of a complete set of organs. The function of digestion implies the proper action of all the organs of the digestive tract, and the perfect accomplishment of this function requires that each of them shall be in that state of health which is secured only by the normal action of all com- bined. The function of insalivation demands that all of the salivary glands shall be in a normal condition, secreting healthy saliva, and that the saliva shall be properly mixed with mgested food. Physiology is the science of normal function. Its proper study demands a knowledge of the structure of the organs con- cerned. It is not confined to man, or even to animal life. Wher- ever there is vitality, growth, organs (that is, in all organic matter) there are certain laws that govern the functional activity of the organism; and the study of these laws is called Physiology. Physiology is divided into animal and vegetable phys- iology. It may again be subdivided, until the functional activity of each of the various orders of animal and vegetable life is specially considered. 2 ORAL PATHOLOGY AND PRACTICE. Pathology is the study of perverted, abnormal, or diseased function. Its comprehension must be based upon a knowledge of healthy action. The study of pathology may be divided in the same manner as is physiology. Wherever there is normal func- tion there may be diseased or perverted action of the tissues or organs, if their activity is in any way disturbed. So we may have animal or vegetable pathological action, and we may study this aberration in any class of animals or vegetables, even in any separate organ or tissue; thus we speak of human or animal pathology, and of pathological conditions of the digestive appa- ratus, the kidneys, the pulmonary tissues, the oral cavity, the nails, the teeth, the hair, etc. This unrestricted nature of the study must always be kept in mind, and the fact that in the consideration of the diseases that are incident to man we are but making an examination of a small portion of the great field of perverted activity, should never be lost to sight. Oral pathology is but a branch of disturbed human function. While we may make special inquiries into its charac- ter, it can never be wholly segregated from its connections, but must always be considered in its relations to impaired conditions of other organs, because its initial lesion, or point of origin, may be in them, and a cure may only be brought about through a return of those connected organs to a true state of physiological action. There is no proper study of the oral tissues or organs, aside from their functional association with other tissues and organs. A physiological state may be changed to a pathological condi- tion by any derangement of function. The modifying influences may be classed as follows : 1. Perverted nutrition (or malnutrition). 2. Unsanitary surroundings or environments. J. External interference. Their importance as disturbing factors is in the order given. Malnutrition means the improper nourishment of the tissues or organs. It may primarily depend upon improper food, a lack of food, or upon imperfect action of the organs of digestion and assimilation. A degenerate condition of these organs is usually brought about either by impaired nutrition or unhealthy environ- ment, and may therefore be considered as a secondary cause. Unsanitary or unhygienic conditions are those that interfere bacteriology: classification. 3 with proper functional activity, by means of some disturbing element or influence, such as a. Coiitaininatioii of the air that is breathed, or the food or drink that is taken. b. Snbjeetion of the organs and tissues to improper extremes of temperature. c. Promotion of the proliferation and growth of parasitie or disease-producing organisms. External interference has reference to factors not primarily connected with functional disturbances. It includes wounds and injuries, the influence of excessive heat and cold, the active agency of corrosive poisons, and such-like extraneous causes. CHAPTER 11. BACTERIOLOGY: CLASSIFICATION. Modern pathological science is largely founded upon a knowl- edge and study of the bacteria — a subdivision of the fungi. The influence of these organisms upon the body is so overwhelming tljat it is impossible to comprehend pathology without a knowledge of their character and action. So many of the diseases most de- structive to man are caused by them, that modern medical science is largely based upon their study. Notwithstanding the fact that they can only be seen by the aid of the higher powers of the micro- scope, and that even then some of them are absolutely indefinable to vision, they work the most important changes in matter. The office of the fungi seems chiefly that of destruction. By their growth they decompose organic matter in which function has ceased, and return its elements to nature, to be again built up into other structures by varying functional activities. Different names have been given to these organisms by different pathologists, though all have the same general signifi- cation. a. Micro-organism means a small body. b. Microbe signifies a small life. c. Bacterium (plural Bacteria), a snudl staff. d. Bacillus (plural Bacilli), a small rod. It will be seen that the first two and the last two are practically ORAL PATHOLOGY AND PRACTICE. synonymous. Micro-organism is a term as comprehensive as any, although it has no strictly scientific significance. All of these bodies that come within the field of the pathologist are microscopic, hence the term micro-organism is more appropriate than to call them fungi, the latter term including many organisms that are merely parasitic upon other vegetable growths, and many of the fungi not being microscopic and having no pathological signifi- cance. They have been differently classified by various observers. These have based their arrangement upon special characteristics. That of Miller, in his "Micro-organisms of the Human Mouth," is perhaps best adapted to the needs of students of oral pathology, and it is therefore accepted as the standard for this work. The following table will give a clear idea of it: Matter Organic Inorganic Animal Vegetable Cryptogams Phanerogams (Flowerless plants, propagating (Flowering plants, propagating by spores) by seeds) Thallogens, or Thallophytes Leafy Cryptogams, (Ferns, Mosses, etc.) Lichens Fungi Algce Screw forms Rod forms Round forms Vibriones (undulating) Spirilla (rigid) Spirocheta (flexible) Bacilli (straight rods) Clostridium (spindles) Leptothrix (threads) Micrococci (small cocci) Macrococci (large cocci) Diplococci (double cocci) Streptococci (chain cocci) Staphylococci (group cocci) Organic matter is that which is the product of function, or growth. Everything that has organs, or in which function exists or has once existed, is organic. The organic world is divided into two great kingdoms, the Animal and the "Vegetable. Each individual member of these bacteriology: classification. 5 great divisions has its organs and its tissues; function exists in each as long as there is vitahty, or Hfe. Death is merely the cessa- tion of function. The food of these two kingdoms materially differs. The animal can assimilate nothing except organic matter. Thus the Graminivora live upon vegetables alone, or matter that has been but once organized, and require a complicated digestive system to extract the comparatively small amount of pabulum for their tissues which it contains. The Carnivora feed upon the animal kingdom, or matter that has been twice organized; first into the vegetable and then into the animal. Their digestive apparatus is comparatively simple, because of the concentrated nature of their food. The Omnivora, to which division man belongs, can subsist upon either, and their digestive organs, while more com- plex than those of the Carnivora, are considerably modified from those of the Graminivora. Only organisms that belong to the vegetable kingdom have the power of living upon inorganic, or unorganized matter. Certain of the vegetable fungi are unable even to do this, but must have the food organized before they can assimilate it, as must all members of the animal kingdom. Inorganic matter is that which exists as it was first created. This earth, when it left the hands of the great Creator, must have consisted of inorganic matter. When, in due process of time, the first organic cell was created, and endowed with the power to adapt itself to changing environments and to perpetuate its species — in other words, was invested with function — its food, or pabulum, must have been derived from the inorganic creation. But only the vegetable kingdom has the power to assimilate or organize this matter, or to subsist and grow upon that which is as it was primarily created. Hence the vegetable was first in the order of organic creation, and all organic matter, which is the product of function and was primarily derived from the inorganic, must have originally been the result of vegetable action. No animal can utilize for trophic, or digestive, purposes any inorganic matter whatever. This is a law of the creation. All the mineral elements that enter into the composition of our teeth, boifes, etc., must be obtained from organic sources. That is, the calcium, phosphorus, iron, etc.,- of our tissues must have been derived from matter that had first been built into other life. Inor- 6 ORAL PATHOLOGY. AND PRACTICE, ganic matter may be utilized in the system as medicine, but it will be extruded in the same form in which it entered; it cannot be built up into the tissues. It necessarily follows, then, that in the order of the developmental history of the world, the vegetable must first have had a being, to provide food for the animal. The vegetable kingdom is divided into the classes Phanerogam and Cryptogam. The Phanerogams include all those plants which have blossoms and which are propagated by seeds. The roots of some phanerogams, as the potato, enlarge into tubers, from which new plants may be grown, but their real generation is from seeds. Most of the plants with which we are acquainted belong to this class. It is the seeds and the tubers of the phanerogams that form the principal vegetable food of man. The Cryptogams never blossom, and their propagation is by spores, or minute erabryos of the plant itself. As the potato may be propagated from divisions of the root or tuber, so do many of the cryptogams grow from divisions of the organisms themselves, but primarily their origin is from spore-cases. The Leafy Cryptogams are not microscopic in their character, and they have distinct branches and stems. But, like all of their class, they grow from spores. The leafy- cryptogams include the ferns, the mosses, and some of the lichens. The Thallogens, or Thallophytes, belong to that divi- sion of the cryptogams that are unicellular in their struc- ture. They are without leaves, stems, or branches. They are divided into Fungi, Algae, and Lichens. Fungi are without chlorophyll (the green coloring matter of plants), and live only upon organic matter. They are found as the parasites of both the animal and vegetable king- doms. Algae contain chlorophyll, but live upon inorganic matter. They are usually found growing in the water. Lichens partake of the character of both the fungi and the algae. They may or may not contain chlorophyll, and they may live upon either organic or inorganic matter, according to their species. It will be observed that only the fungi can be of interest to the pathologist, for the algse do not grow upon organic matter, and hence will not be found parasitic in man, whose structure is organic. FERMENTATION. 7 The Fungi are divided according to their shape, into round, rod, and screw forms. The rovmd, or coccus forms, are subdivided into the macrococci, or large cocci, the micrococci, or small cocci, the diplococci, or double cocci, the streptococci, or chain cocci, and the staphylococci, or those which grow in clus- ters, like a bunch of grapes. The rod forms are divided into the bacilli, or straight rods; the Clostridium, or spindle-shaped, and the leptothrix, or thread- like forms. The screw forms are divided into the vibriones, or undulating screws; the spirilla, or rigid, and the spirocheta, or flexible screws. This subdivision as to form is for convenience, and has no special pathological significance. Classed according to their action the fungi are divided into other classes, such as Zymogenic (fermentative), Pathogenic (disease-producing), Chromogenic (coloring), Aerogenic (gas- forming), Saprogenic (putrefactive). Pyogenic (pus-producing), Saprophytic (parasitic), etc. CHAPTER III. FERMENTATION. Fermentation may be defined as the change brought about in an organic medium by the presence of a ferment. It is only within a recent period that its true nature has been comprehended. It was formerly ascribed to what was called catalytic action. It is now known to be induced by a special organism or substance, and its phenomena are those produced by the decomposition of the medium in which the ferment is growing, or exhibiting its energy. There are organic and inorganic ferments. The organic ferments are certain of the micro-organisms whose growth or proliferation is by the assimilation of the elements of the fermentable substance. This they have the power t(j decompose, as a cabbage disintegrates and resolves into its elements the soil in which it grows. The inorganic ferments are those of digestion. The gastric and intestinal juices, the saliva, etc., contain ferments that decompose and change the fermentable foods, and reduce them 8 ORAL PATHOLOGY AND PRACTICE, to a condition in which they may be assimilated, or built into tissue. It is only fermentable organic matter that can be thus digested and assimilated. Inorganic matter is incapable of fermentation, and hence cannot serve as food for any of the tissues of the animal. The classification of the fungi shows that they are as distinctly vegetable as is a potato or a geranium. The fact that they belong to a different order, and are cryptogams instead of phanerogams, does not change this. They require for their development the same essential conditions and elements. They must have the proper soil, or menstruum, in which to proliferate, or grow. They require a proper amount of moisture-, as does corn or wheat. They demand a fitting temperature, and are destroyed, or cease to vegetate, when that is either too high or too low, as do grass, trees, and shrubs. The media, or soils or materials in which the different species of micro-organisms grow are as various as are the fungi themselves. Some require a sugar solution, made from the fermentable sugars formed by the change of starch into the so-called grape sugar. Some demand an infusion prepared by steeping vegetables belong- ing to the phanerogams. Some grow only in gelatins. Others exist only in the tissues, or extracts of the tissues, of animals. The temperature best adapted to their growth varies with the organism. With those that live in the tissues, that which is normal to the body is also normal to them. The growth of the organisms, although primarily from spores, goes on in various ways. Segmentation is the spontaneous division of a micro-organism into segments, or sections. Each is complete in itself, and each in turn subdivides into others. Gemmation is the process of proliferation by budding. This is the growth of one organism out of another, and its final separa- tion from the parent. Fission is the division, of an organism into two or more parts by a constriction of its body. This contraction gradually deepens until the separation is complete. Spore formation occurs zvhen in certain stages of its life-history an organism undergoes special changes. In these the interior breaks up into exceedingly minute embryos, which are liberated and FERMENTATION. 9 disseminated by the bursting of the external envelope. Many of the organisms which at certain stages of their existence pro- liferate by means of segmentation or gemmation, after a definite time break up into spores. Something analogous to this exists among phanerogams, the potato, for instance, being propagated by subdivision of its tubers, but in due process of time blossoming and forming seed-cases. The growth of micro-organisms proceeds by the decomposition of the medium in which they exist. They assimilate such of its elements as enter into their own composition, and in so doing form various waste products, and give rise to new combinations of such of the elements of the medium as are rejected. Under favorable circumstances, micro-organisms multiply with almost inconceivable rapidity. Cohn estimates the life-history of a single bacterium at an hour, at the end of which time it will divide into two or more. He computes that from a single indi- vidual, if all the circumstances were favorable, within five days the product might fill all the seas of the globe. The proliferation of the Torula, or Yeast-plant, may be taken as a type of the whole process. This fungus consists of single cells, produced by division of the parent cell. It grows in sugar solu- tions with the greatest rapidity, but a short time being required for the permeation of a large mass by the product of a single cell. The process of making bread illustrates this. The housew^ife mixes flour, which consists of starch, that is easily converted into a fer- mentable sugar, with a sufBciency of water; she then places the product in a warm place, after having introduced a few cells of the yeast-plant. Here are all the elements needed for development — a suitable medium, sufficient moisture, and the proper temperature. The yeast-plant commences its growth and permeates all parts of the mixture. It decomposes the sugar, separating the oxygen, carbon, and hydrogen. It builds into itself that which is necessary and rejects the other atoms, which immediately enter into new combinations, forming as by-products, alcohol and carbon dioxid. Wherever a cell of the yeast-plant is formed, there is a bit of alcohol and a minute globule of carbon dioxid gas. The latter distends the dough, or causes it to "rise." When this is completed it is placed in the heated oven, with the result that the yeast-plant is killed, and the dough is fixed, or cooked, and l)econies bread. Beer-making is an analogous fermentation. lO ORAL PATHOLOGY AND PRACTICE. The alcoholic -fermentation is that ivhich results in the formation of alcohol as one of the by-products. The fermentation of grape juice, and the formation of alcohol from the starch of various grains, belong to this class. The growth of the ferment produces alcohol, which is held in solution in the water, and is then distilled off by its evaporation at a comparatively low temperature. The acetous, or acid, fermentation is the grozvth of yet another organic ferment, that leaves as its by-product an acid. Of this char- acter is the organism Mycoderma aceti, or the so-called "mother'^ of vinegar. It decomposes a sugar solution, and produces acetic acid as a by-product. Others of the fungi produce gelatin, and yet others various gases. The putrefactive organisms decompose nitrogenous matter by their growth, with the evolution of offensive gases as their by- products. All the fungi grow at the expense of the medium in which they exist, and through its decomposition, or change. Their by-products vary with the organisms themselves, and, as in the case of the ptomains and toxins, are sometimes of such a poisonous nature as to induce diseased or pathological conditions. Some of the fungi gro^v only in the presence of air or oxygen, and hence are called "aerobic," while others flourish in tissues or cavities to which air has no access, and are called "anaerobic." The bacteria generally are self-limiting. Their own by- products are fatal to them, and when the medium in which they are growing becomes sufficiently contaminated the organisms will perish. Thus, when an acid-producing organism has made its menstruum sufficiently acid, it will die unless the acid is neutralized by an alkali, in which case it goes on proliferating, provided the pabulum is not exhausted. All the fermentable material in a solution may be used up and decomposed, so that there will no longer be food for the organism, in which case it will die out. One organism may destroy and supersede another by its superior activity andpow^er of decomposition, or through its production of a chemical compound that is fatal to the first. The brewer must use the most scrupulous care to prevent the intrusion of a strange organism into his infusion, or the result may be an acid instead of an alcohol, with the consequent souring of his beer. BACTERIOLOGICAL PATHOLOGY. II CHAPTER I\'. BACTERIOLOGICAL PATHOLOGY. From the standpoint of the pathologist, the micro-organisms may be divided into several classes, according to their action upon the animal economy. Pathogenic microbes are those ivhose proliferation or zvhose by- products cause specific pathological changes; they are disease-pro- ducing. Saprogenic organisms are those ivhich cause putrefaction; those idiieh give rise to the formation of pus, or induce suppuration, being termed pyogenic. Saprophytic bacteria are those zvhicJi are merely parasitic; they live at the expense of that upon zvhich they groiv. They are found in connection i^nth putrefactive changes. For the study of any of these micro-organisms it is necessary to make pure cultures, obtained by implanting them, as they are mixed with others, in the best culture media, and separating out and replanting until everything has been eliminated save that which it is desired shall be investigated. They cannot be iden- tif^.ed by a microscopic inspection of the organisms themselves, — they are too minute for this purpose. But by observation of the phenomena of their growth, and by tests of their products, as well as by staining them with certain anilin dyes which do not affect their surroundings, they may readily be differentiated, or distin- guished from other organisms. To produce a pure culture of any organism, an incubator, or growing-chamber, is required, in which the exact amount of moisture and the proper temperature may be maintained prac- tically unchanged for a definite period. Micro-organisms penetrate everywhere that air can go. So innumerable are the different species, and so minute their size, the spores of many of them being invisible even beneath the highest powers of the microscope, that everything conceivable becomes infected with the seeds of disease and decay. A single species has in the past caused greater alarm and devastation than all the armies of the most pitiless conqueror who ever ravaged the earth. The bacillus that produces cholera has decimated nations. The various plague bacteria have invaded great cities and de- 12 ORAL PATHOLOGY AND PRACTICE. stroyed every second person. They have defeated and dispersed invading armies, and have stayed the march of destroying hosts. The bubonic plague, which is the result of the growth of a patho- genic organism, has, in the past, swept away one-third of the population of Europe in a single invasion. A few of the most fatal of the maladies which are the direct result of the growth of some special organism, and which are therefore contagious in their character — the so-called zymotic diseases, of either epidemic or endemic origin — are the following: Cholera, Diphtheria, Relapsing Fevers, Leprosy, Typhoid Fever, Syphilis, Smallpox, Septicemia, Osteomyelitis, Tuberculosis, Lupus, Tetanus, Glanders, Actinomycosis, Malignant Pustule, Gonorrhea, Leucorrhea, Scarlet Fever, Mumps, Meningitis, Ery- sipelas, Carbuncle, Pneumonia, Rabies, Anthrax. Late investigations have shown that the one malady that in this country is responsible for more deaths than any other, tuber- culosis or consumption, is as communicable as smallpox, and can only be acquired through infection. Its period of incubation, or development, is longer than that of most infectious diseases, but it can be as certainly stamped out by disinfection and the use of anti- septics as can choleira, that former scourge, which in the light of our modern knowledge of bacteriology is now so readily con- trolled. Were there no means of resisting the invasion and growth of the special organisms which induce these diseases, and of impeding their multiplication, they would inevitably depopulate the earth. It has already been asserted that they are self-limiting in their proliferation, through their inability to exist in the presence of their own waste products. They may also exhaust the soil or medium in which they grow, and thus circumscribe their own multiplication. The most material factor in the prevention of the in- crease of the zymotic diseases is the resistive power of healthy animal function. Under ordinary circumstances, the human body successfully reacts against infection, and prevents undue proliferation of pathogenic organisms. If, however, the bodily tone is depressed through malnutrition, by unsanitary con- ditions, by fatigue or exhaustion, or because of functional disturb- ances, the resistive force of the body is so much weakened, and the conditions favorable to the growth of the disease fungi so BACTERIOLOGICAL PATHOLOGY. 1 3 augmented, that they multiply to an extent sufficient to bring about that pathological condition which accompanies their inva- sion. Conclusive experiments upon animals have demonstrated this. Rabbits are immune to tubercular infection under ordinary condi- tions. Twelve of these animals were selected; six of them were kept for some- time in a dank and noisome cellar, and insufficiently fed upon unwholesome food. The other six were kept in complete sanitary condition, in light and airy rooms, and were fed with the best food. At the end of a definite period each was inoculated with Bacillus tuberculosis. All of the first six took the infection and died of it; the six whose bodily tone had been preserved by pure air and good food retained their immunity, and successfully resisted infection. Twelve rats were selected, and six of them placed in a revolving wheel that forced them to run at a rapid gait for a considerable time. The other six were allowed to remain in a quiet place, where they would not be annoyed or irritated. When the first six had been forced to run until they were exhausted, all the twelve were inoculated with an organism from which under ordinary circumstances rats have exemption from infection. Those whose resisting powers had been reduced by extreme fatigue and exhaustion took the contagion and died, while the others were unaffected. The resistive power of the human body, according to Metch- nikofif, is inherent in the ameboid white blood corpuscles, which in a state of health envelop and digest the bacteria. When these are not fully formed in the system, when they are diminished in number or reduced in functional activity, the infective organisms may obtain such preponderance as to overcome all resistance, and run their course until they produce death, or become self-limiting through the formation of their own products and the exhaustion of the media in which they grow. The bacteria are greatly multiplied in the presence of any putrefactive or decomposing material. Hence all decaying matter should be destroyed as far as possible, by some quicker and more hygienic process than its decomposition by the fungi. Sanitary conditions imply the removal of all infective matter, and modern hygiene is mainly the study of how best to accomplish this. Such progress has been made within the past generation, that the 14 ORAL PATHOLOGY AND PRACTICE. average period of human life has been lengthened several years, almost entirely through the ability of sanitarians to control the multiplication of disease spores. CHAPTER V. SEPTIC AND ASEPTIC CONDITIONS. The state of infection by disease-producing, or putrefactive, organisms is called a septic condition, and whatever tends to combat this is said to be antiseptic in its character. A state of freedom from all degenerative organisms is an aseptic or sterile condition, and it may be brought about by various agencies, either of a physical or medicinal nature. As moisture is one of the elements necessary to the growth of the fungi, it may be readily comprehended that its entire emoval will stop all development. The proper degree of temperature is essential to growth, and the raising or lowering of this beyond a certain point will limit or prohibit it, a definite amount of heat being sufficient to destroy all organisms, and render sterile any substance whatever. There are also certain drugs that have the ability to destroy or prevent the growth of septic organisms. Those that are fatal to the bacteria and their spores are called Germicides. Those that limit and prevent their growth are classed as Anti- septics. Those that decompose or remove the by-products of infection are called Disinfectants. Those that either mask or remove the offensive smells of putre- faction are denominated Deodorants. The most effective of all the agents used for sterilization is heat. The temperature of boiling water (212° F., 100° C.) is fatal to many of the septic organisms. But as the spores of some of them may successfully withstand this, it cannot in all cases be de- pended upon. Continuous boiling for some time will be sufficient to destroy most of the organisms contained in water. Yet, if it is to be positively sterilized, it must be distilled. If an instrument is passed through the flame of burning gas, or of an alcohol lamp, it SEPTIC AND ASEPTIC CONDITIONS. 1 5 will be made positively sterile, but this is in some cases impracti- cable, because it will destroy the usefulness of steel tools by draw- ing the temper. The tissues of the body, and of most organic mat- ter, cannot be raised to a temperature sufficient to insure an aseptic condition, and hence we are compelled to depend upon germicides, antiseptics, and disinfectants in the treatment of septic conditions. Most germicides are to a greater or less extent antiseptic in their nature. That is, agents that have the power to destroy germs will also prevent their growth. Many of the antiseptics are at the same time germicides and disinfectants, and Z'ice versa. In the selection of drugs for medicinal purposes it is necessary to consider something more than their germicidal or antiseptic qualities. One that is a virulent poison cannot with safety be administered internally, nor can one that is a cauterant be used on delicate tissues. It is therefore necessary to comprehend the therapeutics of antisepsis, and to select the remedy to be used in full view of these facts. Pure germicides are not always demanded in actual practice. If a disinfectant is first employed to remove the products of sepsis, and to cleanse the infected tissues, antiseptics that will prevent further microbic action will ordinarily secure the desired end. The necessities and conditions of oral practice are such as to exclude many disinfectants, unless they are securely sealed up >vithin the cavity of a tooth. If they are of a caustic nature, they will induce complicating lesions. If they are specially toxic^ or poisonous, they may bring about serious derangements. Therefore, in their selection, the judicious practitioner will exercise great care, and choose those which, with the highest degree of efifectiveness in their special action, are at the same time innocuous to other tissues. In this respect car- bolic; or phenic, acid, a drug that has been in most common use in oral practice, is exceedingly objectionable. The following list of remedies, formulated by Prof. W. D. Miller from personal experimentation, and first published in the "Independent Practitioner," June, 1884, indicates their relative antiseptic power, but is not by any means intended as a guide for choice in administration. It gives the dilutions in which each will, under favorable circumstances, limit the growth of micro- organisms: i6 ORAL PATHOLOGY AND PRACTICE. Mercuric lodid, Mercuric Bichlorid, Silver Nitrate, Hydrogen Peroxid, Tinct. lodin, Iodoform, Naphthalin, Salicylic Acid, Oil Mustard, •Benzoic Acid, Potassium Permanganate, Oil Eucalyptus, Carbolic Acid, Hydrochloric Acid, Borax, Arsenic, Zinc Chlorid, Lactic Acid, Sodium Carbonate, Listerine, Alcohol, Potassium Chlorate, " 8 The disinfectants act chiefly through their ability to decompose offensive products. This is usually brought about by the presence of free oxygen, or that which is held in loose combination. Chlorinated solutions are effective through their ability to decompose water, thus setting free one or more vol- umes of oxygen, which is really the agent of decomposition. Hydrogen peroxid is very widely employed in oral practice, because it so readily parts with its extra volume of oxygen. Pyrozone is a more permanent and abiding preparation of nearly the same character. Electrozone, which is a decomposed solution of ordinary sea-water, is very effective, and has the advantage of being entirely innoxious. It may be swallowed, or used on the most delicate tissues, without ill effects. It is produced by an elec- trolytic current, which decomposes the chlorids and bromids of the salts, changing them into hypochlorites and bromites, and these are most effective disinfectants. Deodorants are not necessarily chemical agents. They may merely be able to absorb noxious matter. An excellent one I part m 2oo,oco " 100,000 11 50,000 a 8,000 a 6,000 " 5,000 (( 4,000 « 2,000 <( 2,000 i( 1,500 a 1,000 (( 600 <( 500 (( 500 « 350 (< 250 (( 250 ct 125 a 100 t( 20 ct 10 SEPTIC AND ASEPTIC CONDITIONS. I7 is pulverized charcoal, which has the power to absorb a number of times its own volume of deleterious gases. It thus acts also as a disinfectant. The deodorants most commonly employed by oral practitioners are drugs of such penetrating, though pleasant, perfume that they cover and mask the odors of putrefaction, though without in any way neutralizing or decomposing them. It is need- less to say that they have no special therapeutic value. Detergents are cleansing remedies which are some- times in demand. They have no particular medicinal virtue, but remove certain superficial deposits from tissue surfaces, or from wounds, ulcers, etc. Pure water is excellent for this pur- pose, or a solution of borax, of common salt, or of soap may be used. Suppuration is primarily the breaking down of the product of inflammation, and its infection by a special microbe. Whether the breaking down is due to the organism, or vice versa, was long a disputed question. Late investigations lead to the belief that it is infection that brings about the devitalization of the blood corpuscles and the production of pus, and yet it has probably been conclusively established that it is possible for pus corpuscles to be produced without the presence of bacteria. Such a condition is, however, unusual, and it does not present all the character- istics of the suppuration induced by pyogenic organisms. Ordinary pus is composed of certain nucleolar cor- puscles that are indistinguishable from the white blood cells, and which are supposed to be dead leucocytes, the extravasated serum of the blood, and such broken-down tissue cells as may exist in a certain state of degeneration. This material is found infected with certain pyogenic fungi. The formation and presence of pus is accompanied with the pyogenic fever, and its presence in the tisssues may also, under favorable circumstances, be determined by fluctuation beneath the fingers. When it is formed within the tissues it makes its way to the surface by the readiest route, that of least resistance, through the process of rotting or breaking down of the obstructing tissue, and forms an abscess. The process of suppuration is essentially one of extrusion, or expulsion of effete or dead matter. That inocula- tion, or infection of healthy tissue with the suppurative bacteria will induce the formation of pus and the ])roduction of an abscess is thoroughly estaljlishcd. Hence, in all curative processes it is 3 l8 ORAL PATHOLOGY AND PRACTICE. essential to use the utmost care to avoid infection; and all the modern methods of antiseptic surgery are built upon the ability to. control the growth of septic organisms. All of the pathogenic and pyogenic bacteria are very easily communicated, either by direct contact and contamination, or through their spores, which may be floating in infected air. Modern surgery is superior to that of a few years since in the re- sults obtained; surgeons have learned how to avoid and guard against septic infection. It is now known, for instance, that if erysipelas once makes its appearance in the surgical ward of a hospital, mere exposure to the contaminated air will be likely to induce er}'sipelatous inflammation in any patient, but especially those in an atonic or debilitated condition. Infection may be carried upon the hands, in the cloth- ing, or by instruments and implements. The surgeon who would now attempt even minor operations without the most strict aseptic precautions would be deemed unfit to practice his profes- sion. His hands must be most thoroughly washed, all impurities removed from beneath the nails, and they must finally be care- fully drenched with a sterilizing solution, that no contaminating fungi may be carried to a wound. Every instrument used must be kept in a sterilizing solution, and sponges and lints must be heedfully rendered non-infectious. The ordinary clothing must be covered with clean linen garments, that are less liable to carry infection than woolen, and every article used must be scrupulously clean. The operative dentist, or oral surgeon, needs to exer- cise especial care in this direction. There is no mouth that does not contain some species of bacteria. Indeed, the presence of some of them seems essential to perfect health, because they exercise a distinct diastatic function, and thus in healthy condi- tions may assist in the process of digestion. The human mouth presents all the conditions favorable to the growth of the bacteria, because the debris from different kinds of food, especially of starches, is always present. The diastatic action of the saliva converts these into fermentable sugars, and thus presents the best medium for the proliferation of very many of the bacteria. Moisture exists in sufficient quantity, and the temperature is exactly that best suited to their development, and it is main- tained at a point as constant as could be secured in the most inflammation: its general characteristics. 19 perfect incubator. Indeed, the human mouth is a more perfect growing-chamber for the breeding of germs than any that the ingenuity of man could possibly devise. Not only is the tempera- ture uniform and the media and moisture at the best, but fresh pabulum is constantly added, while the by-products are promptly removed and neutralized, so that there is no limitation of growth through their formation. The importance of every antiseptic precaution on the part of the practicing dentist cannot be over-estimated. He frequently meets with pus in the oral cavity, with gangrenous pulps in teeth, and his instruments are almost constantly infected with septic organisms. These may be deeply buried beneath the debris between the leaves of burs and the serrations of files, so that mere rinsing in a sterilizing fluid will not sterilize, and infec- tion of perhaps the most loathsome character may be carried to the mouth of the next patient, unless scrupulous care is used. It is something more than a professional blunder when an operator will work in the presence of pus, or any infection, without subse- quently cleaning and sterilizing in the most thorough manner every instrument employed, by means of a specially devised apparp;tus, and the use of disinfecting agents, such as bichlorid of mercury, carbolic acid, potassium permanganate, formalin, and other solutions. CHAPTER VI. INFLAMMATION: ITS GENERAL CHARACTERISTICS. A careful study of the etiology, symptomatology, and pathol- ogy of the inflammatory process is of the first importance to the student in dental medicine, because with bacteriology it forms the basis of most degenerative changes. Nor is it only concerned in retrogression. If hyperemia is accepted as one of the early stages of the inflammatory process, it is an important factor in many physiological and progressive metamorphoses as well. Wounds are healed and lesions repaired through its agency in some of its many phases; it is thus an element in the building up. as well as in the tearing down of tissue. There are emergencies in which the oral surgeon or physician desires to invoke its aid, and he some- times deliberately incites its action. But to rench the success at 20 ORAL PATHOLOGY AND PRACTICE. which he aims he must be able to control and limit it, to impede its action here and to further its energy there; at all times to check it before it shall reach a degenerative or infective stage. Unless the practitioner has a fair comprehension of this important process, he will always be at work in the dark, and his treatment of most diseased oral conditions will be wholly empirical. The student will not be able intelligently to investigate any of the dis- orders to which he hopes successfully to minister, without a careful preliminary study of inflammation. The most advanced of modern pathologists, while they have extended the field of observation, have materially simplified the nomenclature. They recognize many added phases which the inflammatory process may assume, but in the light of the most modern bacteriological research they acknowledge but one dis- tinct form, that being the infective. Up to the point of invasion by septic organisms they denominate the condition one of hyperemia. Until disease germs are communicated they declare there can be no breaking down of tissue, or of the elements of tissue. There may be failure to organize the embryonal constituents, but the disorganization of that which has been constructed can only take place after infection. Hence, according to their views, all of the early symptoms and phenomena which are usually classed as a part of the inflammatory process belong to hyperemia, and are indicative of a local plethora, or congestion. In this conception, and according to this nomenclature, inflammation is essentially a destructive process, and its initial point is the beginning of the disorganization of tissue. This hypothesis emancipates us from the old and absurd nomenclature, under which every different phenomenon exhibited by what must necessarily be a single process was given a separate name and classed as a distinct form of inflammation. Some writers have specified as many as fifteen kinds of this process, and treated each as a separate pathological condition. There has been no identity of view, and no harmony in description or terminology. There has been no universally accepted theory which might be adopted, but each pathologist has been in one sense a law unto himself, and has instructed according to his own views. If the most modern hypothesis shall be generally adopted, there is no doubt that it will materially simplify pathological instruction, and reduce to a comprehensible system much that inflammation: its general characteristics. 21 has heretofore been incongruous and unintelHgible. But in the preparation of a book to be used in teaching, extreme views should not be precipitately adopted. They are not likely to be in har- mony with the teachings of the other departments of a school, thev are in conflict with instruction already given and with preconceived ideas, and until they can be generahy adopted tend to produce confusion in the mind of the student, and are preju- dicial to that unity of theory and consecutiveness in thought Avhich are essential to good tuition. It is infinitely better that the student in college should be given but one hypothesis, rather than a number of conflicting theories. When he is familiar with that, he may in practical life leave its limitations and modifications, and become acquainted with other views. This work, then, while fully recognizing the reasonableness of the most modern theories concerning inflammation, will not fully adopt their nomenclature, but will follow the usually accepted views, modified to a certain extent by the indisputable facts estab- lished by the most modern research. Inflammation m.ay be defined as a disturbance of nutrition in a tissue or organ, primarily characterized by hyperemia and accom- panied by certain definite symptoms. Its immediate cause is irrita- tion of some kind, and its ultimate source is a nervous shock, manifested either directly or by reflex agency. Its primary mode of action is through the blood current, and the early changes induced by it are in the blood vessels. That the student may comprehend this, it is necessar)' clearly to define some of the terms used, and to indicate in what sense they are employed. Plethora is that state in which there is an abnormal fulness of the blood vessels; a superabundance of blood; an undue increase in the entire mass of the blood in the system. Anemia is the converse of this. It is a state in which there is a deficiency of the blood as a whole, but especially a lack of the red blood corpuscles, and hence a condition of depression of the tone of the system, and of enfeebled nutritive ability. Hyperemia is a local plethora or congestion of blood. Its special seat is in the capillaries. Ischemia is a local anemia. It implies a lack of nutrition in a part, as anemia does in the general system, because the supply of blood is for some reason insufficient. Hyperemia implies an alteration in the velocity of the 22 ORAL PATHOLOGY AND PRACTICE. current of the blood in both veins and arteries. It also includes a variation of the blood vessels in their character or tone, their nutritive power being modified. There is a change in the condition of the coats of the smaller arteries and veins; they assume a state either of tenseness or laxity that is not normal to them. They become turgescent. The color of the blood in the veins is changed, by modifications of nutrition. It is no longer of a dark or venous color, but more nearly approaches a bright arterial hue, due to its inability to perform its true function and exchange its oxygen for the carbon dioxid that is the result of the degenerations of tissue due to wear. There is a partial obstruc- tion of the current in the arterioles, and they may even begin to pulsate with the larger arteries. Both veins and arteries become distended with the increased flow of blood. The blood corpuscles are greatly increased in number and modified in tone. If the irritation that has produced this condition in the tissues is not continued, the disturbance will be but tem- porary, and will soon subside. The system recovering from the nervous shock, the blood vessels will soon regain their normal tone, the vascular fluid will begin to flow in its wonted manner, the congestion of the capillaries will be relieved, and the hyperemic condition will pass away. It has already been affirmed that it is the nervous shock produced by the action of some irritant w^hich induces the change in the condition of the arteries and veins that accompanies active hyperemia. Technically it is not the bullet in the heart that kills. It is the nervous shock caused by the irritating bullet. The knife stab injures certain tissues that are not vital. But in so doing it produces a nervous impression that is so profound as materially to interfere with the processes of life which are vital, function ceases, and that is death. It was not the wound that killed, but the markedly depressing influence which it induced upon organs themselves untouched. It is necessary to keep this distinction carefully in mind in the consideration of inflammation. Shock may be produced by either direct or reflex nervous action. By direct, ivc mean the irritation that is produced by actual injury to the terminal nervous filaments themselves. Thus a blow upon the cheek will induce a redness, or hyperemia in the capillaries of the tissue that received the irritation, and whose nerve filaments were really harmed. CHANGES ATTEXDIN'G THE IXFLAMMATORV CXINDITIOX. 23 By reflex ncrz'oits action, zve mean that in zcJiich the impulse is carried by one set of nenrs to another set. thus f^roduci)ig its effect at a distance from the seat of irritation. The influence of an irritant may be carried by an afferent, or sensory nerve, to some great center, where it will be transmitted to an efferent, or motor nerve, and the stimulus carried along its course until it reaches the tissue supplied bv it, and it may be upon this that the characteristic effect will be indicated. Or the effect of the irritating agent may be received by one aft'erent nerve and reflected to another of the same system, the subjective sensation, with the local effects, thus being made manifest at some distance from the point of injury. The blush that is brought to the cheek of the sensitive young maiden by an in- delicate remark is the same kind of transient hyperemia that is produced by a blow of the hand. Yet in the former case there is no real impact, no positive injury, no actual lesion of any kind. But the hyperemia will probably be more pronounced and marked than when the nervous action is direct. The face will blanch under the influence of fear, when no direct impact could produce this effect. The hair will stand erect through reflex action caused by intimidation, a state that no voluntary action could bring about. People drop dead at the communication of profoundly affecting news, which acts in a reflex manner. Indeed, instant functional cessation and death are more complete and frequent in cases of shock from reflex than from direct injuries. The influence of external and surrounding impressions upon sick people will not infrequently completely neutralize the effect of medicinal agents. Profound anesthesia cannot readily be obtained in peo- ple with unusually responsive nerves, unless external irritation and interference is cut off. It would appear, then, that of the sources of irritation that may produce hyperemic condi- tions, those that are derived through reflex nervous action are the more important, and should be most carefully guarded against. CHAPTER VII. CHANGES ATTENDING THE INFLAMMATORY CONDITION. The changes in the veins and arteries that induce a condition of hyperemia are produced through the vaso-motor nerves. These 24 ORAL PATHOLOGY AND PRACTICE. are derived both from the cerebro-spinal and the great sympa- thetic systems. They are the terminal filaments whose special function it is to govern and keep in proper relation the coats of the blood vessels to v^hich they are distributed. Upon the larger vessels they form intricate plexuses, sending out single filaments, or bundles of filaments, which twine about the vessels, penetrate their external coats, and are principally distributed to the muscular tissue of the vessel, and by their action in contracting or relaxing the artery or vein they govern the amount of the blood-flow. There are presumably two kinds of nerves in the vaso- motor system, one being the constrictors and the other the dilators. It will readily be seen, then, that either may be excited and the caliber of the vessel modified accordingly. Nor is the amount of blood necessarily and completely gauged by the question as to whether it is the dilators or the constrictors that are excited to action. There may be a lessening of the caliber but a retention of the elasticity of the muscular fibers that will result in a great increase of the velocity, and this may have a tendency to wash away any obstructions in the blood channels. On the other hand, there may be a dilatation with a loss of tone and a complete rigidity of the muscular coats that will eventuate in a reduction of the velocity as well as in the amount of blood conveyed. There may be a contraction of the vessel, with a con- dition of such tonicity as w^ill greatly augment the amount of the circulatory fluid carried, or there may be almost a complete stagnation of blood in a greatly relaxed artery or vein. It may be readily seen, then, that the tone of the walls of the vessels has very much to do with the blood supply. Through the reaction of the vaso-motor nerves, the very character of the coats of a vessel may be materially modified, so that instead of retaining their contents they allow a part to escape through the meshes. The dififerent coats may become so relaxed, that through their walls the red or the white blood corpuscles, or the serum of the blood, may readily exude, and so pass out into the surrounding tissues, infiltrating them and producing the symptoms which attend the condition that is commonly called the inflammatory state. All these changes must be massed in the consideration of the inflammatory process. The first stage is hyperemia^ or an increased blood supply through modification of the caliber of the coats of the blood vessels. CHANGES ATTENDING THE INFLAMMATORY CONDITION, 2$ The second stage consists in the further changes in the condition of the coats of the vessels, by zvhich they become so modified as no longer perfectly to retain all their contents. The third stage is the modifications produced in the tissues through the extruded contents of the blood I'csscls, for the blood having once passed out cannot enter fheni again, but must be otherzcise disposed of. This stage necessarily includes the degenerative processes taking place in the products of inflammation which result from infection. It should be comprehended that the mere change in the caliber of the vessel forms no necessary part of the inflammation, which may terminate with the simple hyperemia. But the third change, that in the vessels, which so modifies them that they no longer retain their contents, produces a more profound impression, and materially affects the tissues supplied by them. When this extravasated matter becomes infected with pathogenic or pyogenic micro-organisms, that impression is intensified, and degenerative processes are set up. This is an active state of inflammation, in which all the nutritive processes of a part are engaged. There are certain symptoms that are peculiar to inflammation and which always attend it in a greater or less degree. They are heat, redness, swelling, pain, and usually a general febrile condition. The first of these, heat, is due to a number of factors. The deeper portions of the body have a higher temperature than those that are superficial and are exposed to external cooling influences. When the blood quickly reaches the periphery it will lose less of its heat than when it makes its way more gradually. Hence, in the increased velocity of inflammation, the surface has more of the heat of the internal portions of the body. Again, this very velocity generates a certain amount of heat by the increased friction. There is also some increased oxidation, and this adds to the higher temperature. All of these factors together account for the increased local heat of inflanmiation. The redness is due to the hyperemic condition, the increased amount of blood in the part, and the unchanged color of the venous circulation. The intensity of the change will depend upon several factors. The amount of the local dis- turbance, the thickness of the superimposed tissues and their degree of translucency will all have an influence. Persons with thin, transparent skins show the superficial hyperemic condition much more plainly than others. 26 ORAL PATHOLOGY AND TRACTICE. The swelling is the effect of the diapedesis, or escape of the elements of the blood through the walls of the vessels, because of their changed condition under the irritation manifested through the vaso-motor nerves. The tissues are thus infiltrated and distended. The amount of this dilatation or extension will depend upon the nature of the tissue in which it takes place, and upon the character of the functional disturbance. The pain is the effect produced upon the terminal nervous filaments by the deranged condition, and the pres- sure of the exudate. Sometimes this will be of a throbbing eharacter, due to the pressure exerted by the arterioles at each heart contraction, or systole, upon the already irritated and sensi- tive terminal nerve filaments. Boring pains are usually connected with inflammations of bone tissue. Lancinating pains ordinarily accompany acute swellings, and are indicative of a ripening abscess. Soreness is due to the formation of an abscess cavity in a very sensitive tissue or organ. That of a boil, which is an instance of suppurative inflammation, is proverbial. The general fever is the result of the sympathy of other organs with that which is directly affected. It is the office of the nervous system to preserve the equilibrium of the various functions of the body. When this is disturbed by an aberration ex- isting in any organ, all the others suffer in a greater or less degree, and thus is produced a general feeling of malaise or discomfort. The causes which excite an inflammatory condition are divided into predisposing and exciting. Predisposing causes are special conditions of the body, which render the organs or tissues more liable to take on the pathological conditions. In the presence of predisposing causes, comparatively slight irritation may result in serious disturbances. A state of atony, or asthenia, or general debility, reduces the resistive force of the tissues and promotes the invasion of disease. Anemia is another predisposing cause, the poverty of the blood, or the lack of certain of its elements, seriously interfering with that nutrition which must maintain the general tone. The exciting causes of inflammation are very many, and include whatever may produce shock, such as cold, heat, traumatism or injttries, etc. A common cold is an inflammation induced by sub- jecting one part of the body to a sudden diminution of its tem- perature, and thus disturbing the general nervous equilibrium or FURTHER DEGENERATIVE CHANGES. 2/ tone. Many chemical substances are nervous irritants, either through direct or reflex action. Poisons act in this way, and these inchide the stings of bees, the bites of many insects, and the pecu- Har efifect of certain vegetables, such as poison ivy and oak. Many of flic patliogcnic micro-orgaius>iis induce a state of inflam- mation through their grozcfh in the system. All lesions, wounds, and injuries give a shock that is more or less profound, and thus bring about inflammatory conditions. A cachectic state, or dyscrasia, is either one of disturbed general nutrition, or of local degeneration, that makes the organs liable to inflammation, as in gout, calculus, etc. It has already been affirmed that a nervous shock that aflfects the vaso-motor system may so change the condition of the blood vessels as to permit the escape of a portion of their contents. John Hunter recognized the intimate connection of the blood current with inflammatory processes, and declared that hyperemia and con- gestion were their initiative stages. Less than thirty years ago, Cohnheim published the results of a series of observations that gave the world a new insight into the pathological changes that ac- company this disturbed condition, especially in the earlier modifica- tions. Other pathologists have carried the explorations further, and some of them have dissented from a part of the conclusions of Cohnheim, but his general deductions are accepted as correct by most pathologists. CHAPTER VIII. FURTHER DEGENERATIVE CHANGES. If the mesentery of a frog is exposed to the air and placed under a microscope, it will be seen that the flow of blood in the capillaries is greatly augmented. They are distended, and many that had been invisible are by this dilatation brought into view. The leucocytes, or white blood corpuscles, are gradually increased in number. Regions in which there normally appears only an occasional one, soon become thronged with them. The increased velocity of the current lasts but a short time, when the flow begins to be retarded, and is soon slower than the normal, the distention still remaining, A partial stagnation succeeds, and the white corpuscles begin to accumulate in the small veins and arteries, and 28 ORAL PATHOLOGY AND PRACTICE. show a tendency to cling to the walls. They are swept back into- the lessening current, but soon find another point of attraction, and finally remain attached to the lining surface. They soon become so enormously increased that the inner surface of the vessels is completely covered with them. In the capillaries and arteries the white corpuscles are mingled with the red, and do not accumulate in such great numbers, but in small veins they seem to have become separated from the red and to cling in greater numbers. Soon they begin to alter their appearance, and to exercise their peculiar ameboid, or spontaneous change-of-form movements. The vessel wall remaining distended, after a little time there is ob- served upon its external surface a minute protuberance, which momentarily increases, the cell opposite upon the internal wall correspondingly diminishing, until it is seen that the whole of the jelly-like protoplasmic leucocyte has penetrated the walls, and been extruded upon the periphery. At the same time with the changed condition of the vessel walls, other of the contents have passed through and invaded the surrounding tissues. Some of the fluid portions of the blood — ^the liquor sanguinis, composed of serum and the substances that go to make up fibrin — are found in the irritated tissues. The fibrinous elements spontaneously unite and form fibrin, and mingled with these will be found the leu- cocytes. These last have been considered as the active agents of repair, themselves forming the initial or germinating point in the organization of the plastic exudate into tissue. This hypothesis seems most consistent with known facts, and offers a ready explan- ation of some phenomena not otherwise comprehensible. It is but proper to say that this theory is not accepted by some histologists and embryologists, who consider the leucocytes but as scavengers for the removal of offensive matter. That the leucocytes have a digestive power, appropriating bacteria, has been shown by a number of observers. They may also be useful in consuming portions of broken-down tissue, and hence assist in the absorption of blood-clots, exudations, etc. But that this is their sole office does not seem congruous or compatible with demonstrated truths, and it is not accepted in this connection. The number of leucocytes is notably increased during inflam- mation. They may be seen to gather in great numbers in the smaller vessels, and they migrate in profusion into the surrounding tissues. Their origin is yet in dispute. It was formerly held that FURTHER DEGENER.\TIVE CHANGES. 2<) their multiplication was due to increased cell proliferation or for- mation under the stimulus of the inflammatory process. But Von Recklinghausen found in connective tissue two kinds of cells, wdiich he called the fixed and the wandering. The former he says are stationary among the fibers of the intercellular substance, and are round, or spindle shaped. In addition to these he observed other cells, in all respects resembling the leucocytes, which take on spontaneous changes of shape by means of the extension of a portion of theii' jelly-like substance (pseudopodia — false feet), such as are characteristic of the ameba, and hence called ameboid move- ments. By means of these mutations they constantly changed their location, passing through the riieshes of the lymph canals, entering from the blood and escaping through the lymphatics, thus keeping up a constant circulation. In normal tissues they were few in number, but in the presence of irritation or inflammation they were inordinately multiplied. This is the generally accepted theory of to-day. The wander- ing cells of Von Recklinghausen are the white blood corpuscles, which even in entire health are escaping through the walls of the blood vessels in small numbers, and by their ameboid movements they traverse the tissues until taken up by the lymphatics and carried out. Their probable generation is in the lymph glands or nodes, the spleen, etc., and in inflammatory conditigns they are enormously increased, and are carried by the blood to the disturbed territory, whence they readily pass into the tissues through the changed condition of the vessel walls. Their multiplication in an inflamed tissue is in proportion to the violence of the disturbance. Corresponding to this increase in the number of the white blood corpuscles in the tissues is the extravasation from the blood vessels of the fluid portions, or the blood plasma. The fibrinogen which this contains, coming in contact with the lerment, or paraglobulin of the leucocytes under their changed condition, fibrin is formed, and the lymph is coagulated or fixed in the tissues. The product thus formed, with the emigrated blood cells, composes that which is known as the "plastic exudate," and it is the progressive or degenerative changes in this substance that constitute the further phenomena of inflammation. The plastic exudate once having been formed in the tissues, it may assume such a complete fibrination, such an entire conversion into a dense compact fibrin, as to produce that which is called an 30 ORAL PATHOLOGY AND PRACTICE. induration. This at times assumes to the fingers ahiiost the hard- ness of bone. In inflammation of the tissues about the jaws it is not infrequently mistaken by the novice for bone, and a wrong diagnosis is accordingly made. It may be immovable, without special sensation or pain, and apparently closely attached to the osseous tissue. In this form the plastic exudate is persistent and indolent in its character, and does not readily degenerate nor assume a progressive aspect. It may disappear under the slow process of gradual resorption, or it may eventually break down. CHAPTER IX. THE PRODUCTS OF INFLAMMATION. The methods by which the plastic exudate, or the coagulable or fibrous lymph, and the remaining products of inflammatory condi- tions may be disposed of, are by (1) Resolution, (2) Building up, (3) Tearing down. Resolution means the taking up of the products by the absorbents, and their disposition through the lymphatic system. There is a cessation of irritation, the blood vessels return to their normal condition, exudation ceases, and there is a gradual return to a true physiological state, as there is when hyperemia alone exists and the disturbance does not extend to the point of active inflam- mation. Building up of tissue means that the plastic exudate has been by regular progressive changes organised into tissue of an embryonic character. The methods of this metamorphosis are — (a.) First Intention. — This implies a regular progression from the commencement, without any degenerative changes whatever. No pus is formed, nor is there infection by micro-organisms. The term "healing by first intention" is usually applied to wounds, either traumatic or surgical, especially to those of an incised character. If the gaping produced by the elasticity of the tissues is closed, and the severed parts brought into nice coaptation, either by stitches, adhesive plaster, or finger manipulation, the fibrin that is formed by the plastic exudate agglutinates or cements them together, and union without any violent or disruptive inflammation may ensue. This can only be secured by thoroughly THE PRODUCTS OF INFLAMMATION. 3I aseptic conditions, and it is this at which all surgeons aim in their treatment after operations. ■ (b.) Granulation, or Second Intention. — This is the building tip of the tissue, or the organization of the exudate by means of papilkc, or grain-like grozvths, that spring up from the base of healing wounds. It is a progression cell by cell, instead of organization more in mass. Capillary loops are formed in the extravasated plasma, which as it is poured out will be found shielded by a kind of transparent glistening film, that protects it until the lost tissue has tfeen restored, and the skin shall have been formed over it. This new growth is known as granulation tissue, and is always of a cicatricial or elementary character. The new formation is primarily of the connective tissue variety, and is subsequently modified into that of which it forms a part. The organization of the tissue, when it proceeds without any degenerative processes, may be clinically studied in the socket from which a tooth has been extracted. The cavity will at first be found filled with coagulated blood, which effectually seals the mouths of the ruptured vessels. Within a very few days at the most, this will have been sloughed away, and the socket of the root will be found occupied by a kind of translucent, jelly-like substance, which is very easily wiped away with a pledget of cotton. If it is left undisturbed a short time longer, it assumes a firmer consistency and becomes opaque and of a whitish color. This is the plastic exudate that has been efifused. It now cuts like gelatin, and has the same general appearance. Another day, and if it be divided with an excavator or the point of a sharp bistoury, a minute drop of blood will ooze out. This indicates the formation of blood channels within the mass. There is no continuance of blood flow, for circulation has not yet been estab- lished, but minute sinuses have been formed, and they are filled with sanguinary fluid. In yet another day or two these will have become connected with the blood channels of the surrounding tissues, and a form of circulation will have been established. The exudate is now firmer, and cuts like new, partially formed carti- laginous tissue. The mucous membrane and epithelia form over it, and it assumes the appearance of the surrounding gums. Then commences the process of calcification, and soon the knife feels the grating of formative bone. Calcification proceeds until the cavity is completely filled with well-organized bone tissue. This 32 ORAL PATHOLOGY AND PRACTICE. peculiar form of healing by first intention will not be observed except in cavities that are well protected from external violence. If this kind of formative tissue in its early periods of develop- ment is examined under a microscope, it will be found filled with small round cells, which gradually assume a spindle form, and the deepest layer will be found composed of bundles of them. This is a part of the process of the formation of embryonal tissue, which gradually is developed into that of a more perfect type. The cicatrix is connective tissue that has contracted in the course of its formation, and which thus tends to draw together the 'edges of a wound, but which may be so excessive as seriously to inter- fere with function, as is the case in extensive burns. The surgeon accomplishes this coaptation of the borders of wounds by means of sutures. When by means of a continuance of the irritation the inflam- matory process is exacerbated, or when new sources of irritation are introduced, the healing process is interfered with and the plastic exudate, instead of being organized into tissue, loses its integrity and is broken down, involving the investing tissue. This may be by (1) Suppuration, (2) Gangrene, (3) Necrosis. Suppuration is the formation of pus. The exudate, from con- tinued irritation or from a lack of nutrition, loses its organizing power, becomes infected by pyogenic micro-organisms, degen- erates, and forms pus. The leucocytes, or white blood corpuscles that have migrated to the inflamed territory, die and become the characteristic pus corpuscle. The plasma melts down and is mingled with the extravasated serum of the blood.- The tissue in the immediate neighborhood is infected, degenerates and breaks down, and a pus cavity is thus formed. Pus is essentially a foreign substance, and Nature puts forth her utmost efforts to expel it from the system. The pressure is considerable, and the tissue in the line of least resist- ance yields and becomes disorganized, thus extending the pus cavity, usually toward the periphery or some natural cavity of the body. This continues until it is discharged upon the surface and an abscess is formed. The determination of this destructive process toward the place of exit is called the "pointing" of the abscess. If the irritation has now ceased, as in the case of the extru- sion or removal of some foreign substance that was in the tissues, THE PRODUCTS OF INFLAMMATION. 33 the process of healing commences, and may proceed by granula- tion until the lesion has been completely restored. If the irritant is not carried away by the first suppuration, the process will be repeated. In alveolar abscess arising from irritation and infection of the pericementum of a dead tooth, the plastic exudate will be efifused about the point of infection, only to be infected in its turn, and to break down with new formation of pus. At first these pointings will be periodical. They may be precipitated by any general inflammatory condition, and follow upon the so-called taking of a cold. After a time the condition becomes chronic. There is a steady effusion of the exudate, and it is as regularly infected and broken down, and thus an almost continuous dis- charge of pus from the sinus formed is the result. Pus was formerly classed as laudable or healthy, serous, sanious, ichorous, etc. We now know that the thick, creamy, opaque, yellowish discharge, which was formerly denomi- nated laudable pus, is the uncontaminated, undecomposed dis- charge from a healthy person, or from a surface in the process of normal healing. Ichorous pus is the thin and acrid ejection from an ulcerative surface, or is that which has passed through a second degenerative process. Sanious pus is that i^'hieh is mixed ivith blood, and zvhich partakes of the nature of both. It is usually an indication of a destructive action, and of the cellular sloughing that accompanies the breaking down of tissue. It may be ichorous in its character. Serous pus is that zvhich is mixed zvith serum from the blood. It differs from sanious pus, in that it is more simple in its nature, and is not an indication of putrefactive changes. • Muco-pus is that zi'hich is mixed zvith the secretions of the mucous glands. This is probably but an accidental complication, and the character of the pus is not thereby materially changed. It does not imply that there has been any secondary infection with destructive organisms, or any putrefactive degenerations. Gangrene is also knozvn as mortification, and zvhen sloughing takes place, as sphacelus. It is the cessation of all nutrition in a territory more or less considerable and circumscribed, zvith a conse- quent loss of function and death in mass. Its origin may be in a traumatism or wound, in a local cause like thrombus or embolism, in continucfl pressure either external or internal, in the too free 4 34 ORAL PATHOLOGY AND PRACTICE. use of certain drugs, such as ergot, phosphorus, mercury, or carbolic acid, and finaUy in constitutional causes, such as diabetes or anemia. It is usually divided into moist and dry, or senile, gangrene. When the degenerative changes which succeed loss of nutrition in a part have commenced, there may be an infection with certain bacteria of decomposition, and the whole territory become highly aseptic. The tissue is in a putrefactive state, and auto- or self-inoculation in other tissues may be the result. In addition to these septic conditions of gangrenous degen- erations, the disease may be the direct result of infection. There are special types, due to the activity of micro-organisms, that have long been distinguished as phlegmonous erysipelas, malignant edema, hospital gangrene, noma, etc. Hospital gangrene is now almost unknown, its disappearance as a separate affection being- due to our increased knowledge of septic conditions, and to anti- septic precautions and treatment. Dry or senile gangrene presents a very marked difference in its objective appearance to the moist type. As its name indi- cates, it occurs usually in old people, being seldom found in those under fifty years of age. It is usually caused by arterial disease or degeneration, through which the circulation in a part is cut off. The part being deprived of blood, the moisture is lost by evaporation, and there is a consequent shrinking and wrinkling of the tissues, which produces that peculiar appearance called mummification. If from the outset putrefaction is prevented, the type of gangrene is always dry. This affection may usually be readily diagnosed. The pecu- liar appearance of the tissues, with the odor of putrefaction, in moist gangrene, and the coldness, dryness, and pallor of dry gangrene, seldom leave the surgeon in doubt as to the nature* of the affection. Necrosis, ivhich in its general signification means the death of a part, may be properly used to include gangrene. In its surgical employment the term is nozv restricted to death of the hard or bony tissue. It is the analogue of gangrene in soft tissues, and it has the same general etiological origin. It is the stoppage of the nutritive currents, with the consequent death of the part. From the nature of the tissue in which it exists, its progress is nat- urally slower than is that of gangrene, but the tendency is the same, and it should end in the sloughing away of the dead part GEXER.\L TREATMENT OF INFLAMMATION. 35 from the living. When such a necrosed portion of a bone is thus separated, it is called the sequestrum. Of all the bones of the body the inferior maxillary is most apt to take upon itself necrosed conditions. This is partly because it is more subject to accidents than most bones, but chiefly because from its pecu- liar connection with the rest of the body, its great mobility and the constant and violent uses which it is made to subserve, nutri- tion is the more readily interfered with. About three cases of necrosis of the lower jaw occur to one of the upper. It will be seen, from a retrospective view of the preceding statements of the condition called inflammation, that it is, as was affirmed at the outset, the initial point of very many changes in the body, of a physiological as well as of a pathological nature. It commences with simple hyperemia, and ends with the final disposal of the plastic exudate by either progressive or retro- gressive metamorphosis. It is the result of an irritant, which produces a more or less profound impression upon the tissues through the nervous shock. The vaso-motor system is so dis- turbed as to modify the conditions of the blood vessels in the neighborhood of any lesion, and to permit the passage into the tissues of their contents, through diapedesis. This extravasated matter is the plastic exudate that is either organized or disorgan- ized, and it is the result of the earlier stages of the inflammatory process. The termination of inflammation, then, is either in the building up of the plastic exudate into new tissue, by first intention or by granulation, or in its degeneration and tearing down by suppuration, gangrene, or necrosis. The final result depends upon the degree of the lesion or injury, upon external sanitary or unsanitary surroundings, upon constitu- tional tonic or atonic conditions, and upon the ability to maintain the circulation practically unimpaired. CHAPTER X. GENERAL TREAT.MENT OF INFLAMMATION. The treatment of inflammatory states will necessarily he largely general in its character. The various remedies to be employed may be classified as follows: 36 ORAL PATHOLOGY AND PRACTICE. For the heat — Reduce the temperature by refrigerants. For the swelling — Use compression : apply bandages. For the hyperemia — Use depletion: leeches, cupping, etc. To produce metastasis — Counter-irritants, blisters, etc. To relieve circulation — Cathartics, diaphoretics, diuretics. To equalize the circulation — Hot pediluvia (foot-baths). For the fever — Febrifuges, antiphlogistics. For the pain — Sedatives, anodynes, local anesthetics. To promote suppuration — Warmth, moisture, poultices. The first remedial measure to be employed will of course be the removal of the caijse of the irritation, provided this can be definitely ascertained. The next will be to give rest to the parts. The latter is best secured by immobility and entire repose. All use of the afifected organ should cease, and it should be placed in the easiest position possible. Saline cathartics may be adminis- tered, with the view of relieving the tension of the blood vessels by a depletion of their watery contents. Diuretics are useful for the same reason. If a laxative only is desired, Seidlitz powders may be prescribed, or -mild doses of castor oil. For a saline cathartic, Epsom or Rochelle salts (magnesium sulphate, sodium tartrate), or cream of tartar (potassium bitartrate), may be employed. But still more eflicacious are diaphoretic remedies, because they not only remove the water of the blood and tissues but act as refrigerants, through evaporation from the surface. They also tend to depuration by opening the pores of that great eliminative organ, the skin. Dover's powder, or spirits of Min- dererus, with warmth and diluent drinks, may be used. In general forms of inflammation, febrifuges, such as potassium chlorate, quinin,- antipyrin, and antifebrin, should be administered, and the general hygiene should be carefully looked to. If there is general irritation, sedatives, either arterial or nervous, as may be indicated, should be given. If the inflammation shall have proceeded to the point of effusion of its products, early efforts are usually directed toward bringing about resolution, or absorption of the lymph. Local cupping or bleeding may be useful, although the best means for securing local depletion will usually be by the applica- tion of leeches. These agents, which have of late been almost entirely abandoned, will often prove of greatest efficacy. In addi- tion to the general remedies recommended, counter-irritants may GEXERAL TREATMENT OF IXFLAMMATIOX. 37 be employed. These induce a change in the location of the inflammation by metastasis, or the production of a new point of irritation, with the consequent transference of the seat of diseased action. Park recommends in forms of phlegmonous "infiltration the application of an ointment composed of resorcin 5, ichthyol 10, mercurial ointment 3, and lanolin 50 parts, as a sorbefacient and antiseptic preparation. This in connection with moist heat may even secure the actual resorption of pus. If there is local swelling, it may sometimes be controlled by bandaging, which prevents further effusion and promotes the absorption of that which has already taken place. It is not, however, usually convenient to apply a bandage or excite much pressure upon any of the oral tissues. If there is considerable local heat, it may be controlled by the application of ice, or by the ether or alcoholic spray. If neither resolution nor building up of tissue seems possible or probable, efforts should be directed toward the promotion of suppuration, thus relieving the tissues of the products of the inflammatory process. It is here that the oral physician or sur- geon will have an opportunity for the exercise of his best judg- ment, and all his experience will be needed in making his prog- nosis, to determine the exact point at which the treatment should be changed. To ascertain when the degenerative process has begun, requires the nicest perception and discernment. In inflammation of the dental pulp, for instance, to know when it is no longer wise to attempt to preserve its vitality, and when devitalization and extirpation are advisable, in view of positive degenerative changes that are imminent, requires a thorough knowledge, not only of the whole inflammatory process, but of the symptomatography of all the lesions and complications as well. The breaking down of tissue having already commenced, or being plainly inevitable, suppuration should be hastened, that the more destructive processes of gangrene and necrosis may not supersede it. Poultices should at once be employed in the direc- tion in which it is desired that the abscess shall break. This promotes suppuration by extending such favorable conditions as are afforded by a maintenance of the temperature, the continued presence of moisture for the softening of the tissues, and the dila- tation of the vessels. Any poultice that will secure this will suffice. 38 ORAL PATHOLOGY AND PRACTICE. although if it is of a fermentative substance, that process will assist in the weakening of the superincumbent tissues. It is not convenient to use for oral application the poultices commonly employed in general medicine. A freshly cut fig or a split raisin may often be applied when no other can, and they act very effectually. They should usually be softened and warmed by dipping in hot water. They are pleasant to use in the mouth, and when one piece becomes too much softened another is readily substituted. They will usually be held in place by the facial muscles. There are certain general remedies that promote suppuration under definite conditions, but they are little adapted to oral prac- tice. In the treatment of inflammation the aim should always be, after diapedesis has taken place, to relieve the tissues of the exu- date material, and to promote healing when there has been any traumatic wound or lesion. Whenever pus is present it must be promptly evacuated. There ^ is no precept in practice that is so imperative as the one which instructs the practitioner at once to get rid of pus. There is no surgical risk that one is not justified in taking if this product can be eliminated in no other way. It is always irritative, always degenerative, in its influence. Sometimes a mere puncture will evacuate it, at other times a serious operation is demanded; but, whether simple or complicated the means of elimination, it must not be permitted to remain. Some judgment may be required in securing perfect drainage if an opening is made, and this demands that the artificial sinus shall be at the lowest, most dependent point when the body is in its natural position. Drainage tubes may be demanded; or gauze, catgut strands, or other media may be used to keep the opening patulous. These may be retained in position "by strips of adhesive plaster. After evacuation the pus cavity should be cleaned and disin- fected with hydrogen dioxid, pyrozone, or some other effective antiseptic or disinfectant solution. The utmost care should after- ward be exerted to keep the cavity clean and aseptic, if proper heal- ing after the discharge of the broken-down infiltrate is to be secured. DISEASES OF THE GUMS. 39 CHAPTER XI. DISEASES OF THE GUMS. The* gums are largely made up of fibrous tissue covered by mucous membrane. In their normal condition they are of a deli- cate pink color, and are dense and hard. They invest the teeth closely, and are adherent at their cervical portion. They are not especially sensitive, and in the absence of the teeth most kinds of food may be crushed upon them without great discomfort. Any departure from this general appearance or state is a pathological condition that demands attention from the dentist or oral physi- cian. Local irritations, inflammations and hypertrophies, or hyperplastic conditions of the gum tissues are, however, too seldom recognized, or if noticed are not accorded proper treatment. That which should form a considerable proportion of the practice of every dentist is sadly neglected. Inflamed, irritable, turgid gingivae, loosened from their attachment to the teeth so that the point of an explorer can pene- trate some distance beneath their free margins without resistance, with degenerated, atonic, congested blood vessels that discharge their contents at the least irritation, are so common as to excite little comment, and the patient is dismissed without the proper professional advice or remedial attention. These same unfaithful practitioners perhaps bewail the multiplication of dentists, and insist that our schools should limit the launching of new graduates upon an already crowded profession, because there is not enough of practice for those already in, while themselves neglecting a large proportion of the field that should be covered. Properly to care for the disregarded conditions of the mouths of the people of this country would more than employ the time of all the dentists now existing. The proper remedy for a stream that overflows its banks is to widen and deepen its channel, instead of attempting to dry up its waters, and there are unoccupied fields within the province of dentistry not only as yet uncultivated but almost unexplored. Local irritation is the cause of most of the inflammations and hypertrophies of the gums that are so commonly met with. Usually this is due to lack of care on the part of the jialient. Foreign mat- ter is deposited at the cervical portions of the teeth, and this by its excitant action stimulates the tissues to abnormal activity. The 40 ORAL PATHOLOGY AND PRACTICE, consequence is an overgrowth, an hypertrophy or hyperplasia of tissue. This may be confined to a single tooth, or it may be more widely diffused and involve nearly or quite the whole of the denti- tion. The tumefaction will be especially pronounced in the gum covering the septum between the teeth, where the irritation is greatest. If there are carious cavities, not infrequently they will be completely filled with hyperplastic tissue, connected with the rest by a slender pedicle. The margins of the gums will be thick, everted, and of a deep red color, almost approaching a purple. There may be a breaking down of the tissue with pus formation, entirely distinct from that condition called pyorrhea. The mucous follicles of the gums are in a degenerative state, and their secretion no longer properly lubricates the tissues, but adds to the disturb- ance by its perverted character. These conditions arise as the effect of local irritation due to the presence of foreign substances, rough projecting fillings, or deposits about the necks of the teeth. Diagnosis is not difficult, for the very existence of the disturbance indicates the presence of exciting agents. The first curative measure to be adopted obviously is the removal of any local deposits or foreign substances. Nor is it sufficient to do this superficially. Wherever there is any undue amount of tissue or tumefaction, beneath it, perhaps at the very edge of the alveolar walls, will be found some- thing foreign. It is absolutely essential that the instrument used should penetrate to the very point of attachment, beneath the inflamed tissue, and to this end one that has a chisel edge, adapted to a pushing motion, will be most effectual, for anything thicker will not reach to the very extremity. It should not be forgotten that the most mischievous irritant matter is that which lies deepest, and nearest the point of actual attachment of the pericementum to the tooth. Minute spicules of calcific matter are those which cause the greatest disturbance. Whether these have their origin in the fluids of the mouth, or of the circulatory system, whether they are salivary or sanguinary, local or constitutional, their operative treatment is the same. That such deposits of hard, sharp, segregated granules beneath the gums differ from the ordi- nary tartar or salivary calculus that is precipitated upon the supra- gingival portions of the teeth must be patent to everyone, but DISEASES OF THE GUMS. 4I whether this divergence is due to its derivation, or merely to the manner and place of its deposit, we need not now inquire. Certain it is that its removal is more difficult than that of ordinary salivary calculus. It perhaps will not be detected without the exercise of considerable care, for it sometimes exists in minute spicules that would be invisible even if not covered by the inflamed gum. A solution of trichloracetic acid, of from twenty to fifty per cent, will greatly aid in the removal of these deposits. It may be carried on the edge of a sharp, wedge-shaped piece of orange wood that has been dipped in the solution. While the acid does not remove the deposits by dissolving them, it will loosen their attach- ment to the teeth, and soften them enough to facilitate their removal with the scaler. At the same time the remedy acts as a slight cauterant, inducing a slough of the superficial parts of the degenerative tissue, and reducing the inflammatory condition by its astringent and alterative action upon the distended, congested capillaries. A solution of lactic acid has been highly recommended for the same purpose. The patient should' be directed to use fre- quent massage of the gums with the ball of the finger, and the per- sistent use of a soft tooth-brush should be insisted upon. The mouth should be gargled and the gums washed with a solution of twenty grains of chlorate of potash to the ounce of water, and if necessary a solution of chlorid of zinc may be prescribed for oral use. If there is a great deal of bleeding, tannic acid may be rubbed upon the gums with the finger. If, as is probable, an antiseptic wash is needed, a solution of boroglycerol in water, one part to ten, may be used as a wash or with the brush. It will not usually be wise to attempt the removal of the deposits from all the teeth at one time if many are afifected. The medicinal treatment needs repeating at intervals of a few days until the condition is changed, and it is well at each of the visits to explore still further for irritating substances. An indica- tion of their existence and their locality will be found in the local persistence of the inflammation. Any red, irritable point of hyper- trophied gum will be found to cover the cause of irritation. Of the inflammations arising from loose or ragged teeth it is unnecessary to speak. The removal of the source of irritation will be sufficient. The gums beneath ill-fitting plates frequently become tumefied, and sometimes sloughing ensues. This is 42 ORAL PATHOLOGY AND PRACTICE. especially the case with rubber plates, not because they generate any heat, but because they are non-conductors and the tissue beneath them is not subjected to the same variations of tempera- ture as the other and surrounding tissues. The condition may sometimes be found beneath metal plates that are not adapted to the mouth, if they are worn continuously, but there is not the same degenerative lack of tone in the blood vessels that is found beneath rubber dentures. The congestion is usually less intense, and sloughing is more infrequent. The cure for this condition will be found in the construction of a proper denture, and its inter- rupted use. No artificial plate should be allowed to remain in the mouth over night. The tissues should be given that opportunity for rest and the recovery of their normal tone. CHAPTER XII. • STOMATITIS. The word is derived from the Greek "stoma," a mouth, and the termination "itis," inflammation, so that it implies an inflamma- tory condition of the tissues of the mouth. The term is a very broad one, and may be made to cover very diverse conditions. Its application, however, is usually restricted to the mucous ' mem- brane and the soft tissues in immediate relation with it. It is very common in infants among the lower classes of foreigners espe- cially, and is usually due to bad hygiene or unsanitary conditions. Especially is this the case with those that are artificially fed instead of being nursed by the mother. Either the food is of an improper character, or the nursing-bottle is not often enough scalded or boiled out to prevent the growth of fermentative organisms, and the milk used is thus infected. The rubber nipple and tube are often the source of irritation to the oral tissues. The rubber under the influence of light and heat rapidly commences decomposition, and thus becomes the means of poisoning the mouth. Or it may harbor destructive fungi, and these are especially irritating to the mucous membrane. Follicular Stomatitis, the simplest form, is an inflammation of the mouths of the mucous follicles. It is either accompanied by or will bring about degenerative changes of the mucosa itself, and this STOMATITIS. 43 may add materially to the irritation. Perhaps but a portion of the surface may be affected, and the membrane presents a punctate appearance — fiecked over with red points. With the iiicrease of the inflammatory condition more of the follicles are involved, until the patches become confluent, and the whole surface is tumid and ttirgid. In this condition the tissues of the mot;th look hot, dry, and red. The mouth becomes sensitive, and the child shrinks from its examination. There will, in the earlier stages, be an excessive slavering, or flow of watery saliva. There will be more or less of febrile disturbance, and the bowels will probably be irregular, a constipated condition predominating. During a later stage the secretions of the follicles become yet more depraved and no longer give the normal lubrication to the parts. The de- generation spreads to the connective tissue, the mouth becomes dr\' and parched, the blood vessels are congested and active nutri- tion is interrupted, the congestion reaches the point of stasis, or stoppage of the circulation, and sloughing commences. Acute Stomatitis may be induced by improper feeding, aside from unsanitary conditions. The infant that is fed with a food that it cannot digest will be poorly nourished, and all kinds of degenerations may be established. The irritative condition of the digestive tract may produce diarrhea and gastric disturbances which by mere continuity of tissue may extend to the oral mucous membrane, and an ulcerative stomatitis may be established as the result of the atonic, innutritive state, and the spread of the inflam- mation from the irritated digestive tract. Ulcerative Stomatitis is merely an advanced stage of the first condition. The mucous follicles become so degenerated that their functions quite cease, and cracks and fissures open in the unlubri- cated tissues. All the preceding symptoms are aggravated. The child cannot without great difficulty take its food, and what is ingested affords little nutriment, because of the gastric disturb- ances that are always present. There is a constant swallowing of offensive matter from the mouth, with a wasting diarrhea or dysen- tery. About this time the submucous tissue will perhaps become thickened and indurated in spots. Sometimes there will be ptyal- ism, with a great flow of watery saliva succeeding the dried condi- tion of the oral cavity. The submaxillary gland may become ten- der and tumid. Small vesicles may appear in the mouth, seem- 44 ORAL PATHOLOGY AND PRACTICE. ingly filled with a, watery serum. These burst and form an ulcer, with a dirty-white slough. The child becomes greatly emaciated, and there is excessive swelling of the oral tissues. The breath becomes very offensive, and the ulcers show a considerable slough- ing. Unless speedy relief is obtained, the child will soon succumb through lack of nutrition, as well as to the infectious products of the septic condition. Aphthous Stomatitis is a form that may attack people of almost any age, and is characterized by some special appearances. Small round or oval ulcers appear upon the reddened mucous membrane of the lips, cheeks, tongue, or gums. They are from one to three lines in diameter, very little depressed, with a yellowing or white floor, and a red, narrow, perhaps slightly indurated, border. Sometimes two or more of them become confluent, thus forming an irregular, large ulcer. When these heal they leave no cicatrix. Usually there is an increased flow of saliva accompanying them, the mouth is hot and feverish and the tongue heavily coated. Sometimes the saliva excoriates the skin and the lips are thus kept constantly sore. Thrush is a form of stomatitis occurring in children and depend- ent upon the growth of a parasitic fungus. This consists of long, jointed threads, the Oidium albicans, which seems to belong to the family of the molds. Thrush appears to be contagious. On look- ing into the mouth of young infants a layer of thin white mem- brane may perhaps be seen covering the palatal arch and appearing as white spots upon the tongue, while the mucous membrane about or at the borders of this coating seems to be in a healthy condition. Thrush in children is apt to be a sequela of chronic diarrhea, prolonged starvation, exhausting fevers, or any severe and debili- tating illness. It is indicative of and usually accompanies a low, atonic condition, and its cure will depend more upon feeding than medicines, first allaying any gastric or intestinal irritation. Noma, Gangrenous Stomatitis, or Cancruni Oris, is a kind of ulcerative stomatitis, hut as the term is usually epiployed it implies a specially vicious degenerative condition, dne to infection by a peculiar bacillus. The preceding remarks are more especially applicable to in- fantile stomatitis. The same or analogous conditions may be induced in adults by like causes. Anemic and poorly nourished TREATMENT OF STOMATITIS. 45 persons are especially liable to inflammations of the oral tissues. The lips are dry and parched, and superficial fissures and cracks in the mucous membrane appear. In a less degree this will be ob- servable upon the tongue, the buccal surfaces, and in the vault of the mouth. This may continue for some time, until finally, with the progression of a general febrile state, a more active stomatitis is developed that may result in a local breaking down or ulceration. Neglect of the teeth and the mouth tissues is a fruitful source of stomatitis in adults. Food is left to ferment and putrefy, and the products of this action will be exceedingly irritative to the soft tissues, as well as destructive to the hard. There will always be gingivitis present in the mouths of those who do not give proper attention to the removal of foreign substances from about the teeth, and this, by continuity of tissue, may spread all over the mouth. Usually the action of the saliva upon the portions freely washed by it is suf^cient to keep them clean and normal. But between and about the teeth, where food remains for an indefinite time, in the absence of proper care the gums are always irritated and more or less congested, and this may spread to adjoining tissue, with the result of an acute stomatitis in atonic conditions. CHAPTER XIII. TREATMENT OF STOMATITIS. In infantile affections the very first measures to be adopted necessarily imply an inquiry into the food and feeding. If the child is artificially fed, the nursing-bottle should be carefully inspected, and the food that is given must be scrutinized. If there is anything unsanitary about either, it must be at once corrected. The rubber nipple and tube must be sterilized, or, what is better, discarded and substituted by a new one that has been made thor- oughly aseptic. If the child is poorly nourished through improper or insufficient food, that must be remedied, and plenty of nutritious matter that can be readily digested and assimilated should be given. If there are diarrheas or other wasting disorders, which will too often be the case, they must at once be attended to; it will be impossible to build up a patient while any process of waste is going on. All unhygienic surroundings must be remedied, and 46 ORAL PATHOLOGY AND PRACTICE. the patient should be given plenty of light and air, and proper exercise. In short, beneficent Mother Nature, upon whom we must finally rely for a cure, must be afforded every opportunity. Functional activity must be promoted, and all obstacles removed. After securing perfect sanitation the local treatment will be mainly depurative and stimulative. If a cathartic is indicated, two drams of castor oil may be administered. For the local irritation, a mouth-wash consisting of a solution of five to ten grains of chlorate of potash to the ounce of water may be used as a gargle. If the child is too young to use this itself, a swab may be made by tying soft linen to a stick of proper dimensions, and this may be used to apply the solution, employing a proper degree of friction. If the mouth is sore, it may be applied with a soft brush. The mouth may be occasionally washed out with the following preparation, especially after eating: 5 — Borax, 30 grains; Sodium bicarbonate, i dram; Distilled water, 4 ounces. Or the following may be substituted in its place : 3J — Boric acid, Potassium chlorate, of each 15 grains; Lemon juice, J/^ ounce; Glycerol, 6 drams. If an antiseptic is needed, a solution of listerine, one part in ten parts of water, may be used in the same way, or it may be administered internally when diluted with simple syrup. Or the following may be prescribed: IJ — Listerine (Lambert's), 2 ounces; Glycerol, i dram; Water, to make 4 ounces. Sig. — A teaspoonful after nursing or feeding. If there are cracks in the tongue or fissures in the cheeks, a solution of borax and honey may be used locally, made by adding one dram of borax to each ounce of clarified honey. If there are deep erosions of the mucous membrane, or ulcera- tive surfaces, it may be necessary to cauterize them, either with silver nitrate, pure carbolic acid, or chromic acid crystals. The last named are preferable in instances in which they can be con- veniently used. The cauterized places should be subsequently dressed with a solution of calendula. TREATMENT OF STOMATITIS. 47 The treatment of follicular, or ulcerative, stomatitis in adults does not materially differ from that in infants, except that more active measures may be used. The reme- dies may be proportionally increased in strength, and personal care insisted upon. The teeth should be thoroughly cleaned, and all broken or sharp edges removed. A soft tooth-brush should be employed after every meal, and with it should be prescribed some antiseptic wash. A two per cent, solution of zinc chlorid may be used as a gargle. At night a spoonful of Phillips' milk of magnesia should be taken into the mouth and rinsed about all the teeth, to be left upon them until the morning. Enough of good nourishing food should be given, and the patient should have plenty of pure air and sunshine. There is a form of ulcer that is the result of the careless appli- cation of arsenous acid in the devitalization of teeth, which may be referred to in this connection. Arsenic is a corrosive poison. It produces its characteristic effects in destroying the pulps of teeth, not through congestion and the production of consequent stasis at the apical foramen, because it will promptly kill the pulp of a partially developed tooth in which the root is entirely open, no foraminal constriction having yet been formed, and in which strangulation is therefore impossible. When arsenous acid is insecurely sealed up in the cavity of a tooth, such a defective agent as a solution of gum sandarac being employed for that purpose, it may come in contact with the buccal tissue and devitalize that, gradually eating its way in until a considerable slough is pro- duced. When this is the case, the ulcer should be thoroughly satu- rated with dialyzed iron, to limit the action of the arsenic. It should then be dressed with a solution of calendula, and kept clean and aseptic until it has healed. Should the corrosive effects be manifest between the teeth, and reach to the alveolar bone, it will probably induce an osteitis that may end in caries or necrosis. When this is the case, the affected bone should be promptly burred away before using the dialyzed iron. In Gangrene, or Noma, or Cancrum Oris, thorough cauteriza- tion or removal of the affected tissue will probably be necessary, and the strictest antiseptic precautions must be employed. For the general symptoms constitutional treatment must be taken. Tonics should be employed, with fresh air and a sufficient amount of 48 ORAL PATHOLOGY AND PRACTICE. exercise. Every possible effort should be made to promote nutri- tion, and especially that of the locally affected tissues. In fact, when stomatitis reaches the point of deep ulceration or extensive breaking down of tissue, it is such a grave condition that general constitutional treatment should not be delayed. Sometimes the pulps of teeth assume a gangrenous condition. When this is the case, there is great danger that septicemia and pyemia may be the consequence. Miller details a number of cases within the sphere of his own observation, in which death within a very few days has been the result of the gangrenous infection of a tooth pulp. When the symptoms of general septic poisoning are manifest, no time should be lost in the institution of the proper general remedial measures, the consideration of which is beyond the scope of this work. In cases of thrush in infants that are badly or insufficiently nourished, there is usually more or less of gastric or intestinal irri- taLion in connection with the markedly atonic condition. This will probably require the administration of such correctives as rhubarb and soda, lime-water, and vegetable bitters. When the aphthae occur in older persons they are often spoken of as "canker spots," or "canker sore mouth." The usual treatment is roughly to cau- terize the spots, and dress them with a solution of calendula. If an active cauterant is not desirable, as in children, the aphthous patches may be repeatedly touched with the following solution: 3? — Sodium salicylate, i dram; Distilled water, ' 6 drams. Or in place of the preceding this may be used : IJ — Borax, 45 grains; Sodium salicylate, 75 Tinct. myrrh, i dram; Simple syrup, Distilled water, of each Yz ounce. If the aphthae exist in considerable numbers, they may demand the use of antiseptic mouth-washes. If they are the consequence of a general anemic condition, tonics and alteratives are of course indicated. While they are peculiarly uncomfortable, the aphthae have no serious pathological signification, except as they are in- dicative of an atonic condition. PHARYNGITIS AND TONSILLITIS. 49 CHAPTER XIV. PHARYNGITIS AND TONSILLITIS. There are many pathological conditions of the oral cavity, and of the immediately connected tissues and organs, that should fall within the province of the oral physician or dentist, but which are usually relegated to the general medical man. When the time shall come in which no man will be allowed to enter upon oral practice who is not thoroughly qualified to treat all oral condi- tions, dentistry will occupy a very different place in general esti- mation from that of to-day, and there will be plenty of room for all the competent men whom it will be possible for the colleges to turn out. At present, diseases of the pharynx are usually sup- posed to be beyond the scope of the dental practitioner. And yet there are no specialists to whom such affections should so naturally fall, and there are none who have such opportunities for observa- tion and detection of pharyngeal lesions. It but needs that these shall be brought within the limits of his practice, and that he shall properly qualify himself for their treatment, to bring great benefits to both the dentist and the people. The pharynx is a poiicli, largely aponeurotic, which is divided into tzi'o parts by the soft palate. It has seven openings — that of the mouth, the two Eustachian tubes, the larynx, the esophagus, and the two nares. Its diseases are mainly those of the mucous membrane. There is no more common alTection than angina simplex, a common sore throat, the effect of that inflammation that we call a cold. It is accompanied with irritation, huskiness, and pain in swallow- ing, and its remedy is in cleansing, antiseptic, and anodyne gar- gles, a solution of chlorate of potash being that most commonly used. A large proportion of pharyngeal affections are the direct results of lesions within the oral cavity, brought about by con- tinuity of tissue. There are certain diseases of the tonsillar glands that are not included in this origin, and there are inflammations dependent upon laryngeal lesions as well, but a considerable number of the aflfections are due to oral trouble. Complications arising from impactions of the wisdom tooth and its investments are one of the most frequent of these. Owing to a lack of develop- ment, especially in the length of the body of the lower jaw, fre- 5 50 ORAL PATHOLOGY AND PRACTICE. quently there is not sufficient room for the eruption of the tooth, and it becomes imbedded in the tissues, a constant source of irri- tation. Sometimes the inflammation about it is so intense as to prevent the opening and closing of the mouth. At times there is a breaking down of tissue, and suppuration ensues. From the initial point of the lesion, dark-red lines extending down into the pharynx may be observed, and there is a distinct and sometimes an acute inflammation of the pillars of the fauces, with great dis- comfort, or even acute pain. In cases of cleft palate there are almost always com- plications involving the anterior and posterior nares. When these are presented to the dentist he usually proceeds to the construction of some prosthetic apparatus for the purpose of supplying the loss, without any preliminary attention to the soft tissues themselves. In all cases of complete or incomplete cleft, the pharyngeal walls, as well as those of the nasal cavity, are in an irritable, inflamed, hyperemic state. This could not well be other- wise, because they are not protected by the usual palate, and are subjected to the irritating action of food and drink every time it is taken. Not infrequently there are excoriations and abrasions of the edges of the palatal cleft, with degenerative conditions of the mucous membrane of the posterior nares that require active treatment. The oral physician or surgeon seldom notices them, because they do not form a part of the regular practice to which he confines himself. Inflammations of the pharyngeal tissues, arising from the changes in the neural currents commonly called "taking cold," are quite common. If the tongue is depressed by placing upon it a broad spatula, the whole pharyngeal cavity will appear of a bright-red color, with the parts considerably swollen. The uvula will appear lengthened and pendulous. There will be a dryness in the fauces, with huskiness of the voice and con- siderable pain on swallowing. The Eustachian tube will appar- ently be closed, and the hearing will be materially affected. These simple follicular inflammations usually result in a ready resolution, but their time may be cut short by proper remedial measures. If there are no abscesses or deep erosions, hot pedi- luvia should be resorted to, with saline cathartics and diaphoretics. The latter class of remedies is of importance, and a general diaphoresis will usually greatly hasten a cure. Twenty or thirty PHARYNGITIS AND TONSILLITIS. 5 1 grains of potassium bromid, with five drops of tinct. veratrum viride, may be taken in a small glass of water, when the patient should go to bed and cover up warm. A gargle of chlorate of potash may be used if the attack is not very acute. If there is any infection, an antiseptic gargle, such as a teaspoonful of phenol sodique in a glass of water, or five grains of chlorid of zinc to the ounce of water, may be employed. If there are excoriated surfaces they may be touched with a cauterant. Tonsillitis. The tonsils are sometimes severely attacked by parenchyma- tous inflammation. Where this is comparatively slight, a careful examination may be necessary to distinguish it from some forms of pharyngeal inflammation. But there are instances in which the tonsils become so greatly inflamed as to prevent swallowing and to impede breathmg, and active scarification becomes a neces- sity. Usually, however, the swelling may be allayed by a phenol- sodique gargle, or one of which sodium bicarbonate forms the base. If there is much pain the tonsils may be painted over with a cocain solution. If suppuration ensues despite all measures to prevent it, the pus should be voided as soon as possible, and the usual antiseptic treatment follow it. In tonsillitis of an especially acute character Prof. F. J. S. Gorgas recommends the following prescription: R — Acidi gallici, gr. xl; Liq. soda; chlorinatse, oij ; Glycerol, oij ; Aquse dest., oviij. M. Sig. — To be used as an antiseptic and astringent gargle. It should not be forgotten that the tonsils are frequently marked with deep sulci and furrows, especially if they have been the seat of repeated attacks of septic inflammations. These de- pressions form favorable harbors for the proliferation of different forms of pathogenic and saprogenic bacteria. When this condi- tion is observed, great care should be exercised to keep the exter- nal surfaces of the glands in an aseptic condition, lest the sup- purative condition commonly called quinsy becoine chronic. 52 ORAL PATHOLOGY AND PRACTICE. CHAPTER XV. DISEASES OF THE TONGUE. Properly read, the appearance and superficial condition of the tongue is an index to most gastric and to many other general dis- turbances. In health it is of a delicate whitish pink color, smooth and moist. Any departure from this appearance indicates a patho- logical condition, not necessarily of the organ itself, but of others whose disturbed state is reflected upon the tongue, and especially of functional aberrations which interfere with digestion. It may be covered with the so-called "fur," which is a coating made up of the epithelial scales that have not been thrown off, of certain gran- ular matters, of inspissated or degenerate mucus, and of detritus. The investment of the tongue with this coating always commences at its base, and gradually invades the dorsum until the tip is reached. The clearing up of the tongue during convalescence is from the tip and borders toward the base, so that the progress or recession of this coating will furnish an index to the condition of the patient from day to day. A furred tongue is a symptom of a defective circulation. In addition there are certain well-established appearances that are indicative of special pathological conditions : Extreme humidity — Indicates atony, with anemia. Extreme dryness — Nervous irritation or weakness. Flabbiness or tremuloiisness — Extreme weakness. A grayish ivhite color after eating — Normal digestion. A yellowish zuhite — Acidity, with biliary irritation. Very zuhite, thick coating ("flannel mouth") — Intense venous congestion. A delicate pinkish red — Digestion completed. A deeper hue of red — Arterial congestion; irritation. Very deep dark red — Active inflammation. Bright red, raiv or gLa.ccd — Approaching fatal exhaustion. Brozvnish red, zuith thick dry coating — Prostration; danger. Black, not a deep hue — Blood poisoning ; pyemia. Bluish tinge — Cyanosis ; lack .of oxygen. The indications upon the tongue of a dangerous condition are tremulous action, extreme dryness, blueness, a very red, shining or glazed aspect, and heavy furring of a dark or black hue. DISEASES OF THE TONGUE. 53 In considering- the tongue as a diagnostic organ, however, its indications are not to be depended upon alone. Its appearance should always be studied in connection with other symptoms, which may dominate the decision. It is to be considered only as an important auxiliary in arriving at a conclusion. Of itself the tongue is subject to many pathological conditions. It is manifestly impossible within the limits of a work like this to consider all these, or to do more than to note those degenerations that are of greatest interest to the oral specialist. The remainder more especially belong to the general practitioner. Glossitis, inflammation of the tongue itself, whether sympa- thetic or idiopathic, belongs to the first-named class. When it is the result of some injury or traumatism, it especially appeals to the oral practitioner. The tongue may be wounded by the careless use of instruments, and great inflammation may be the result. An excavator or bur that has been used in a gangrenous tooth pulp may wound the tongue and cause alarming symptoms as the result of the septic infection; a very short time may suffice to cause such an intense infiltration that suffocation will appear imminent. The swollen tongue may fill the mouth to the utmost point of distention. The general system may sympathize and the pulse grow rapid, a feverish condition supervene, and a state ensue that causes the most intense anxiety, from the alarming symptoms presented. An acute glossitis will usually, however, end in complete reso- lution without such startling symptoms. It may be necessary, and it is usually advisable, to administer an active cathartic, and to promote diaphoresis by means of potassium bromid, or spirits of jMindererus, with warm drinks. If there is a septic wound it should be opened to its bottom, to permit the escape of any infec- tious products. If the swelling assumes dangerous proportions, no time should be lost in making deep incisions into the body of the tongue. These should not be long or continuous, but merely deep punctures with a bistoury, and as many as may seem indi- cated. Syphilitic ulcers, swellings, cracks and fissures, indurations, hypertrophies, etc., are comparatively common, but their consid- eration need not engross our attention at this time. Injuries from the teeth are not uncommon, and sometimes 54 ORAL PATHOLOGY AND PRACTICE. undoubtedly result in degenerative conditions of the gravest char- acter. The tongue is continuously irritated by the sharp edge of a decayed or broken tooth, and a thickening of the tissue, with induration, follows, even though the mucous membrane is not broken. The irritation being kept up, the scirrhosis increases until there comes a time when it breaks down in the center, an indurated border yet remaining. This may present the appear- ance of syphilitic gummata, and may have consequences almost as disastrous. No dentist should leave in the mouth any such tooth, if it falls under his observation, for it may result in a serious com- plication. When such a thickening is found all source of irrita- tion should be removed, and if it does not disappear it may be necessary to remove it by surgical interference, lest it assume a malignant form. If an eroded ulcer is the result of such a sharp tooth, and if upon removal of the cause it presents an indolent appearance, a chlorid of zinc wash of not more than ten grains to the ounce of water may be used, or one made by the addition of a little compound tincture of capsicum in water. Violent, or drastic, or surgical measures should not, however, be lightly resorted to. Plenty of time should be given for nature to bring about a cure, and general measures, like tonics and alteratives, should be resorted to, lest too active local inter- ference bring about the verv state that it is desired to avoid. CHAPTER XVL DISEASES OF DENTITION: GENERAL CONSIDERATIONS. The fact that a considerable portion of the human family die before they have reached the period at which the last of the deciduous teeth shall have been erupted, and that the period of greatest mortality is that during which the teeth usually make their appearance, has led to the popular belief that the one is necessarily dependent upon the other; that dentition is the cause of the high death-rate among children, instead of being coinci- dental. That it is possible for a retarded or disturbed dental development to induce very serious derangement is indisputable, but that it is a principal factor in inducing the great number of DISEASES OF DENTITION. 55 deaths that occur in children can scarcely be maintained. There are manv cogent reasons for the contrary belief, while there is nothing, save the mere fact of coincidence, to sustain the theory too commonly accepted without inquiry or consideration. There is a lack of comprehension as to the true character of the diseases that cause this high death-rate in children. Digestive derangements are not the main factor, and yet, if we except ner^-ous disorders, these are the only ones that can with propriety be urged as the possible result of disturbances in dentition. Statistical summaries nowhere give the cutting of teeth as a cause of death. The following tables will be found very instructive in the study of infant mortality. They are derived from reliable sources, and are presented in the hope that they will afford assistance to those who desire to investigate for themselves, rather than to obtain all their information at second-hand. The traditionary instruction given in medical schools is that the teeth are a very important factor in producing the high death-rate of infancy. It is the imperative duty of dentists to examine the facts, and to inquire if this hypothesis is not founded in error, due to insui^cient study and knowledge, like that other assump- tion of certain medical authorities, that pulpless teeth are the principal source of disease of the maxillary sinus, and a continual menace to health. Percentage of probability that a child born alive i^'ill die of different diseases. Phthisis 1 144 Diphtheria 0049 Diarrhea and dysentery 0343 Brain diseases 1218 Typhoid 0381 Lung diseases 2640 Scarlet fever 0300 Stomach and liver diseases... .0524 Whooping-cough 0151 Heart disease and dropsy 0766 Measles 0128 Kidney diseases 0149 This shows that diseases of the lungs, which include phthisis, are the most fatal, and that more than twice as many people die of brain disease as of stomach troubles. Mean age at death of people dying from 7'arioiis diseases. Males. All causes 28.2 Whooping-cough 1.7 Measles 2.5 Croup 3.1 Females. Mean. 30.8 295 1.8 175 2.8 2.7 3-2 3-15 Females. Mean. 8.1 7-9 5-6 5-4 10.6 11.9 14.9 134 32.4 314 32.8 34-3 41.4 40.6 48.8 45-8 57-2 58.6 56 ORAL PATHOLOGY AND PRACTICE. Males. Diphtheria y.y Scarlet fever 5.2 Smallpox 13.2 Diarrhea 1 1.8 Cholera 30.4 Erysipelas 35.7 Rheumatism 39.8 Influenza 42.8 Carbuncle 59.2 This table indicates that the diarrheas are not confined to childhood, but that they are also destructive in middle life. Average infant mortality in different countries. Percentage of the population dying under five years of age. Norway 17 France 31 Ireland 17 Prussia 32 Denmark 20 Holland 33 Scotland 20 Austria 36 Sweden 20 Spain 36 England 26 Russia 38 Belgium 27 Italy 39 This table shows that in the warmer and more thickly popu- lated countries infant mortality is greater than in those lying farther north, and' which have fewer people to the square mile. In this connection the following table will be of interest: Death-rate per 1000 under increase of the population to the square mile. Population to sq. mile 166 186 379 1,718 4,449 12,357 65,823 Death-rate at all ages 16.94 19.18 21.90 24.81 28.02 32.96 38.67 Under 5 years 37-8o 47.53 63.06 82.10 94.04 111.90 139.52 This table shows that with an increase in popiilation the death-rate in young children is very much greater than in adults. Number of births in the several months of the year in different countries, 100 being considered the general normal average. France. Germany. Spain. Italy. January 105 103 114 107 February iii 105 108 114 March 109 103 112 no DISEASES OF DENTITION. 57 France. Germany. Spain. Italy. April io6 loo 102 106 May 99 97 100 95 June 95 95 89 89 July 96 96 88 91 August 96 98 91 93 September 97 106 98 100 October 95 100 100 98 Xovember 97 100 97 98 December 95 99 100 97 It is only in the older countries that these statistics, which are compiled from government records, are kept. In America the census reports have not until lately been thus complete. The lesson to be learned from these presentations is, that while birth- rates do not widely dififer, the death-rate is subject to many contin- gencies. • The diseases of which children mostly die are not those which could be materially influenced by the cutting of teeth. Xo one will claim that dentition could be active in increasing the number of deaths from contagious disorders, like measles, scarlet fever, and whooping-cough. As has been already stated, nowhere is the cutting of teeth statistically given as the direct cause of mortality. Although it may in some instances induce death through some other complication, its influence is too insignificant to be included as a separate cause. All these facts should lead us to give close scrutiny to the assertions of those who claim that any considerable number of infants die from cutting teeth. A distinction should be clearly drawn between the so-called diseases of dentition, which may be digestive disturbances, and those that are actually produced by mal-development of the teeth, whose pathological history is quite different. The former class of derangements may properly belong to the general practitioner, while the attention of the oral pathologist should be more particularly directed to the latter. But as it is essential that both should be comprehended to make a clear diagnosis, each must in turn be considered, and they will for con- venience be divided into the "so-called" and the "true" disturb- ances of dentition. 5o ORAL PATHOLOGY AND PRACTICE. CHAPTER XVII. THE SO-CALLED DISEASES OF DENTITION. Those which we may deiiommate imputed diseases of dentition are the diarrheas, dysenteries, and fevers of infancy, which are true digestive disorders, and instead of having their etiology in the advancing teeth, arise from improper feeding during the period of most active development. All growth, whether in the vegetable or animal kingdom, is by alternate periods of activity and repose. In plants, winter is the season of rest and of the gathering of forces for the season of advancement. With the spring comes the period of growth, when the organism assumes an extraor- dinary energy. The leaves are put forth, and each twig shoots out with an amazing activity. The whole growth of a year is then made within a few weeks. But the tissue so developed is soft and succulent, without the woody structure that gives it strength and consistency. The summer, when increase and exten- sion have ceased, is devoted to the maturing and consolidation of the newly formed material, while in autumn all the energies of the plant are employed in perfecting the fruit or seed by which the preservation of the species is insured. The growth of the plant is analogous to that of the animal. Vegetable physiology does not in essence differ from that of the sentient being. The latter has also its periods of increase, of active expansion, and those devoted to the matur- ing and perfecting of that already formed. Many people have observed that children, after a period of seeming suspension of development, will within a few months add an inch or more to their stature. This is succeeded by another term of rest, when the tissues pass through a process of maturing. It is well known that during these terms of rapid growth young persons are more liable to injuries and illnesses of different kinds than they are either before or after them. It should not be forgotten that the teeth, like the other organs of the body, have their distinct eras,, and that they develop with the rest of the body, and not inde- pendently of it. When the child is cutting its teeth, at the same time it is practically getting a new stomach and new digestive organs. Local causes aside, if the muscles do not develop, the THE SO-CALLED DISEASES OF DENTITION. 59 jaw and teeth will not grow, for all are dependent upon the same digestion and assimilation of food. In the newborn infant none of the tissues are suffi- ciently developed to perform independent function. The muscles of the legs will not support its weight, and those of the arm are not sufficiently advanced to give it controlled action. The nutritive apparatus is as yet so imperfectly organized that it cannot fully digest food, and the child must be given pabulum that is already partly prepared for assimilation. It finds this in the greatest perfection in the milk of the mother, in which all the elements necessary to growth are held in solution in a condition exactly adapted to the state of development of the child. At birth this milk is less highly organized than it will be six months later. When the physician seeks for a wet-nurse for a newly born infant, he does not choose one whose child was born months previously, because her milk would be of such a character that the w^eak organs of the young babe could not finish its digestion. The milk of one who has been a mother for two months would be too highly organized for the babe of a week. Nature has made all provision for the regular development of the child, and as its digestive organs become better developed the milk of the mother changes accordingly, until by regular progression, through successive advancing periods of growth, the various organs are sufficiently perfected for independent existence, and food that is partially digested is no longer a necessity for healthy functional action. This will only, in normal conditions, occur when the other organs are as far advanced as the digestive tract. The muscular system will have enough strength to enable the child to perform necessary motion. The brain and intelli- gence will be adequate to the proper selection of its food, while the teeth will be in a sufficiently advanced state to prepare the pabulum that is proper for its condition. As after this the body gradually develops, so that more highly organized food becomes a necessity, additional teeth are given, the small ones of childhood are succeeded by those larger and stronger, until with the period of full puberty the dentition is completed simultaneously with the perfection of the other organs. Unless the regular graduation of food keeps pace with the evolution and progressive growth of the organs, all the processes of nature are deranged, function is interfered with, and disease is 6o ORAL PATHOLOGY AND PRACTICE. the result. If the young child, with its digestive apparatus but httle developed, is given food too highly organized, indigestion, with its consequent vomitings, diarrheas, and febrile disturbance, will be the result, and it is here that the "so-called" diseases of dentition have their origin. With the advent of the deciduous incisors, the muscular system is sufficiently advanced to allow the child to sit erect, and in the average family it is taken to the table at meal-time. The injudicious or ignorant mother places in its mouth some soft food, fit only for adults. The instinct of the child teaches it to reject the offered dainty. The sense of taste has not yet been wholly developed, nor will it be normally until the organs are sufficiently advanced for full digestion, and the morsel is ejected with a wry face. But the mother persists, and after a time it is swallowed. Perhaps a morbid, abnormal appetite is stimulated, much as later in life one for whiskey or tobacco or opium is acquired. The bolus having been swallowed, it must lie in the ele- mentary stomach as undigested as if it were leather or rubber. It is perhaps regurgitated, and thus expelled from the system. If the bad feeding is persisted in, this means of rejection is soon exhausted, and the foreign matter remains in the stomach, a continual irritant, until it is violently passed through the pyloric opening and into the tender duodenum. Thence, by its irritating- action as a foreign substance, it induces the violent peristaltic movements which, when kept up by the successive irruptions of the irritant, become a pronounced diarrhea, possibly to degen- erate into a dysenteric condition, with final death. And this, because it occurs about the period when the teeth are erupting, is ascribed to dentition. As well might puberty in the male be imputed to the growth of the whiskers, because they begin to appear at about this time. It is essential that the oral pathologist should have correct views upon this subject, and hence some time must be devoted to its consideration. There are a number of cogent reasons why the prevailing belief among physicians that diarrheas and other digestive disturbances are due to advancing teeth is erroneous. In the first place, their connection is remote, while that between the diarrheas and improper feeding is so close that the probabilities are greatly in favor of it as the cause, even on other than physiological grounds. THE SO-CALLED DISEASES OF DENTITION. 6l The growth of the teeth is as much a physiological process as is that of the hair or nails. Their development commences some time before birth, and continues for a long time after it. The mere erupting of the organs is but an incidental step in the process, and by no means its most significant or important one. Why should the growth of the teeth not induce disturbances of nutrition before birth, if it does after? The so-called diseases of dentition are confined to a comparatively small portion of the year, and that is pre- cisely the period when a change in the food of infants is most liable to be made in the average family, while denti- tion goes on all the year alike. There are as many teeth cut in January as in July, but the so-called diseases of dentition are as a hundred to one. This is abundantly demonstrated by the accompanying diagrams (see pages 62 and 63), which represent the mortality of the city of Buffalo for three years. What is true of that city is true of all others, except as the tables for the different months may be a little modified by latitude. From November to May, in the northern temperate zone, the death-rate of children from diarrheas and other digestive disturbances is about the same with each month. With the latter month it begins to rise, shoots upward with an amazing increase during June, and reaches its highest point in July. In August it falls slightly, rises a trifle in September, and then falls as rapidly during that month and October as it rose in June and July, again reaching the low point in November, where it remains until the succeeding May. This is more or less true of all cities. Statistics show that the rule is general, but it is especially appli- cable to the poorer people, and the diarrheas and dysenteries are most fatal in the wards and districts in which they chiefly live. The diet of the average workingman's family is necessarily restricted in its character during the winter. In April may be seen by the wayside, and in the yards and in fields, his wife and children gathering the early herbs, dandelion, plantain, and others, to boil for greens. These form a welcome change of diet and are appetizing. What is grateful to their own palates, they argue, must be good for the baby, and it is fed from the family dish. Digestive disturbances commence, and they are intensified by giving it other early vegetables, and perhaps stale fruit. There is a period of incubation of the disease; it gradually increases in intensity, and 62 ORAL PATHOLOGY AND PRACTICE. Table I. Death-rate, -from All Causes, of Children under Three Years, in the City of BniTalo, for the Years 1888, i88p, and i8go. (The^interrupted line indicates the average temperature, the continuous line denoting the rise and fall of the death-rate.) AV. TEMP. JAN. FEB. MAR. APR. MAY JUNE JULY Aur,. SEPr. OCT. NOV. DKC. DEATHS 72° 378 70° '^' .° 364 68° /N 350 66° / / \ 33t) 64° ;4= '327 .« 322 62° n .aV . 308 60° / / \ >o 294 58° 1 / \ \ 280 56° 1 / \ 266 54° h' / \ \ 252 52° 1 \ 238 50° 1 2 >5 Y 1 224 48° r r -« — \ 210 46° 1 w- t 196 44° 1 1 179 I » \ V 182 42° 1 A I V \ \ 168 .— 1°:.. • __• ,„„„ B •_ .y^ "A 1/ veifAc f rfoi 'Zt*£^ '\\f7> >yrx. -L54.., 38° i^ l£ \ V39 a 140 36° i30_ J-i^ 1 1 126 34° IZS 1 < K ^w^ 112 32° / 112 \ 98 30° 1 1 \3I ' 84 28° f '>" 70 26° 527 -a / 56 24° V' 42 22° ^24 28 20° 14 THE SO-CALLED DISEASES OF DENTITION. 63 Tarle II. Mortality from Diarrheal Diseases in the City of Bntfalo for the Years 1888, i88q, and iSgo for the Months Named. (The interrupted line indicates the average temperature, the continuous line denoting the rise and fall of the death-rate.) AV. TEMP. MAY JUNbl JULY AW<.. SliPT. OCT. NOV. DKATHS 70' 4^ 2 217 69 = /v 210 68= f 1 \ \ -'03 67 = - / \67» [96 66= / IS9 65^ As" \ % 182 64° 1 V7A \ 175 63° 1 \ \ [68 62= 1 \ \ [6[ 61° 1 \ \ 154 60° 1 \60«» 147 59' ( 140 58= f « t 1 133 57' 1 I 126 56= f 1 1 * 119 55' • t I 1 \ % 112 54' 15^° \ . 105 53' \ \ 9S 52' \ I t 91 51' \" \ \ 84 50' \ 1 / / 49' , \ % 70 48' ' \ \ \ 63 47' \ 1 »47<' 56 46^ 49 45° \ % 4-' 44' \36» 35 43° 1 28 42° > 2-^ i 21 41' y V 14 40= -r' \v 7 39' ^390 64 ORAL PATHOLOGY AND PRACTICE, death is not reached until the hot weather of July exacerbates the condition, and perhaps adds some kind of fermentative infection as the immediate cause of the death, the first degenerative step having been taken in the improper feeding of April or May. The teeth have been erupting during this time, and the unrefiective physician, if he is called in, will quiet the anxious parents and friends with the old plea of teething, perhaps lancing the gums when no tooth is near eruption, and neglecting the organs really at fault, until the sexton closes the scene by burying the fatal mistake beneath the churchyard turf. CHAPTER XVIII. TREATMENT OF THE SO-CALLED DISEASES OF DENTITION. It is the first duty of the dentist or the oral physician, when he is called to examine the mouth of a child suffering from the so-called diseases of dentition, carefully to examine and see if there are any indications of disturbed dentition. A correct diag- nosis can only be made with certainty after a very careful con- sideration, not only of the child itself and the attending symptoms, but of its past history, its sanitary environments, and its diet. The age should be accurately determined, that it may be seen whether the dental development corresponds with that of the general system. This is important, because it is not infrequent that morbid conditions are ascribed to teething when the teeth due at the time are all in place. A medical journal reports a case of infantile palsy in a child more than three years of age, as due to teething. Both legs were cold and powerless. There was sufficient irritation of the gastrocnemius muscles to cause a permanent contraction, thus producing a kind of talipes equinus. Nothing is said about the state of forwardness of the dentition, but, unless it was unusually delayed, the physician, as is 100 often done, jumped at his conclu- sions and ascribed to teething a trouble that had a deeper origin. The condition of the gums should be carefully noted. If they are normal, without any special inflammation or thickening, we should look elsewhere for the source of the irritation. It should be remembered that the gum is naturally very hard and dense, from the large amount of fibrous tissue in it. Normal growth, when THE SO-CALLED DISEASES OF DENTITION. 65 the tooth is near tlie point of emergence, will find the gum whitish, glistening, and tense in appearance. There may be such a condi- tion of impermeability, of toughness and hardness in the gum that the advancing tooth is retarded thereby, and hence undue pressure is brought to bear upon the, as yet, insuf^ciently protected pulp, thus inducing reflex nervous disturbances, but this condition will be of comparatively rare occurrence. Unless there are constitu- tional and general disturbances that seriously interfere and require immediate attention, the tooth easily makes its way through the gums, by their absorption under the slight but continual pressure induced by the developing roots which lift the crown. A clear distinction should, then, be made between those dis- eases which are, or even may be, the results of improper feeding, and the nervous disturbances caused by retarded or impeded denti- tion. Physicians are year by year more clearly recognizing this difference and governing their practice accordingly; yet by far too large a proportion of them still refer the diarrheas and fevers of childhood to teething, and make no special efforts to correct the vicious diet which may be the source of the disturbance. The treatment of the so-called diseases of dentition properly comes within the province of the medical man; yet so frequently are young children who suffer from bad feeding brought to the dentist for advice or gum-lancing, that some practical general directions may with propriety here be given. If the gums present their natural light pink, tense, hard, glistening appearance, it matters little whether there are or are not indications of an advancing tooth; the presumption is that there is another cause for the trouble. Retarded or disturbed dentition will leave an index upon the tissues about the point of irritation, and there will be found some departure from the normal appearance. There will be local inflammation, turgidity, and tumefaction, with redness and soreness. In the absence of these, the diet should be very carefully looked after, hygienic conditions inquired into, and in case of any departure from that which is proper, the food should immediately be changed and correct sani- tary conditions established. If there is a simple diarrhea, of not long continuance, with little of pyrexia, or fever, a simple correction of the diet will probably be sufficient. If the mother shall have weaned the child, or her milk is insufficient, some one of the peptonized foods 6 66 ORAL PATHOLOGY AND PRACTICE. should be substituted. There are so many of these, chiefly pro- prietary, that it is scarcely proper to recommend any one above the others. It should be sorhething of a very simple nature, in which digestion has already been begun by partial peptonization, or the diastatic action of some proper digestive ferment. A mild cathartic is needed, and this is sometimes the first necessity, that the stomach and intestines may be relieved of irritating material. Castor oil in doses of from one to three tea- spoonfuls may be given. This will especially be indicated if the stools are of a green appearance. If, as will probably be the case, there is an acid condition, the following may be prescribed: ^ — Castor oil, Calcined magnesia, of each equal parts. Sig. — Dose, half teaspoonful, to be repeated in three hours if necessary. Or the following: IJ — Pulv. ipecac, gr. ss; Pulv. rhei, gr. ij ; Sodse bicarb., gr. xij. Fiat chart, xii. Sig. — One every four to six hours for a child of one year. If there are no special inflammatory symptoms, the following may be used for the purpose of checking the discharges: 3J — Tinct. opii, gtt. xvj ; Bismuthi subnit., 5ij ; Mist, cretee, "^jss; Syr. simp., ojss. Sig. — Shake well, and give in teaspoonful doses every four hours. If spasms are imminent or present, the following may be used: IJ — Potas. brom., gr. iij ; Tinct. cantharidis, gtt. iij ; Spts. camphorae, gtt. x. • Sig. — Repeat p. r. n. in water. In simple diarrhea, after an evacuation of the bowels, the following may be prescribed: IJ — Bismuthi salicylat., 3j; Pulv. ipecac, et opii, gr. x; Pulv. aromat., 3j. Fiat chart, xii. Sig. — One powder every three or four hours for a child of one year. If the stools contain mucus and blood and are jelly-like, the following may be given: REAL DISEASES OF DENTITION. 67 IJ — Hydrarg. bichloridi, gr. l^i ; Liq. potas. arsenitis, gtt. xxxij ; Syrupi rubi, Syrupi rhei, aa 5ij ; Listerine, adoij. Sig.- — Fifteen to twenty drops every two hours. If there is much pain, add one-hah' dram of deodorized tinct. of opium to the mixture. If there is considerable fever, Dover's powder may be given in small doses of one to two grains, or potassium bromid in five- grain doses. Sponge baths with tepid water will be found useful, and in extreme cases alcohol may be added. But the change of diet, and the most careful sanitary precau- tions as to the cleanliness of the nursing-bottle, if such is used, and of all the surroundings of the child, will be the chief care of the physician. Lancing the gums, or other operative procedures, will not be found necessary and should not be advised. Usually the case will be put in the hands of a general practitioner, but the dentist should be competent to prescribe in his absence, or iji an emergency. CHAPTER XIX. REAL DISEASES OF DENTITION. The real disturbances of dentition are the pathological condi- tions accompanying the advent of the teeth, in contradistinction to those which arise from improper feeding. Both are sometimes of the most serious character, but their origin and the phenomena that they exhibit are quite different. Usually, with the eruption of the tooth, the superincumbent tissues are absorbed away, and give place to the erupting organ. It should be remembered that up to this time there has been no formation of alveolar process; the bony walls that envelop the germ are very thin and slight, and they are not closed over it. There is very little if any pres- sure, the fibrous gum tissue offering the only obstacle to advance- ment. In normal conditions this is readily absorbed, but there are instances in which, through some malformation of the tooth or imperfection of its tissues, or perhaps because of local disturb- ances, considerable pressure is exerted upon the tooth pulp, which at this stage of growth forms the greater part of the contents of the crypt, and upon which the enamel and dentinal cap already formed are resting. 68 ORAL PATHOLOGY AND PRACTICE. In such instances the tissues will not be in their normal state, and will be predisposed to inflammatory conditions. The tooth pulp will be especially irritable, and will respond to comparatively feeble impressions. The pressure that may be exerted upon the susceptible pulp in such instances may cause serious complications, but these will necessarily be of a reflex nervous character. The irritation to the delicate pulp tissue will react upon other tissues, through their nerve connections, and various functions may be disturbed. A diarrhea may possibly be the consequence, but it will not resemble that produced by digestive disorders. The child will plainly show- nervous irritation; it will suddenly wake from sleep, perhaps with a scream. There will be spasms of the facial muscles, and inter- vals of pain will be succeeded by entire relief. There will be alternate slavering and dryness of the oral cavity. If a diarrhea is at times present, it will probably be succeeded by constipation. The appetite will be exceedingly variable, and there will be present that peculiarly fretful condition that indicates nervous irritability. It will be afraid to bite upon anything whatever, and will strenuously resist all attempts to touch the gums. This will be in marked contrast to the condition when, despite digestive disturbances, dentition is proceeding normally. The child then delights to bite upon some yielding substance, like the finger or a rubber ring. If now the mouth is examined the gums about the advancing tooth will be found swollen, red, and turgid, and exceedingly tender to the touch. The mucous membrane will have lost the pink, tense, and glistening appearance of health, and will plainly show its disturbed state. During examination the child will perhaps scream hysterically, and plainly indicate its exalted nervous excitement. When these symptoms and appearances are present, no time should be lost in extending surgical aid. Prompt and deep scarification over the advancing tooth should be made, to divide the swollen gums and disengage the tooth. A crucial incision is usually best, if it be a molar, while a longitudinal one may answer for an incisor. In either case it should be deep enough thoroughly to divide all the tissues over the tooth, and extensive enough to free it. If there is any overlapping oper- culum of bone, this should be divided, for it will be the greatest obstacle in the way of the tooth. REAL DISEASES OF DENTITION. 69 This will usually be sufficient to give immediate and entire relief. If the diagnosis of the condition was correct, and the incisions sufficient to disengage the whole tooth, the change that ensues will sometimes be fairly startling. It may be well to give a small dose of potassium bromid (two to five grains), or an enema of chloral hydrate (five to ten grains), in water, to quiet the nervous excitement and induce sleep, but usually this will not be found necessary, the removal of the cause of irritation being sufficient. There may occur instances in which the child is in spasms, or in convulsions, and the administration of chloroform necessar}' for their control before surgical measures can be safely resorted to, in which case there should be no hesitation on the part of the operator. In any instance of suspected disturbance of dentition, careful examination should be made to determine if any tooth is, or should be, nearly due, and if it is properly developing. This may usually be determined by the appearance of the jaws, which by their growth will indicate it. Many instances have occurred in which lancing has been resorted to when no tooth was due for months. Mothers, and some general practitioners, will frequently urge lancing when there is not the slightest demand for it. In the hospital and college clinics of the author, not one case in twenty of those presented for it demanded any surgical interference whatever. The instrument best adapted to the division of the tissues over advancing teeth is the curved and pointed bistoury. It would be difficult to devise a worse one than the ordinary double-edged ovoid lancet, which cannot be made to cut at its extreme point. Something that can, if necessary, be forced deep down into the tissues at its point, and then drawn toward the operator, is essential. A pushing force should never be resorted to, as control of the instrument cannot be maintained, and there is serious danger of wounding surrounding tissues by its employment. 70 ORAL PATHOLOGY AND PRACTICE. "^ CHAPTER XX. DENTAL CARIES. A POPULAR impression has long existed that caries of the teeth is of modern origin, and that it is due to an artificial mode of life, to a departure from the laws of nature, and to factitious environments. It has been held that our early progenitors knew not the pains of toothache, and retained their dental organs to a late period of life. The application to these fanciful speculations of the facts evolved by actual observation has shown that this is an error, and that there is not now and there never has been a pathological condition so universal throughout animal life as is caries of the teeth, for it is by no means confined to man. There are few of our domestic animals in whose mouths careful exam- ination will not reveal some form of oral disease, and among them caries plays an important role. Nor is it confined to domestic animals; the author has in his possession many skulls illustrating this, among them being that of an old male gorilla, with extensive decay of the teeth, that has resulted in alveolar and antral abscess, with necrosis of the superior maxilla. No people have yet been found among either civilized or savage races in which dental caries was not prevalent. Even the most ancient had no immunity, and the skulls of Egyptian mum- mies, four thousand years old, exhibit the same decay that is observable to-day. Hence we are not dealing with a condition that depends upon recent degeneration when we attempt the consideration of the subject. It is as old as the human race, and has probably caused more of pain and distress to the human family than any other disease with which man is afflicted. It would naturally be expected that a condition so universal, so ancient in its origin, and so distressing in its results would have been carefully studied, and long since thoroughly compre- hended. The fact really is, that until within fifteen years almost nothing was known of the real etiology of caries, or of the changes it involved. Speculation there had been in abundance, and many ingenious theories had been evolved, none of which satisfied the existing conditions. It is within the memory of even compara- tively young practitioners, Avhen at our dental associations and meetings the most contradictory hypotheses were advanced. It DENTAL CARIES. Jl was declared to be the effect of an inflammatory process of the tooth tissues. It was ascribed to mineral acids that dissolved out the calcic salts of the teeth. It was by some believed to be due to a perverted nutrition, whereby there was a breaking down instead of a building up of tooth elements. It was claimed to be the effect of a lack of mineral elements in the food during the period of growth. In fact, the etiology of caries was a common battle ground, on which the advocates of the different theories met to try conclusions, without the possibility of victory for either combatant through the positive establishment of any special hypothesis. With the comprehension of the true principles of fermenta- tion and the advance of bacteriological knowledge, light began to dawn on the dark places, until at last by the exhaustive researches of Prof. Dr. W. D. ]\Iiller, an American dentist resident in Berlin, the problem of the ages was finally solved, and the true nature of dental caries was determined. It was found that those who had described it as a decalcification through the action of an acid were partially correct, but greatly mistaken as to the source of the acid. The advocates of the vital hypothesis had a section of the truth, but not enough upon which to base a practice. Miller demonstrated that dental caries is due to a number of factors, but the principal and basal one is the growth of oral bacteria. It has been shown in a previous chapter that the mouth is especially adapted to the growth of micro-organisms. Here are found the proper temperature, the most fitting media, and the required moisture; the temperature is as evenly maintained as it can be in any incubator, while the proper soil for their prolifera- tion is always provided. The various foods, especially the starches, will by the action of the ferments of the mouth be changed into forms admirably adapted to the growth of the acid- forming bacteria. Of some of these Miller made cultivations, analyzing their by-products, and he found, as the result of the proliferation of one special organism, lactic acid. Further obser- vation enabled him specifically to point out the exact method by which caries is produced, which is as follows: In the sulcus of a tooth, or between two teeth, or in any pit or irregularity of its surface, food lodges. By the action of some ferment, this is perhaps changed into sugar. This forms a suitable 72 ORAL PATHOLOGY AND PRACTICE. medium for some of the bacteria, and it is perhaps at once infected with the "Delta" organism of Miller. In its growth this splits np the fermentable sugar, building into its own substance such ele- ments as are necessary for it, and leaving the remainder to form new combinations, or by-products, one of which is lactic acid. This acid, especially active in its nascent or formative condition, attacks the teeth, dissolving out the calcic salts, and forming a depression in which more food lodges, to pass through the same changes and to be in turn decomposed by new colonies of bacteria, thus forming more acid to continue the destructive work. The dissolving out of the calcareous parts of the tooth leaves behind the organic or living portion, which may pass through inflammatory or degenerative stages, finally to be de- stroyed by putrefactive organisms. This is the essential principle iOf Miller's discovery. The enamel once penetrated by the pro- ducts of the growth of the vegetable fungus, the progress of the disorganization is more rapid. The bacteria penetrate the dentinal tubuli ; the acid generated within them, through the action of the micro- organisms, enlarges the tubules, melting down tw^o or more into one, thus forming minute chambers or cavities in the dentin, which ultimately are blended into a yet larger one, and thus decay proceeds. Microscopical exam- ination shows these small spaces to exist at a considerable distance beyond that which is actually broken down, and to account for the friable, crumbling dentin about the margin of the cavity proper. The area denominated by Miller "the zone of infected dentin" is that pervaded by the organism, but in which the dissolving out of the calcareous inorganic matter of the tooth has not yet fairly commenced. Yet farther into the structure of the tooth have penetrated the bacteria, filling the tubuli without having distended them. Not infrequently a number of these distinct zones of infection or caries are seen in their different stages, and readily traced. They are all the result of tooth infection and tooth decalcification through the action of bacteria. Miller, having demonstrated the true nature of this disease by analytical methods, next attempted a kind of synthesis, arriv- ing at the same result; thus by an independent process proving the correctness of his previous observations. Obtaining a pure DENTAL CARIES. 73 culture of the bacillus of decay, he immersed an extracted tooth in a proper culture solution, and with the utmost solicitude keeping it in the proper condition and at the exact temperature, he infected it with the bacillus and produced true caries outside the mouth and removed from all physiological or vital connections. He thus demonstrated that caries is not a vital process, and that the pro- liferation of the bacillus under proper conditions will produce it as readily outside the body as in it. It must, then, be accepted as finally proven that dental caries is the result of an infection, and a true germ-produced disease. It is essentially a septic condition, and its medicinal treatment must be antiseptic. All prophylaxis must be in this direction, and the general principles of Listerism are as applicable to caries as to the treatment of wounds. To proceed farther than this in the consideration of the etiology of dental caries would be outside the scope of this work. CHAPTER XXI. DENTAL CARIES (Continued). Physiologists, pathologists, and histologists are inclined to consider the teeth as organs isolated, dissociated from the rest of the body, as of such dissimilar, diverse characteristics that their relation to other tissues is but a minor factor in their study. Dental practice has been too exclusively confined to the teeth themselves, reputable practitioners asserting openly that there is no need for the dentist to study general anatomy or physiology, and protesting against everything save the very narrowest and most restricted teachings in our colleges. Almost unconsciously the great body of practitioners have been led to think of the teeth as segregate organs. There are many of our number who, while claiming professional relationship, treat their vocation as exclu- sively mechanical, and unwittingly debase their own condition to that of a mere artisan. The teeth are true modifications of bone. The study of com- parative dental anatomy teaches through what gradations they have passed; very rhany of the intermediate steps are recorded in the oral or pharyngeal cavities, and even in the gastric regions, 74 ORAL PATHOLOGY AND PRACTICE. of animals now extant. In some instances mastication is abso- lutely performed upon true bone, of compact structure, which, however, is soon lost if it is submitted to any rough usage. We sometimes marvel that the teeth decay as they do. Were they not differentiated in their structure from the bone of which they are only modifications, they would not last as long as they do. That the teeth are vital organs, with a vital dependence upon other tissues, that they are intimately connected with the rest of the body, is readily indicated by the fact that they are nourished by the same blood supply and receive their innervation from the same nervous system with the other organs. It is true that they are the hardest, densest tissues of the body, but in this they differ comparatively little from true bone. They are made up of a living matrix, into which calcium salts have been incorporated to give to them consistency. They are developed from the same connective tissue elements with other analogous tissues. They only differ from bone in having a little more of the calcic salts and a little less of the living matter, in this respect the different tissues of the teeth showing the same variations that are observable in different kinds of bone. To illustrate this the following table is presented: Bone. Cementum. Dentin. Enamel. Animal matter 34-00 32.00 28.00 5.00 Earthy matter 66.00 68.00 72.00 95-00 100.00 100.00 100.00 100.00 Calcium phosphate Si-04 56.73 62.00 85.00 Calcium carbonate ii-30 7.22 5.50 8.00 Calcium fluorid 2.00 1.63 2.00 3.20 Magnesium phosphate 1.16 0.99 i.oo 1.50 Sodium salts 1.20 0.82 1.50 1. 00 This table gives but an average of the proportional constitu- ents of the tissues. It would be well if a careful study of it could be made by every dentist. It will be seen that the same elements enter into the composition of all the hard tissues. The essential variation of tooth tissue from true bone is that through the progressive modifications of cementum, dentin, and enamel there is a gradual loss in the proportion of animal or organic matter, and a proportionate increase in the earthy or inorganic. This is most manifest in the calcium phosphate, upon which the teeth mainly depend for their density and hardness; there is DENTAL CARIES. 75 comparatively little variation in the relative amounts of calcium carbonate, magnesium phosphate, and the other salts. In bone the living- matter is nearly half that of the inorganic, while in enamel it is but one-nineteenth. But it is not alone in its constituent elements that the modifications of tooth from bone are exemplified. In their physical structure the gradation is still more marked. In bone the most distinguishing feature of the nutritive apparatus is the Haversian canals, about which are arranged in concentric group- ing the cells containing the living matter. These corpuscles, the lacunae, communicate with each other and with their source of nutrition by minute canals, the canaliculi. Each regular arrange- ment or system of these communicating lacunae is called a lamella, and these in turn are in relation with each other through connecting canaliculi. The first modification, or differentiation, is found in the cementum, which has all the distinguishing features of bone, if we except alone the lamellae. The lacunse are present, and the canaliculi; even the Haversian canals are some- times found. They are not as constant as in true bone, but even in that they are not always present. The lamellar, concentric arrangement of the lacunse about the Haversian canals is alone lacking, and this is the case even when these vascular canals are found in the cementum. The proportion of animal and earthy matter has been but slightly changed, the variation between differ- ent bones being sometimes greater than that between bone and cementum. Cementum, then, essentially differs from bone only in the loss of the lamellar arrangement of the cells. The next step in the differentiation is found in the dentin, which has lost the lacunal corpuscles that distin- guish cementum and bone. As these contain the-^reater pro- portion of the living matter, we naturally anticipate a considerable deficiency in that element, and analyses show that it has but about four-fifths the amount found in bone, while the earthy salts are correspondingly increased. In its physical structure, then, dentin retains but the canaliculi of bone, and these appear in their analogues — the dentinal fibrillse. Instead of being the channel of communication between the lacunae, as in bone and cementum, they serve to connect the pulp, the analogue of the medulla of Ijone, with the cementum, the ultimate dependence not being very 76 ORAL PATHOLOGY AND PRACTICE. apparent. As in bone and cementum, they are the medium of nutrition to the interstitial parts and the parenchyma. Dentin, then, is bone modified in structure by the disappearance of the lacunse, as well as their arrangement into lamellae. Finally, enamel is developed, — the densest, hardest, heaviest tissue of the body. This is that which alone is exposed to attri- tion, and to the direct action of foreign substances. Bone, cementum, and dentin are normally protected from exposure. If the former is uncovered, even to the external air, the most serious consequences may follow. Cementum is a little, and dentin considerably more tolerant of submission to external influ- ences. But neither of them accepts it without a pathological protest. Enamel alone successfully withstands external contaci, and even that is in better condition when in possession of its natural covering, cognate to the skin and mucous membrane, Nasmyth's membrane. The very circumstances under which enamel exists must demand a material modification of structure. Accordingly we find that not only the lacunas of bone and cementum are lost, but the canaliculi of bone, cementum, and dentin have disappeared, and the principal remnant of the living matter left is the microscopical septum between the enamel prisms. But it is not dead, inert matter. Three per cent, of its structure is animal, so that, tenuous as is the thread, it has yet a vital connection with the other living portions of the body. The necessities of its existence demand that it shall have but a very minute proportion of animal matter to protect it against the exposure and rough usage which it must receive, but still it is identical with bone in its constituent elements, though widely variant in their relative proportions. Enamel is bone deprived of the lacuna: and canalicidi, cut off from its genrric organ, without independent nutrition, hut still retain- ing a proportion of that animal matter luithout which it zvoidd he something alien and foreign. It is from this standpoint that the tissues of the teeth are properly considered. It is in their relation to other tissues, and as a part of the living organism, that they are to be studied. The teeth are not lifeless, passive, extraneous objects. They have their pathological degenerations that demand medicinal agents. Their treatment cannot properly be exclusively surgical or op- THE MEDICINAL TREATMENT OF DENTAL CARIES. // erative. It is true that their nutrition is limited and sluggish, but it exists, and must be considered. They are amenable to the same general laws with the rest of the body. They contain a large proportion of inorganic matter, but even that must be elab- orated in the alembic of nature, — it cannot be taken ready-made; the calcium phosphate that forms so great a part of their body is of organic origin, and was distilled by nature's process from the organic matter that alone can be used as food or built into the system. Every tissue of the tooth, as is the case with all other tissues, is the product of growth, hence is truly organic, and the assimilative processes can no more accept for nutritive purposes such inorganic matter as crude calcium phosphate than it can utilize carpet tacks to give iron to the blood, or lucifer matches to furnish phosphorus for the brain. Such preparations may act as medicines, to be excreted as received, but their administration for metabolic purposes is an utter absurdity. That an hereditary tendency may be a factor in the etiology of dental caries, no one will for a moment dispute. One may inherit a diathesis, a congenital atonicity or a lack of resistant power, but a bacillus is not received as a patrimony. Modern investigation proves that so many of our disorders are of infec- tious origin that the doctrine of heredity must be materially modified. Prof. G. V. Black, by his experiments, has demon- strated that there is less of difference in the structure of so-called good and bad teeth than has been usually imagined. This throws UG more directly back upon the z'is medicatrix naturcu for our cures, and places us in a more intimate relation than ever with the vital principle, the innate resistant power of the body, and directs our thoughts into new channels. Dental caries must be studied from the vital standpoint, and in this view we approach the subject. CHAPTER XXII. THE MEDICINAL TREATMENT OF DENTAL CARIES. It having been demonstrated that caries of the teeth is chiefly due to the action of micro-organisms, it naturally follows that the remedies employed, aside from operative ones, — which it is not the yS ORAL PATHOLOGY AND PRACTICE. province of this work to consider, — must be mainly antiseptic. Were it possible completely to sterilize, and to keep sterilized, the oral cavity, there could be no decay. But this is impracticable, and even undesirable. The peptonizing action of many of the bacteria may be an important factor in digestion, hence it may not be best, even if it were possible, to eliminate them. But of the advisability of at least limiting their action there can be no ques- tion. The putrefactive organisms certainly can have no useful ofiQce in the mouth, and common cleanliness demands that their growth should, as far as possible, be prevented. Could the teeth and the oral tissues be kept entirely- clean and free from food and other debris, caries would be so limited that it would be of little moment. A carefully polished surface does not retain detritus or debris. Unless there are depres- sions, or pits, or roughness, there is nothing to which particles of food can cling. It is evident, then, that the first prophylactic measure against caries is the careful polishing of the teeth. Every deposit upon them must be removed, every pit obliterated, and every rough surface made entirely smooth. This will be the work of the dentist, but the keeping of them in that state will depend upon the exertions of the individual himself. A set of natural teeth in a state of perfect cleanliness is a sight seldom vouchsafed to anyone. Quite as rare would be a patient, just from the chair of the dentist, whose teeth had been put in perfect order. The average practitioner neither recognizes nor attempts the cure of half the pathological conditions that exist in the mouths that he treats. He fills the most conspicuous cavities, removes deposits that actually obtrude themselves upon his notice, and ignores the rest. Nor is it necessarily his own fault in every instance, for patients sometimes might ofifer serious objections to expending the time and money necessary for the treatment of all diseased con- ditions and the putting of the mouth in complete order. There is, however, no excuse for failing to call the attention of decently clean people to minute sedimentary precipitations upon the teeth, depressions or erosions of their surfaces, and inflam- mations and irritations of the soft tissues about them. That which is neglected is mainly in the line of prophylactic treatment. Were dentists generally more faithful to duty, their practice would be widely extended, while the people would be greatly benefited. THE MEDICINAL TREATMENT OF DENTAL CARIES. 79 It is unnecessary to call the attention of the student or practi- tioner to the most approved methods of cleaning the teeth. That duty devolves upon the teachers of operative measures. But the proper medicinal agents may be adverted to, and their use recom- mended. In the performance of this task it is impossible entirely to avoid mention of proprietary remedies, whose employment, when others can be substituted for them, should be eschewed; yet they are sometimes a convenience, and, when the formula is a public one, may be professionally prescribed. A convenient, effec- tive and unobjectionable antiseptic mouth-wash, consisting of a single simple remedy, is almost unknown. The most efficient germicides possess toxic or caustic properties that are sufficient to exclude them. The best antiseptics are liable to the same objec- tions, and we are thus forced back upon the essential oils, which must be combined with other things to make them most useful. Listerine, borine, borolyptol, and other combinations are proprie- tary preparations, and therefore objectionable on ethical grounds, for no physician has any right to make a prescription for a patient unless he is fully aware of its entire character and thoroughly con- versant with every drug in it. He is paid for the expert knowledge of which the patient is not possessed, and he betrays that patient's professional confidence if he does not exercise entire intelligence. Hence proprietary and secret remedies have no place in this work unless their complete working formulae shall have been submitted to and approved by the author. For antiseptic use in the mouth, lysol presents some advan- tages, and the following may be used with the tooth-brush: IJ — Lysol, Bss; Aqua', .oxvj. Carbolic acid is not palatable, and it possesses toxic properties that forbid its use in strong solutions. But it is excellent as an antiseptic, and the following formula may be found useful: ^ — Carbolic acid crystals, Glycerol, Rose water, of each 2 ounces. Five to ten drops in a wineglass of water should be used as a gargle, or with the brush. Thymol is similar in its action to carbolic acid, while it is free from its disagreeable odor. 8o ORAL PATHOLOGY AND PRACTICE. ]? — Thymol, 4 grains; Benzoic acid, 45 " Eucalyptol, i8o " Water, 2 quarts. This should be used as a gargle, after cleaning the teeth. The following is recommended by Professor Miller as an anti- septic gargle and wash : I^ — Thymol, 4 grains; Benzoic acid, 45 " Eucalyptol, 3J/2 drams; Alcohol, 25 " Oil of wintergreen, 25 drops. Hydronaphthol has been employed as an antiseptic, but was formerly more used than it is at present. The following formdla has been recommended for a mouth-wash : IJ — Hydronaphthol, oij ; Tinct. calendulEC, 5iv; Aquae dest., adoviij. Any of these may be used with the tooth-brush, or as a gargle after cleaninsf the teeth. CHAPTER XXIII. PULPITIS— INFLAMMATION OF THE DENTAL PULP. Save as it is modified by surrounding conditions, inflammation of the pulp does not differ from that of other analogous tissues. The initial processes are the same, and hence the remarks in the section on Inflammation are applicable to the condition now under consideration. When the subject of general inflammation is fully comprehended, then, and then only, can the phenomena presented in pulpitis be clearly understood. It is but necessary to consider the peculiar complications brought about by the environments of the dental pulp, and to make due allowance for them, when the whole matter becomes plain and lucid. These complexities arise from the fact that the tissue of the pulp is somewhat modified in structure, and at the same time is enclosed within unyielding, osseous walls, which in health form its sure protection and in disease its rigorous prison-house. Whether or not the dental pulp, in its healthy, normal condi- INFLAMMATION OF THE DENTAL PULP. 8l tion, is or is not sensitive to external impressions is a disputed question Avhich cannot be satisfactorily answered, because if it is responsive it is at once claimed that it is not in a normal condi- tion. Certain it is that an entirely healthy tooth gives no sentient signs of the presence of a living pulp. It is sometimes a difificult matter positively to diagnose a dead pulp from a healthy living one in certain conditions. Both are equally unresponsive to ordinar\^ thermal changes, and the enamel and dentin of each are equally insensitive. Those who have had occasion to drill into or excavate a tooth that is entirely without disturbance of the pulp tissue, know that the dentin is unresponsive, while the pulp may be, and often is, punctured without the knowledge of the patient. But if there is recession at the gums, or if there shall have been any pain in the teeth whatever, indicating pulp complications, or even any pulp disturbance insufficient to produce pain, both dentin and pulp may be exquisitely sensitive. There are many instances in which caries has ex- tended to the pulp tissue, but in which there never has been either pain or sensitiveness. This cannot be r^easonably accounted for upon the theory of personal idiosyncrasy, for individual tempera- ment will scarcely cover a departure from general physiological laws. There must be a good and sufficient reason for such an immunity. The blood vessels of the pulp possess a modified structure, in that they are without the complete muscular coats of those found in most parts of the body. In this respect they resemble those of the brain, which also is a tissue protected by unyielding, bony walls, analogous to those of the tooth. The nerves of the dental pulp are also modified, for while they are composed of nervous elements they lack the general structure of those of most other parts of the body, and they are without the usual sheaths. The connective tissue of the pulp is not especially modified in struc- ture, but it must be peculiarly so in function, through its excep- tional blood and nerve supply. These variations will be specially considered in the chapter devoted to the diseases of the peri- cementum. The dentin is without nerve supply, and yet when in an irritable condition it becomes acutely responsive. Sen- sation can only be conveyed through the dental fibrilhe, whose 7 82 ORAL PATHOLOGY AND PRACTICE. embryonal structure, containing all the elements of nerve tissue, becomes inordinately responsive in certain conditions. It is well established that formative tissue, embryonic matter, may take on inflammatory conditions, and under such circumstances possess characteristics unknown to it when in a normal state. It might be reasonably inferred, then, that the sensitive- ness of either dentin or tooth pulp may be the direct result of irritation, and the inceptive stage of an inflammatory process ; that sensitiveness of dentin is but the result of that abnormal, irritative, inflamed condition; that the peculiar phenomena presented are due to the modified blood and nerve supply, and that in its normal and healthy state it may be quite irresponsive to external impressions ; that any special responsiveness of either of the tooth tissues to external impressions is an indication of a pathological con- dition, and that in treatment this should always be kept in view. The pathological changes presented and the phenomena exhibited in inflammation of the tooth pulp will differ from the corresponding phenomena in most other tissues just so far as the structure of these latter is varied and their environments are modi- fied by the tissues with which they are in relation. The peculiari- ties of the nerve supply will change the character of sensation, while the special vascular system will vary the phenomena pre- sented in the earlier stages of inflammation, and materially modify diapedesis. Proceeding upon this hypothesis, it is not difficult to comprehend some things heretofore unintelligible in the pathology of the dental pulp, and to find indications that may be a more com- plete guide in diagnosis and treatment. A specially sensitive tooth is one whose tissues are in an irritable condition, and this is either the initial step in, or a positive stage of, an active inflammation. The irritant may be any one of a long list. 1. Caries has perhaps invaded the tooth, and micro-organisms have penetrated the tttbuli, becoming themselves the irritant, or expos- ing the deeper dentin and pidp to the irritating action and thermal changes of external agents. 2. It may he that an inserted filling is this outward irritant. J. There may be recession of the protecting gum tissue at the cervical portion of the tooth. INFLAMMATION OF THE DENTAL PULP. 83 4. A traumatic injury, a bloiv, inordinate use, the attrition of mastieation, or any mechanieal violenee may be the source. 5. Structural changes icithin the tooth pulp, such as the forma- tion of calcific deposits, are a sufficient excitant. Whatever the cause may be, there will be a determirxation of blood to the irritated pulp tissue and an engorgement of its capillaries. Because of the absence of the usual arterial and venous coats, the blood channels at once yield to the pressure. There is not the usual vaso-motor system of nerves to control the resilience of the vascular system, and diapedesis, or the escape of the elements of the blood into the pulp tissue, is materially modified. It does not at once take place in the usual acceptance of the term, but a stage of active engorgement of the blood channels ensues. The dental pulp is without the full and complete chain of lymphatics of the absorbent system, because the modification of the blood supply in a measure makes it unnecessary. The compara- tively unrestrained yielding of the blood channels, and the retarda- tion of the infiltration of the pulp tissue allows for a return to a physiological state, if once the irritations cease, without the neces- sity for the usual process of resolution through the activity of the lymphatics in relieving the hyperplastic condition. It follows, then, that the treatment of ordinary pulpitis, after the removal of the irritating cause, should be directed towards the relief of the congested condition by deflecting in some manner the determin- ing blood current and allowing the engorged vessels to empty themselves. So long as the possibility for this exists, it is quite possible to preserve the vitality of an inflamed pulp. When the pathological condition shall have proceeded to the extravasation into the body of the tissue of inflammatory products, the lymphatics are not able to take them up, and their removal is as impossible as is that of any great effusion in the brain. Pulp cap- ping under such circumstances will be a hopeless proceeding, and the presence of any infiltrated or effused matter will contraindicate it. The fact that some pulps become fully exposed and their investing tooth walls are broken down without either pain or special sensitiveness may be accounted for through their never taking upon themselves real inflammatory conditions, because of a modification of nerve structure greater than that which is usual. 84 ORAL PATHOLOGY AND PRACTICE. CHAPTER XXIV. TREATMENT OF INFLAMMATORY CONDITIONS OF THE DENTAL PULP. Usually, the first indication of irritation of the dental pulp is responsiveness to external impressions, manifested by a sensi- tiveness to thermal changes. Cold air or cold water cause pain of a sharp, lancinating character. Not infrequently the neck of the tooth, or any abraded surface, is also sensitive to any outward irritant, such as a metal tooth-pick or instrument. This indicates dentinal irritation. The responsiveness to thermal changes in- creases and becomes more persistent, until there is a distinct odontalgia or toothache. This pain will be rather paroxysmal, returning upon slight provocation and passing away in a few moments. It may be difficult for the patient to determine exactly which tooth is affected, because of its sympathetic nature and because it is distributed over a considerable territory. Suc- cessively isolating each tooth by the rubber-dam, and the applica- tion of alternate heat and cold, will, however, usually determine the matter. Sometimes there is a response to percussion, and a diagnosis may thus be reached. This earlier stage will be that of hyperemia, and the beginning of engorgement, or congestion. The exalted sensibility is due to the irritable condition of the nerve tissue. If relief is not obtained, the pain, with the exacerba- tion of the inflammatory condition, becomes more intense and continuous. With the increased engorgement the pulp, which is held immovably within the bony tooth walls, becomes intensely irritable, and the pain instead of continuing remittent becomes almost continuous. The lancinating flashes can no longer be dis- tinguished, but are so quick in succession as to be practically unin- termittent, and there is at the same time a deep, boring pressure felt, which indicates that the inflammation is passing to its second stage, that of effusion, in which there is a passing out of the ele- ments of the blood into the tissues. Up to this point the vitality of the pulp may readily be pre- served, if active measures are taken for the relief of the inflam- matory condition. This stage once passed, and extravasation into the pulp tissue having taken place, the probabilities are largely against conservation. TREATMENT OF INFLAMMATORY CONDITIONS, ETC. 85 About this time the pain changes its character somewhat and it is not of such a sharp, lancinating nature. It becomes more steady and less paroxy-smal. There is a greater feeHng of pres- sure, and it is more readily located. The pulsation, which up to this time is very distinct, now ceases. The congestion soon reaches its height, and entire stasis of the blood current in the pulp is immi- nent. Cold is no longer irritative and warmth grateful. The opposite condition ensues, and ice water will relieve the pain, while any warm application exacerbates it. The suffering caused by the affected organ is intense, but the end is probably near at hand. With complete stasis sensation is gradually lost, the pain pro- gressively abates, neither cold nor heat aggravate, and the tooth is irresponsive to any ordinary irritant. The inflammatory process has run its destructive course, and the pulp is dead. This is the usual train of symptoms and the ordinary progress of the disease. The treatment in the earlier stages should be abortive. The first essential is to make a clear diagnosis of the case, by carefully considering all the symptoms. The exact stage of the disease should be determined if possible. This having been done, the next point will be to remove the cause. If it is progressive caries, the cavity of decay should be carefully washed out, all debris removed, and an anodyne introduced. If any foreign substance is the irritant, it must at once be eliminated. The tooth must be relieved of all labor of mastication and given entire rest. Counter- irritants, such as iodin and aconite, or capsicum bags and plasters, are useful by promoting metastasis; that is, a new focus of inflam- mation is created in an approximate territory, but which is upon the surface where it can be reached and where resolution may be expected. This has a tendency to divert the impending blood cur- rents, and thus to relieve the threatened engorgement of the pulp. Hot pediluvia, or foot-baths, should be prescribed, the water to be as hot as can well be borne, and these to be continued for at least thirty minutes, for the purpose of equalizing the circula- tion and relieving the plethoric condition of the pulp. Saline cathartics are useful, because they reduce the blood tension, removing from the sanguinary fluid a " portion of its watery constituent, and thus greatly diminishing the stress. Diaphoretics are perhaps the most important of the general remedies. They not only extract a considerable amount of water from the system and from the blood current, but they act as general OO ORAL PATHOLOGY AND PRACTICE. depurators, promoting healthy functional action and removing local obstructions. Anodynes are indicated, because they equalize nervous func- tion and tend to restore the proper tone to the arteries and veins through the vaso-motor system, and to allay the general nervous excitability. Probably there never was a case of pulpitis that would not yield, temporarily at least, to the vesicant action of a powerful counter-irritant at the back of the neck, a foot-bath continued for thirty minutes, and twenty to forty grains of potassium bromid. Such drastic measures are not often called for, and are inadvisable when milder means will suffice. Any of the preceding measures may be resorted to in cases in which there is no actual or threatened exposure of the pulp through progressive caries, or by accident. When there is a large cavity of decay, it must first of all be thoroughly opened up, and all debris and foreign substances removed as carefully and as completely as possible. It should next be washed out with tepid water in which a little salt has been dissolved, by injecting the stream from a mouth syringe. The cavity should be dried out, and a pledget of cotton dipped in oil of cloves, or dilute creosote, or hamamelis inserted, this to be carefully sealed up without pres- sure, by means of gutta-percha or a pledget of cotton dipped in chloro-percha. A solution of sandarac in which to dip the cotton should not be employed, because it insecurely seals it and because it very soon decomposes, leaving the cavity in a worse state than at first. It is also likely to encapsule the remedy, and thus to isolate it and preclude its action. If there is actual exposure of the pulp tissue, after the cavity of decay has been opened up and carefully cleaned and washed out, the rubber-dam should be applied, the opening dried out by means of hot air, and the pulp and cavity walls sterilized by the application of mercuric chlorid, solution i to 2000, or some other efifective germicide. If there is considerable congestion, a pledget of cotton dipped in the following may be carefully placed over the point of exposure and sealed up: 3J — Plumbi acetatis, gr. v; Tinct. opii, 3ss; Aquas, oij. This should be allowed to remain for some hours, when it may TREATMENT OF INFLAMMATORY CONDITIONS, ETC. 8/ be changed for a dressing of dilute oil of cloves or of cassia. All pain will usiiallv cease with the application of an anodyne. When more" active measures are demanded, the following dressmg may be applied after the sterilization: B — Atropinse sulph., gr. j; Aquse dest., 5]. If the pulp shall have been wounded and bleeding ensue, or if there is exudation of serum from the exposed pulp, it may be dressed with a solution of tinct. iodin and persulphate of iron in equal parts. Tinct. opii may sometimes be necessary for the purpose of soothing the disturbed tissue. The inflammation and congestion once relieved, the necessary operative measures for the further preservation of the tooth may be instituted. If there is no actual Dulp exposure these may, if skillfully executed, be con- fidently relied upon to serve their full purpose. If, however, any portion of the pulp tissue is really uncovered, the prognosis will not be as favorable. In the earlier stages of inflammation, before there is any exudation from the blood vessels of the pulp, the best results may be predicted. If there has been extravasation of the contents of the blood channels into the body of the pulp absorp- tion cannot be expected, owing to the absence of lymphatics, and breaking down of the tissue or death of the pulp will result. The successive stages in degeneration may be tabulated as fol- ^^^'^ ■ First stage. Second Stage. Third Stage. Fourth Stage. Symptoms Sensitiveness. Pain (cold ex- Pain (cold Insensibility. acerbates). relieves). Condition Irritation. Inflammation. Infiltration. Stasis. Pathology Hyperemia. Diapedesis. Congestion. Death. Prognosis Good. Doubtful. Bad. Hopeless. The dififerent remedies in the several classes that will prove best adapted to dental practice may be summarized as follows: Food Laxatives.— Gr ten and dried fruits, cracked wheat, oat- meal, etc. Medicinal La.ra/n'cs.— Seidlitz powder, castor oil (doses for adults of 4 to 8 drams, and for children i to 3 drams), lac. sulphur (^ to 3 drams, in syrup or milk). Saline Cathartics.— Epsom salts (2 to 8 drams in carbonated water), citrate of magnesia (dose according to preparation). Z^m/)/!^?^^//^.— Warmth and exercise, cold drinks. Dover's 8o ORAL PATHOLOGY AND PRACTICE. powder (5 grains), spirits of Miiidererus (2 to 8 drams every two to four hours), sweet spirits of nitre (2 to 4 drams frequently). Diuretics. — Diluent drinks, mineral waters, beef tea, whey, gruel, cream of tartar (i to 4 drams combined with ^ dram bibcrate of soda), borax (20 to 40 grains). Anodynes. — Potassium bromid (5 to 20 grains), sulphate of morphin ^ to :j grain), aromatic spirits of ammonia (10 to 60 drops). CHAPTER XXV. PERICEMENTITIS— INFLAMMATION OF THE PERIDENTAL MEMBRANE. Sometimes this afifection is closely connected with inflamma- tions of the dental pulp, and it may be derived from mere con- tiguity or proximity of tissue. Usually, however, it arises quite independent of the other disorder, and indeed is more severe when the pulp has been devitalized, either by design or disease. The pericementuin is an exceedingly vascular organ, and it has an abundant nerve supply. This is necessary to its proper functional action. It is the placental organ which affords the pulp of the tooth its vascular and nervous supply. The text-books and preparations which represent the arteries and veins of the tooth pulp as passing out at a single foraminal opening and travers- ing the tissues until they anastomose with some larger vessel of which they are branches, and which is not in relation with the tooth at all, are misrepresentations of the actual condition. No blood vessel or nerve can be directly traced beyond the investing pericemental membrane. The foraminal opening of the normal tooth root is not a single direct aperture, having its axis in line with that of the pulp, but, especially in early life, is a delta with a number of communicating origin, which begin to diverge at about the apical junction of the dentin and cementum, and with a kind of circular sweep reach the pericemental membrane, with whose blood vessels the branches from the dental pulp anastomose. Indeed, in early life the ana- logues of Haversian canals are not infrequently found penetrating the cementum and dentin at different points along the periphery of the tooth root, and containing accessory blood vessels for the PERICEMENTITIS. 89 further supply of the pulp. Later in life these are usually oblit- erated by the advancing calcification. That this is true, the clin- ical observation of almost any dentist of wide experience might establish. There are few such who have not seen the whole apex of a tooth root denuded through some pathological process, with- out interference with the vitality of the pulp. Many have known instances in which, through diseased action or by accident, one side of the root of an anterior tooth, with the whole of the apex, was completely denuded without any devitalization of the pulp. When this tissue has been restored by functional activity, the tooth was found as responsive to thermal changes as ever. The author has frequently had occasion to remove all the investing osseous tissue from a tooth root, save perhaps a comparatively small por- tion at one side, and that without final prejudice to its vitality. In some of these instances there could have been no vascular supplv to the pulp, unless it was through some kind of Haversian canal penetrating the cementum and dentin upon a lateral aspect. It is well known to oral surgeons that resection of the inferior dental canal, with entire obliteration of the internal dental artery and nerve, does not in any way interfere with the vitality of the lower teeth, which the text-books frequently represent as receiving their vascular and ner- vous supply from that source. These considerations should materially modify our views of the pathology of the dental peri- cementum, and change some previous conceptions of its function and susceptibility to diseased action. In the light of these views, much that was before incomprehensible becomes plain and intelli- gible. We can understand why and how it is that the blood and nerve supply of the tooth is modified, and how it arises that the vessels of both are without the usual external muscular coats, and approach those of the brain in character. Having the important and compound functions of afifording the pulp of the tooth its nerve and blood supply and giving nutri- tion to the cementum and bone, and being in close relation with the gum tissue, the pericementum is very likely to take upon itself an inflammatory condition. It serves as a cushion to break the force exerted upon the tooth in occlusion, or from a blow or any other external violence. Hence it is liable to injuries and acci- dents. It is also very subject to infection by micro-organisms from a decomposing tofjth pulp. This last is without doubt the 90 ■ ORAL PATHOLOGY AND PRACTICE. most fruitful source of inflammatory conditions, and such instances are constantly falling under the notice of the dentist and oral physician. Another common cause is the bad occlusion, or ab- sence of some of the teeth, which throws upon a few the work of many. Many practitioners have no clear conception of the diflference between pericementitis and pulpitis, inasmuch as each produces a distinct odontalgia or toothache, which only close observation will distinguish from the other. And yet the two conditions have little in common except the pain, and that is not of the same character. It may be well to compare their pronounced symp- toms as an aid in diagnosis. Pulpitis. Pericementitis. The pain is of a sharp, lancinating The pain is dull, steady, boring, character, and in its earlier stages it throbbing in its character, and is not is distinctly paroxysmal. at all paroxysmal. The tooth is exquisitely sensitive There is no sensation to changes of to thermal changes: in its inceptive temperature, and neither cold nor state cold, and in its later condition hot applications materially affect it. heat, exacerbating it. There is no swelling of the tissue The tooth becomes exceedingly about the tooth, and no tenderness to sore, and the least pressure upon it pressure in ordinary cases. causes' pain. In the later stages swelling is common. It is at times quite difficult to de- There is no trouble in deciding termine exactly which tooth is af- which tooth is the diseased one, the fected, the pain being fleeting in its pain being steady in degree and in nature. position, and the soreness readily locating it. The pain is apt to be worse upon The pain remains nearly constant going to bed, and excitement and without much reference to external fatigue increase it. conditions or circumstances. It is possible to bite upon the tooth The tooth is very sore to the without any special sensation, and to touch, any occlusion in mastication use it in mastication, if thermal ex- or ordinary shutting of the mouth Iremes be avoided. giving pain, irrespective of thermal changes. The tooth is not elongated, nor The tooth is raised in its socket, does it strike first in occlusion. and strikes before any of the others occlude. Treatment of Pericementitis. The first care should be to give the offending tooth rest, by preventing its occlusion. This may be done by placing gutta- PERICEMENTITIS. 91 percha caps over other teeth, to prevent the striking of this. The cause should be determined, and if possible removed. If it be infection from a dead pulp, the chamber should be carefully cleaned and sterilized, and an anodyne applied in the root channel. It may be advisable to seal up in it some of the essential oils, properly diluted, such as cassia or cloves, as an antiseptic. A counter-irritant should be applied over the apex of the affected tooth, for the same reason that it is used in pulpitis, and it is even more likely to be efifectual. The same general remedies may be employed, such as saline cathartics, diaphoretics and nervous sedatives. Refrigerants are. useful, and lumps of ice wrapped in muslin may be placed between the lip and the tooth. If these are not effectual, resolution may sometimes be in- duced by hot fomentation upon the face and neck. Prof. C. N. Johnson recommends that water as hot as can be borne be directed upon the part, with some force, for twenty or thirty minutes, to promote resolution. An acute pericementitis has also been readily aborted by the precisely opposite treatment of directing an ether or rhigolene spray upon the part until it has become bloodless. Both are useful, but are best adapted to dififerent stages of the disease. If infection is present Prof. A. W. Harlan recommends the administration of one-tenth of a grain of calcium sulphid every ten minutes for an hour, the interval then to be grad- ually increased. If there is a great degree of pain, the following may be administered: 3J — Acetanilid., gr. viij ; Syr. simp., 5ij ; Spts. frumenti, oij. 5"!^. — One-half at 6 p.m., the remainder four hours later. The patient should be given a hot foot-bath, placed in bed and kept warm. If the inflammation is exceedingly acute, scari- fication of the gums about the affected tooth may be resorted to. If there is great tension of the tissue, a sharp-pointed scalpel or bistoury may be used to cut through the gum tissue over the apex of the tooth, a little cocain having been previously applied, or the point of the instrument dipped in pure carbolic acid and applied to the surface until it has become white, when it mav be forced through the alveolar walls until the seat of inflammation is reached, thus removing the tension and giving immediate relief. \> 92 ORAL PATHOLOGY AND PRACTICE. CHAPTER XXVI. ALVEOLAR ABSCESS. An Abscess is the formation of pns somewhere within the body, as the result of some local or circumscribed inflammation. An Alveolar Abscess is an infective inflammation within the alveolar walls. It may be the result of some foreign substance acting as an irritant, or some injury may have been the exciting cause. Either of these agencies may result in an inflammation so violent as to induce a breaking down of tissue, and infection with sup- purative organisms will induce the formation of pus, which reaches the surface by the route presenting the least resistance. An alveolar abscess does not, therefore, necessarily presuppose the death of the pulp. If the inflammation does not materially involve that tissue, or if the pericementum involved does not include that from which the blood supply of the tooth is derived, an alveolar abscess may be established without pulp devitalization. But such a condition is not that which is usually denominated alveolar abscess. The common acceptation of the term is that affection which is the result of inflammation and death of the pulp, its infection, and the consequent inflammation and infection of the pericementum from contiguity of tissues. If we take up the subject of the last chapter at the point of its closure, and suppose the pulp of a tooth to be devitalized as the result of stasis of the blood currents, with the consequent stoppage of all nutrition through a distinctive inflammation, the next inquiry will be concerning the final disposition of the devitalized pulp. If there is no source through which it can become infected with micro-organisms, it will probably become mummified and desiccated; the moisture will be absorbed from it, and it will assume the condition of dry gangrene, in which it will remain for an indefinite period without being the cause of any irritation what- ever. If, however, such a pulp chamber be opened without the strictest antiseptic precautions, perhaps years after the death of its contents, germs of infection will be carried in upon the non- sterilized instruments or admitted with a particle of saliva, and septic inflammation, with perhaps consequent alveolar abscess, will be the result. ALVEOLAR ABSCESS. 93 The infection may arise from either one of two sources. If there is a cavitv in the tooth that penetrates to the neighborhood of the pulp, the bacteria may there find entrance, and decomposing the pulp tissue by putrefaction they may cause the formation of oiifensive gases, which forcing their way through the foraminal openings will act as an irritant upon the pericementum, and induce an acute inflammation of that tissue. If there is no special cavity of decay in the tooth containing the recently devitalized pulp, through which infective organisms may find entrance, it may still become contaminated from some other center of infection that may exist in the body. The bacteria may be transported by the blood, or may in some other manner be carried within the body to the dead tissue, and in this manner form a source of contagion. By whatever method the pulp becomes inoculated with putrefactive or suppurative organisms, whether from external sources or by auto-infection, the result will be the same, — the formation of suppurative products and the infec- tion of the pericementum and other tissues in the neighborhood of the foraminal openings. Pus will then be formed and an abscess established. TJie condition that has existed up to this point is frequently denominated Incipient Alveolar Abscess. This simply implies the earlier stages of the destructive inflammation, before pus shall have been fully formed, during which period it may be possible to abort the abscess, or prevent the breaking down of tissue. A Blind Abscess is one in zvhich there is a cavity of decay com- municating zi^'ith the pulp chamber, and in zchicli it is possible for the pus to be drained through the pulp canal. If the pus forces its zvay to the surface through the alveolar zualls, it establishes a fistulous opening constituting a Discharging Abscess. The formation of an alveolar abscess depends upon infection by septic organisms. These are always a source of irritation, and induce inflammatory conditions. The pericementum about the foraminal opening of the root of a tooth being thus aiTected, there will ensue under the stress of the inflammatory conditions the phenomena described in the chapter (\T.) on General Inflamma- tion. There will be changes in the blood vessels of the vascular tissues that will finally result in diapedesis, or the pouring out of the jjlastic lymph. This will be infected by the organisms, and in- 94 ORAL PATHOLOGY AND PRACTICE. stead of being either removed by resolution or built up by regular progressive metamorphosis, it will be broken down. The leuco- cytes, or white blood corpuscles that have thronged to the irritated neighborhood, will lose their vitality through the irritation and infection, and assume the character of pus corpuscles; the invest- ing tissue will be broken down and decomposed, thus forming a cavity about the foraminal opening; the water of the tissue and the serum of the blood will mingle with these, and the whole mass will be that fluid that forms the contents of the abscess cavity, and which is discharged from the fistulous opening as pus. There may be about the periphery of this pus cavity, when so formed through the breaking down of the tissue, a partial attempt on the part of nature to build the exudate into tissue. It may possess a kind of consistency, and this par- tially organized, partially desiccated plastic lymph will form a line of demarcation that will enclose the disturbed territory. Upon its periphery it will exhibit the characteristics described, but its center will be a collection of pus and disorganized lymph. If the tooth is now extracted, this mass may be found clinging to the root, the size of an ordinary pea, and when so removed with a deciduous tooth it has been mistaken by the unintelligent for the germ of a permanent tooth. It is only the plastic exudate that filled the cavity produced by the breaking down of the tissue, whose surface is desiccated or dried, while its interior is completely broken down. The infected point may not be at the foraminal apex of the tooth. The fact that the blood and nerve supply of the dental pulp are derived from the pericementum, and that channels analogous to the Haversian canals of bone may in comparatively young persons communicate with the pulp through the cementum and dentin at almost any point, naturally introduces another complica- • tion in the proper treatment of so-called dead teeth. Not infre- quently is an exceedingly sensitive point found somewhere along its course when a broach is passed into the pulp canal of a devital- ized tooth, and it may be that the oozing of blood and serum from such a point, even after the foramen has been stopped, will give great annoyance. This may be the mouth of one of these communicating blood channels, and it is easy to comprehend that the pericementum at the point at which this is given off may ALVEOLAR ABSCESS. 95 readily become infected from a septic canal, and thus form a focus of inflammation and disorganization quite distinct from that about the usual foraminal opening. The latter may be thoroughly drained and completely sterilized without beneficial result, because it is reinfected from another opening in the pulp canal as fast as it is rendered innocuous. In teeth having more than one root, these collateral vascular branches are sometimes given ofif from the pericementum at the bifurcation, and at these points may be established a focus of infection and inflammation which it is difficult thoroughly to drain, and impossible entirely to disinfect and sterilize. Pus having once formed at any point about the periphery of a tooth, it becomes necessary for it to be evacuated, as it is essen- tially a foreign body possessing peculiarly irritating properties. It secures egress through the breaking down of the tissue that encompasses it. The pressure of the gases of putrefaction that are evolved, with that of the constantly increasing pus, causes resorption of the investing bone, while the inflammation and infection induce progressive decomposition, and thus an opening is made to the surface, the pus is evacuated and the acute symp- toms^pass away. If no remedial measures are instituted, the sinus perhaps then closes up and the patient may fancy that a cure is established. But the pericementum at the infected point, and the tissues about it immediately involved, remain in a septic condition, and the efforts of nature to restore a true physiological condition are made nugatory by constant reinfection. An acute inflammatory stage again ensues, the plastic exudate is once more poured out, only to be reinfected, with a fresh breaking down into pus. The abscess "gathers" again, but this time, as the old sinus will not have been completely obliterated, there will be less resistance, and the pus will with decreased difficulty reach the surface. This process may be periodically repeated until a complete and con- tinually patulous sinus shall have been formed, when all acute symptoms disappear and a chronic abscess is established, through the disorganization of the nutritive currents and the continuous effusion and uninterrupted breaking down that ensue. This con- dition may persist until a cavity of considerable extent shall have been formed in the alveolus, or even in the body of the bone. The course of the pus in reaching the surface in the 96 ORAL PATHOLOGY AND PRACTICE, usual forms of alveolar abscess is directly through the thin alveolar walls. This is the shortest route, and the one that ordinarily presents the least resistance. It may be, however, that special conditions point to a different road, and the pus may find some other cavity, and finally be discharged into the anterior or posterior nares, or into the maxillary sinus. Or, penetrating the alveolar walls, it may reach the fascia, and follow along the course of a muscle until it arrives at a point considerably distant. A discharging abscess under the chin, the direct result of a devital- ized inferior incisor tooth, has often puzzled the medical man, who never once thought that the dentist might give quick relief. Pus has been known to burrow along the fibers of the platysma- myoides muscle until it has reached the clavicle, or, penetrating the cervical fascia, finally strike the omo-hyoid and follow its course until it emerged at the point of the scapula. In some instances of rather indolent abscess, the pus makes its way through the alveolar walls until it reaches the periosteum of the bone, which it detaches, and spreading out beneath it com- pletely cuts off all periosteal nutrition, — a condition which, if not relieved, will result in osseous necrosis. This may be observed more frequently in the vault of the mouth, when the pus has penetrated the palatal process of the superior maxillary. The tough, fibrous character of the tissue immediately beneath the mucous membrane of the roof of the oral cavity presenting a great obstacle to the course of the pus, it not infrequently spreads over a considerable portion of one side of the vault. There are cases in which the pus burrows to some distance in the alveolus, establishing separate pockets v^^hich become distinct points of infection. In one such instance, from an infected point at the apex of a superior cuspid, which had a discharging sinus between that and the point of the lateral incisor, and which persistent treatment failed to cure, a secondary sinus was finally traced back to a point between the first and second premolars, or bicuspids, where was a second focus of infection, and from this another led yet farther, back of the roots of the second bicuspid, where there was a third pus chamber. It was not until all these were explored and sterilized that anything approaching a cure could be obtained. These secondary pockets, or foci of infection, whether upon the periphery of the tooth as the result of a former collateral SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. 97 blood supply to the pulp, or existing as pockets within the alveolus in consequence of the burrowing of pus back into the bone, are especially perplexing to the practitioner, because he never knows when to expect them, and he has no early means of diagnosing the septic condition. After the proper disinfecting and sterilizing process has been resorted to in vain, it may be suspected that there are somewhere foci of infection that have not yet been reached by the remedies used. The continuation of the discharge of septic or sanious matter indicates that disinfection and anti- sepsis are not complete, and no entire cure may, under such condi- tions, be expected. CHAPTER XXVII. SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. The objective as well as the subjective symptoms of Alveolar Abscess are sufficiently pronounced to obviate any mistake in diagnosis. That which is under special consideration, the result of the infection of the contents of a pulp chamber or canal, begins witn a pericementitis that gradually increases in severity. The soreness is extreme; the tooth is materially lifted in its socket and becomes loose, with that peculiar feeling of non-support that indicates f^uid at the extremity. This is the extravasated lymph and serum. Within a few hours there is the distinct febrile condi- tion, with its elevatibn of temperature, quickened pulse and suc- ceeding rigor, the septic fever that invariably indicates the forma- tion of pus and which is idiopathic. The red line or red blotches that are characteristic of pericemental inflammation, and which are peculiarly observable up to this point, now begin to fade away or to be succeeded by a deep red that is continuous with that of the neighboring tissues, and there is, in very acute cases, a tumor or distention of the alveolar walls. The pain, which is deep-seated, continuous, and of a boring character, is now intense, but there is little swelling of the soft tissues. The pus is burrowing its way toward the surface of the bone, and the pressure exerted by the confined matter is the source of the suffering. This continues until the alveolar walls have been penetrated, and the pus escapes into the soft tis- 8 98 ORAL PATHOLOGY AND PRACTICE. sues. Great swelling now ensues, with amelioration of the pain, consequent on the escape of the confined fluid into the tissues that can yield to the pressure. Sometimes the infiltration of the tissues by the inflammatory products is so great as to close the eye and greatly distort the face. But, although the appearance at this stage is much more serious and alarming than at previous ones, the pain and soreness are very much less, and the tension is re- lieved. Finally, there is "pointing," fluctuation may be distinctly detected beneath the finger, and the abscess is ready for the lancet. The general indications of the septic condition, the infection by pyogenic organisms and the formation of pus, will be as fol- lows: Anorexia, or loss of appetite; chills, or rigors of a more or less pronounced character; headaches, sharp and persistent; fever of a distinct type — septic fever; coated tongue; constipation; urine scanty and of a high color, and, finally, nervous disturbance, vary- ing from m.ere restlessness to violent delirium, according to the extent of the septic poisoning. If there are wounds through which the infection takes place, their edges will become red, swollen, tense, and angry in appearance. Treatment. Abortive measures should be instituted in the early stages of the pericemental inflammation. At this time counter-irritants, hot foot-baths, with laxatives and diaphoretic remedies, will be found useful. If a dead pulp is present, the pulp chamber should be opened under the strictest antiseptic precautions. The rubber-dam should be placed upon the tooth, to segre- gate it from the septic fluids of the mouth. The drill should be carefully sterilized, either by heat or by being allowed to remain a little time in some germicidal fluid. Debris should be removed from the cavity of decay, if such cavity exists, and it should be effectually sterilized with a bichlorid or some other energetic solution. As soon as the walls of the pulp chamber are punctured, the drill should be withdrawn and a sterilizing solution injected or carried in upon a pledget of cotton. The opening may now be enlarged, and the antiseptic or germicide carried to every possible point of the pulp cavity and canal. With a sterilized broach, all debris and remains of the decomposed pulp should be removed, and the canals made as clear of obstruction as possible. A few fibrils SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. 99 of cotton dipped in some antiseptic, such as one of the essential oils, mav be carried as near the apex of the root as possible^ and sealed up in the cavity. If there is much pain, some anodyne, like tincture of opium, may be introduced into the canal on a very few fibers of cotton. This treatment, both local and general, should be continued until the inflammation with its soreness and pain shall have passed away, when operative measures for the preservation of the tooth and its protection from further attacks may be instituted. If from any reason the treatment shall prove ineffectual, the inflammation gradually becoming worse until the symptoms give indication that resolution cannot be expected, that degeneration has already commenced and infection has taken place, the treat- ment should be promptly changed, and suppuration encouraged. The general abortive measures must be abandoned, and the pus directed toward the surface. Warm fomentations may be used, a cloth wrung out in hot water being applied to the face over the seat of trouble, and carefully covered, while the patient is kept warm. Indications of "pointing" must be carefully noted, and any tendency toward the exterior of the face should be re- pressed by painting it over with iodin solution, the application of cold, and other like measures. A poultice consisting of the fresh surface of a split fig, or raisin, that has been warmed and softened in hot water, should be placed over the alveolar wall opposite the root of the tooth or within the oral cavity where it is desired that the abscess shall point, and suppuration invited by that channel. This process should be hastened by every available means, that the formation of secondary pockets, with osteitis, or inflammation of the bone corpuscles, may be avoided. If the indi- cations are that the pus is burrowing in the wrong direction, thus threatening a prolongation of the condition, with the probable infiltration of the bone by septic products, the practitioner should lose no time in reaching the disturbed place with an instrument, and thus establishing a sinus at the proper point. The pus evacuated, the next step should be the disinfection of the whole territory. The pulp chamber should be opened and cleaned out, and the principal foraminal opening made patulous. About the extremity of the point of a suitable metal syringe, a rope made of a sufficient quantity of cotton fibers dipped in a chloro- lOO ORAL PATHOLOGY AND PRACTICE. perclia solution may be wound, the point introduced into the cavity of decay, or that artificially made into the pulp chamber, and the cotton then closely packed around it. The barrel of the syringe filled with tepid water may now be attached and considerable force used until the stream entering at the pulp chamber emerges at the fistulous opening. The barrel of the syringe is now removed and filled with a solution of three per cent, pyrozone, or with electro- zone, and this is injected as a disinfectant. This is succeeded by a solution of bichlorid of mercury or some other effective germi- cide, and the cavity may be sealed up for a day or two. If at the end of sufficient time the indications warrant the belief that sterilization is complete, and that there are no secondary- pockets of infection, the root may be permanently filled. If, how- ever, the septic condition continues in the least degree, or if there are signs of osteitis, the cavity should be opened and the sterilizing process repeated, or an antiseptic anodyne introduced still further to test the case. If the fistula is an old one and the abscess not of recent forma- tion, and especially if there are no acute symptoms, thus indicating a chronic condition, something more active should be introduced as an antiseptic. After the cleansing out of the pulp chamber and the root canal, the rubber-dam should be applied and a broach wound with cotton fibers dipped in a saturated solution of carbolic acid introduced, and the caustic antiseptic pumped through the tooth and along the sinus until it appears at the fistulous opening, where it may readily be detected by its turning the tissues white. This cauterizes the whole tract, inducing sloughing to a limited extent, and brings on acute symptoms, with effusion of plastic lymph, which in the thoroughly sterilized territory may be built into tissue by regular progressive metamorphosis. A solution of chlorid of zinc, five grains to the ounce, may be forced through with a syringe in these chronic cases, and this may bring about an acute condition and stimulate the indolent func- tional activity. Some operators proceed at once to fill after a single treatment such as has been indicated, but unless there are special reasons for haste it is better and safer to wait until it has . been thoroughly demonstrated that there are no secondary pockets or foci of infection, and until the reparative process and the up- building of the waste territory has fairly commenced. This may SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. lOI usually be determined by the dryness of the root canal. To test this a fine broach should be thrust to the apex of the root, or as far as possible, quickly withdrawn and wiped upon a piece of rubber-dam. Any moisture will show at once, and will indicate that there is still a septic condition. There are instances in which it is impossible to force fluids through the foraminal opening or openings. This will more fre- quently be the case with the molar teeth, in which perhaps the infected point will be at the opening of one of the buccal roots, but it may occur with even the anterior teeth. Some operators insist that they are able to open the apices of such roots with a drill, but when it is recollected that seldom or never is the foraminal opening in a direct line with the canal, it will be found that none except men of the most phenomenal skill will be equal to this task. The average operator will hesitate before proceeding to such heroic measures. If it is impossible to pass a flexible broach through the foraminal opening', or to establish communication between the out- side and the inside of the apex of the tooth, after the cleansing of the canal and the use of the general remedies recommended, the antiseptic may be introduced on a few fibers of cotton as near the apex as possible, and then sealed up within the tooth. The agent used should be one that is of as penetrating a nature as possible, and the experiments of Miller show that in this respect none possess any special advantage over pure carbolic acid. It should be changed as often as necessar}', sometimes every hour, until the pulp canal is thoroughly and completely sterilized. Then by slow infiltration and absorption it will be carried beyond the apex of the tooth and sterilize the investing tissues. It may be necessary to continue such treatment for some time, especially when the inflam- mation is of an indolent, subacute character. But when the pro- cess is complete the sinus that may have existed will disappear, and all inflammatory signs will depart. Sometimes treatment from the outside is the only resource. There are instances in which none of the usual curative measures are effectual. It is impossible to get through the foraminal open- ing, or perhaps the dentist has been too precipitate in filling the root and tooth with a material that it is difficult to remove. In such a case the seat of disturbance must be reached by establishing a sinus, or through that already in existence. With a properly I02 ORAL PATHOLOGY AND PRACTICE. shaped inflexible probe it is usually possible to follow the course of a discharging canal to the apex of the root. A few fibers of cotton wet with a solution of cocain, or with carbolic acid, should first be introduced as an obtundent, and allowed to remain for a short time. The probe is then introduced, and the sinus carefully explored to its extremity. It will usually be found that the open- ing through the external alveolar wall is considerably above the fistulous opening, and its course may not be a direct one. But a little patience, with the knowledge obtained by some experience, will enable one to reach the apex of the root with comparative readiness, provided the lesion is not upon the palatal root of a superior molar. Having clearly outlined it, the opening may now be enlarged with a trephine or drill, if it is necessary, and the proper remedies carried to the diseased point. Deposits may be removed from the root, or its apical point amputated if necessary. All debris having been removed, and the parts carefully sterilized, granulation from the bottom wall probably close up the opening. If it does not, the operator may be assured that there is dead or foreign matter in the cavity, or that it has not been effectually sterilized. In filling a sterilized devitalized root, it is not at all essential that the filling material shall be pushed farther than the junction of the dentin and cementum, at the point where the division of the canal into the foraminal delta begins. The broach will readily indicate this point, because it is sensitive beneath it. It is only the dentin that is devitalized, the cementum which forms the real apex of the root retaining its vitality. The delta or divided canal exists within the living cementum, and hence does not need to be filled. Dentists sometimes find this point exceedingly sensitive, and imagine that the pulp is not yet wholly devitalized. They perhaps introduce arsenical paste, and so do considerable injury. They should remember that the cementum at the apex is probably in an irritable condition, and needs an anodyne rather than a corrosive poison. There are instances in which the inflammation stops short of the formation of pus. The plastic exudate has been poured out, and has infiltrated the tissues and caused a distinct swelling. But the degenerative process has not begun, either because there is no septic infection or because sterilization has destroyed the organism. The inflammation is of a low, subacute DEPOSITS UPON THE TEETH. IO3 character, and there is no pain or violence. The plastic exudate loses its usual consistency, either through the extraction of its watery part or because of some partial organization or other change, and has become indurated. The swelling is perhaps within the bone, and there is a distinct protrusion of the external wall. This condition may remain for an indefinite time, and it sometimes causes considerable deformity of the jaws. If this is the result of a pericemental inflammation at the apex of a devitalized tooth, resolution or reabsorption may usually be brought about by the injection through the tooth of tincture of iodin. If the foraminal apex is not open, cotton saturated with tincture of iodin may be sealed up in the tooth cavity, and changed as occasion requires, until the process is completed. If the offend- ing tooth is extracted, there will usually be immediate resolution, but this is not always advisable, and the iodin treatment may be resorted to for the slow relief of the indurated condition. CHAPTER XXVIII. DEPOSITS UPON THE TEETH. Under this head will be considered such superficial precipi- tates of inorganic matter as may induce pathological changes. They must be derived either from external sources or from some of the fluids of the mouth or the body. There are many forms of oral debris, the sediments of organic matter, deposits of food, etc., that will not properly come within this category. The "white deposit," that cheesy deposition that is so often found encircling the cervical portion of the tooth and forming a narrow white line just at the gum margin, belongs to the latter class. It is composed of the debris of food that is partially fermented, micro-organisms, etc., and when it has been allowed to remain for any length of time the tissue immediately beneath it will be found partially decalcified and softened. But the deposit itself is not of a calcareous nature, and is easily removed by the brush. The so-called "green stain" of childhood is wholly superficial. It is called "green" stain, although it may be dark, or bronze, or yellow in color. It has by some been considered a disease-pro- rlucing kind of fungus, which penetrates the substance of the enamel, disintegrating it, and thus injuring the tooth. ^But if one I04 ORAL PATHOLOGY AND PRACTICE. will immerse a tooth discolored by it in a ten per cent, solution of lactic acid he will in a few moments see the so-called Nasmyth's membrane separate from the tissue, and it will carry with it all the deposit, leaving the exterior white and uneroded. Sometimes it is found upon the surface of eroded, or even decayed enamel, but it can be removed in such a manner as clearly to indicate that it was deposited subsequent to the erosion, or caries. It has, then, no special pathological signification, except so far as it may be a symptom of some unhealthy condition of the fluids of the oral cavity. Salivary calculus is a deposit from the saliva. If one will through a tube breathe into a glass of lime-water, he will soon observe that the fluid becomes milky in appearance. If he will continue the process for a while, and then set the glass where it will be entirely undisturbed, he will after a time find deposited upon the bottom more or less of a fine amorphous powder. This is the calcium that was held in solution in the water, and which was thrown down as carbonate of lime. A few drops of hydro- chloric acid will clear up the fluid by again dissolving the pre- cipitate. It is in an analogous manner that the deposits of salivary calculus, which are composed of carbonate of lime, are formed. The CO, of the breath uniting with the saliva which contains the calcareous matter, the latter is at once precipitated. Naturally it will be found in greater quantity near the mouths of the salivary ducts, and so the largest deposits are upon the inferior incisors opposite the mouths of Wharton's duct, and upon the superior molars opposite the discharging mouth of the duct of Steno. Sometimes this material is precipitated in great quantities, binding several teeth together in one mass. In some instances the utmost care of the patient will not enable him to keep the teeth entirely free from it. This will usuall}^ occur in the presence of an alkaline reaction. In mouths in which the oral fluids are acid it will commonly be continued in solution, and not precipitated on meeting the breath. When it is deposited in great quantities it is usually soft, of a creamy yellow color, and is easily removed. When it is deposited more slowly it has time for consolidation and becomes hard, and is usually stained a dark color by pigmentary matter from the oral cavity. It has no special pathological signification aside from the fact DEPOSITS UPOX THE TEETH. IO5 that it is a mechanical irritant, and keeps the teeth and mouth in a filthy condition by constantly acting as an absorbent, and as an obstruction against or under which food debris lodges. It should be carefully removed with instruments, the teeth polished, and, if necessary, the irritated gums touched with a stimulating astrin- gent. The so-called sanguinary or serumal calculus has another origin and is distinguished by separate characteristics. It is not found external to the margins of the gums, nor is it a precipitate from the oral fluids, — for no reference is here intended to the hard, black, smooth, supragingival, slow deposit which is but a modifica- tion of the usual form of calculus and is undoubtedly of salivary origin. The so-called serumal deposits are upon the side of a root that is not denuded when they are formed. They may be found when there is absolutely no break at the gingival border, and when consequently their precipitation from the oral fluids would be an utter impossibility. Instances of this are cited in the chapter on Pyorrhea. It is not deposited in a smooth, continuous, amorphous mass, as in the case of salivary calculus. It is found in dense, hard, closely attached, separate nodules, which may by further deposition become confluent. It cannot be scaled off cleanly and readily, as can the oral variety. It clings so closely as to make it necessary to chisel it away, in which process, unless great care is used, a scale of the tooth may be taken or a thin layer of the deposit left. It has not the same color as the salivary concretion, the latter, except when it has been discolored by subsequent pigmentary deposits or infil- trates, being of a dark yellow or yellowish white color. The serumal or sanguinary deposit is of an olive-black tint, with some- times an olive-green tinge. It is never identical, either in color or in manner of deposition, with salivary concretions. It is more distinctly irritating to the tissue than is the salivary deposit. Perhaps the location of it within the tooth socket may serve to account for the difference, but aside from that there appears to be a rather distinctive irritation in its presence, not known in connection with the salivary deposit. Chemical analysis shows that there is a synthetic difference between the two, for, while calcium forms the base of both, the serumal contains certain elements not found in the other. The I06 ORAL PATHOLOGY AND PRACTICE. analyses of it have not been sufficient in number or so exhaustive in character as to reveal all that may probably be learned from them. It is, then, accepted that this calculus is and must be derived from the blood, through the pericementum. Just what are the pathological changes accompanying its deposition has not yet been definitely determined. Whether it is a manifestation of the uric acid diathesis, and the concretions are the result of the lack of elimination of effete matter, as claimed by the advocates of that special origin of the pyorrheal condition, or whether it is a degenerative state of the pericemental membrane, the initiatory lesion being in that organ, has not yet been fully ascertained. One reason for supposing that it may not be due to a constitutional dyscrasia, that it is not a manifestation of a general disorder, but rather a symptom of a local degeneration or disturbance, is found in the fact that it is usually confined to one or two teeth. Certain it would seem to be that the trouble is not in the tooth itself, for the cementum does not appear to be affected in any way, further than secondarily through the mere mechanical separation from it of the pericementum. No morbid changes have been recorded as occurring in that membrane, except subsequent to the deposition of the calcific matter. Nor has any immediate connec- tion with other calculous deposits yet been traced. In gout and rheumatism there are enlargements of the joints, and sometimes intra-articular deposits of calcific matter. Concretions are found in the salivary and other ducts, but they seem to bear no relation to those of pericemental origin. Calculi are found in the bladder, the kidneys, and the prostate gland, but not coincidently with serumnal deposits upon the teeth; hence it would scarcely be inferred that they were part of an expression of the same pathological condi- tion. As far as our present knowledge goes, it must probably be accepted that these concretions are deposited by the pericementum upon the tooth, because of or through some aberrant or disturbed functional activity, the exact origin and progress of which has not yet been determined. The early presence of sanguinary calculus is not easily deter- mined. Salivary calculus exhibits itself unmistakably to the eye, and so there can be no error in its diagnosis; but such is not the case with the sanguinary concretion. It is hidden within the tooth PYORRHEA ALN'EOLARIS. lOJ socket at a point where examination is impossible. No prophy- lactic measures can therefore be employed. There may be a localized inflammation, with pustular swelling, but this comes too late for preventive measures. When a pocket reaching- down to the deposit has been formed from the gingival margin, there is nothing left but its instrumental removal. There are instances in which pericemental irritation and sore- ness may, to the expert, give some warning of nodular formations. But these are too easily confounded with those which may be caused by hypercementosis, or by the presence of any other foreign substance, to afford any positive pathognomonic sign. \\'hen we comprehend the morbid changes of the disease better perhaps we will recognize premonitory indications, but, as it is, we must wait for its development. The usual revelation will come through the formation of the characteristic pockets beside the affected tooth, and the point of irritation, when near the apex of the root, may in some instances be detected by the localized inflammation and swelling. The treatment for the condition is laid down in the chapter on Pyorrhea Alveolaris. CHAPTER XXIX. PYORRHEA ALVEOLARIS. It is not a matter for lioastfulness that so little should posi- tively be known concerning a disease that, after caries, is responsi- ble for the loss of more teeth than any other. It is but recently that any attention whatever has been paid to it. For many cen- turies it has been doing its destructive work without remark and Avithout any attempt to determine its pathology. Not alone in man is it prevalent, but many animals suffer from its ravages. Do- mestic cats are especially liable to its attacks, while dogs are far from cxemjjt. Horses sometimes suffer extremely from it, but their teeth are not as often extruded and lost, because of the length and shape of the roots, which do not end in a closed foraminal opening. None of the teeth of persistent growth in the various orders of animals are materially affected Ijy these disorders, so far as the author is aware. I]ut he has in his possession the skull of an African gorilla, an animal that it has been found impossible to I08 ORAL PATHOLOGY AxXD PRACTICE. keep in captivit}^, in which the characteristic appearance of this disease exists unmistakably. The condition has been known by various names. The late Dr. J. M. Riggs, of Hartford, Conn., was probably the first to call public attention to it, about the year 1850. For some time it was called from him "Riggs' Disease," but the impropriety of this being manifest, the term Pyorrhea Alveolaris was proposed, and has been generally accepted. Prof. G. V. Black has denominated it "Phag- edenic Pericementitis," which is expressive of his very intelligent conception of its pathology. Dr. J. N. Farrar has proposed the name "Loculosis Alveolaris," from the fact that, very often at least, it has its origin in a kind of pocket beside the alveolus. Others, recognizing a communicable nature, have denominated it "Infectious Alveolitis." When its true nature and exact pathology are determined, a term that is descriptive of it will undoubtedly be universally accepted. In the meantime Pyorrhea Alveolaris, which signifies a discharge of pus from the alveoli, although somewhat in- definite, is as applicable as any. It has been intimated that the exact nature of the disorder has not yet been determined. At least no exposition of it has been generally accepted. That its seat is within the alveolar socket is easily demonstrated, and that either the tooth root or its investing membrane is an essential factor in its existence is quite plain, for extraction always affords a radical cure. Beyond this there is no admitted certainty concerning its etiology. Professor Black be- lieves the initial point to be in the pericementum. Others have held that it commences with a degenerative condition of the in- vesting margin of the alveolar process. Prof. W. D. Miller says that there are three active factors in its production; constitutional diathesis, local causes, and micro-organisms. Perhaps the hypothesis that has attracted the most attention up to this point is that so strenuously urged by Prof. C. N. Peirce, Prof. E. C. Kirk, and others, that it is but an expression of the uric acid diathesis, and is closely alHed to gout, rheumatism, and allied disorders. It has been asserted, indeed, that it is always connected with them, either as a forerunner, a successor, or a substitute. It is urged that as urea is the effete product of the using up of tissue in functional activity, which the excretory organs should eliminate, its presence in the body is an in,dication of inactivity on their part. It is undoubtedly true that such effete matter must, from its very PYORRHEA ALVEOLARIS. IO9 nature, by its continued presence excite a more profound influence than would any innoxious foreign substance. We all know the extreme violence and general character of the protests of all the tissues of the body against its presence when manifested in uremic poisoning. The dense, hard, dark-colored nodules sometimes found vipon the roots of teeth, and which are considered in Chapter XXVIII., dealing with salivary and sanguinary calculi, it has been claimed are induced by and contain the urates of the blood, and are prime factors in inducing the pyorrheal condition. Could these asser- tions be substantiated as indisputable facts in all cases, they would be conclusive. But it is urged in answer that it is not positively demonstrated that the concretions referred to have their origin in the blood, that they are necessarily an expression of the uric acid diathesis, that they invariably contain any uremic salts, are at all essential to the pyorrheal condition, or are in any considerable proportion of instances the cause of it. They point to the fact that while they may be frequent or even usual concomitants, pyorrhea exists in its worst form without the presence of any such deposits, and quite unconnected with either gout or rheumatism. In the midst of this conflicting mass of evidence the only sure conclusion at which it is possible to arrive is that the subject has not yet been sufficiently considered, and that we have not verified ultimate facts. There is abundant cause for investigation and observation, and every real student should strive to add something to the knowl- edge of the subject, until enough has been learned to form a basis on which to build an hypothesis that shall be unassailable. Some patient investigator will yet solve the problem, as Miller gave us the solution of that of dental caries, which was for so long a time in the same unsatisfactory, unsettled, disputed condition. In the meantime it only remains practicable to present as clear an expo- sition as the present state of knowledge will permit. CHAPTER XXX. PYORRHEA ALVEOLARIS (Continued). True Pyorrhea Alveolaris should be a manifestation of some distinct, perhaps specific, pathological condition. The term itself, while expressive of our present knowledge, is too broad, covering no ORAL PATHOLOGY AND PRACTICE. altogether too much, for there are many exudations of pus from the alveolar walls that are easily explainable, and of very simple origin. But until its exact nature is distinctly marked out, and all its phenomena comprehended, we must recognize at least three separate pathological degenerations that are covered by the term, and which without doubt are often confounded with each other. The first of these will be entirely local in its character. It will have its origin in an easily comprehensible cause — local irri- tation. The second will have its etiology in deposits of a hard, nodular character upon the roots of the teeth. It will be distinguished by the formation of distinct pockets within the alveolus. The third will give evidence of some distinct cachectic condition or dyscrasia. It will present phenomena that are peculiar to itself, and will be without either of the two previously named factors. The first condition is a localized gingivitis, with possible alveo- lar caries, or a slow solution of the alveolar edges. It is charac- terized by inflamed, turgid gums, which are everted at the cervix. There will probably be a degenerate mucous secretion of a viscid character and acid in reaction. The gum is not adherent to the teeth, and the point of an instrument can be passed between them. Instead of the hard, dense appearance that the gingivae usually pre- sent, they bleed at the slightest touch. A little pus can be forced out from between the gum and tooth, but it is small in quantity and thick in consistency. The patient gives the teeth but little care, and they usually present anything but a healthy appearance. The redness is principally confined to the gum margin, and there are few or none of the peculiar red blotches higher up that are indica- tive of pericemental inflammation. An explorer cannot be passed up far beneath the gum, and, with the exception of roughened edges, the alveolar process is perfect. The prognosis of this condition is always good. The first care should be thoroughly to clean the teeth, and to remove from about their necks, especially from beneath the gums, any foreign substances that may have accumulated. Not infrequently delicate rings of salivary calculus will encircle them close up to the alveolar border. All traces of this must be removed, and the necks of the teeth be carefully polished. Sometimes foreign substances, PYORRHEA ALVEOLARIS. Ill like slivers from wooden toothpicks, or spiculae of bone from the food, will be found driven beneath the gums, and these will be the source of irritation. After careful cleaning the gums should be well rubbed, and a soft tooth-brush, with some antiseptic wash, should be prescribed. Listerine is good for this purpose, or any of the pleasant essential oils, largely diluted. Care and cleanliness, with the removal of every foreign substance, will be sufficient to produce a cure, for the condition was only the result of a lack of attention, and the irritating presence of foreign substances. The second condition is one of greater moment. It is charac- terized by the presence of deep pockets in the alveolus, at one side of the anterior teeth, or perhaps between the roots of the premolars or molars. There may be little of the turgidity or tumefaction described in the previous paragraph, but an exploration with an instrument will detect a resorption of the alveolar walls of the tooth socket, and pus may be forced out. Often the tooth, especially if it is one of the six anterior ones, will commence an inclination away from its neighbor. It loses its upright position, perhaps falls out of the line of the arch, and the previous regularity of a well- ordered dentition becomes sadly broken. The affected tooth is always deflected from the side on which is the pocket, and not toward it. A more careful exploration of this pocket will usually detect, well up toward the apex, or along the body of the root, dense, hard, gritty nodules, that are closely attached to the side of the root, enveloping more or less of the surface that has been denuded of its pericemental membrane, but which is yet covered by the gum. These are the sanguinary deposits described in the opening of this chapter. Whether these are the cause or the result of the diseased con- dition has formed a fruitful subject of discussion among etiologists. Those who believe them to be deposits from the fluids of the mouth insist that there must be some connecting opening between them and the oral cavity, along the side of the tooth. But competent observers have described instances in which there absolutely was none. One such case fell within the observation of the author. His associate in practice found opposite the lower third of the root of a lower central incisor, in the mouth of a woman who took excel- lent care of her teeth, a peculiar swelling that had somewhat the appearance of incipient alveolar abscess, but which had none of the other symptoms that attend that disorder. The author counseled 112 ORAL PATHOLOGY AND PRACTICE. pursuance of the expectant plan, and waiting for developments. In a very few days pus gathered in a comparatively small amount, and was discharged. The opening was enlarged, and opposite it were the characteristic nodules of the so-called sanguinary, or serumal calculus. Yet the gingivae were absolutely unbroken, and there was not the slightest indication of irritation about the neck of the tooth. The nodules were carefully removed, the open- ing antiseptically dressed, when it healed, leaving no sign whatever of the lesion, nor has any since appeared. It must be accepted that, in some instances at least, the serumal nodules are the first indications of the disturbance. Whether these are the result of any special diathesis we need not now in- quire. We know that they are specially irritative in their nature. If they form the initial point of the disorder, the subsequent patho- logical changes may be easily comprehended. They lift the peri- cementum from the tooth, and by their presence originate the breaking down of tissue. Infection follows, and the pus forces its way to the gingival margin, thus making an opening into the pocket already formed. Or perhaps the pocket is completed by the continuation of the deposits to the gum margin, the infection being subsequent to this. Perhaps, in a proportion of the cases, the deposition of the calculus commences at the neck of the tooth and proceeds toward the apex, forming the pocket from the margin instead of from the interior of the alveolar socket. The prognosis of this condition depends upon the ability completely to remove the deposits, and upon the general tone of the system, or its ability to bring about a restoration of the lost tissue. The first remedial measure is thoroughly to cleanse the teeth and pockets. This must be the v.'ork of time and patience. If the disease has extended so far as to induce much soreness and looseness of the tooth, it cannot be accomplished without considerable pain. So dense and closely attached is the deposit in many cases that a sharp, stiff chisel, with considerable force, is demanded. The drawing motion of a scraper is insufificient. Only the thin edge of a chisel will reach its last particle, which may lie just at the point of union of pericementum and tooth. There is no chemical agent that can be depended upon to dissolve the deposits away without injury to the sur- rounding bone and tooth. The usual mineral acids attack the PYORRHEA ALVEOLARIS. 113 latter quite as readily as the concretion. Trichloracetic acid has been found of benefit in softening it, so that it may more readily be removed with instruments. This may be used in from twenty to fifty per cent, aqueous solution, the exact strength to be determined by trial. It should be carried to the extremities of the pocket on a narrow, wedge-shaped piece of orange wood that has been dipped in the solution, and by a pumping motion continued for a sufficient length of time every nodule may be saturated with it. Or it may be carried upon a rope consisting of a few fibers of cotton wet with the acid. Dr. W. J. Younger, who has made a specialty of the treatment of pyorrhea, uses and recommends lactic acid for the same purpose, and claims that it is of special therapeutic value in this disease. It may be necessary to repeat the operation more than once, carefully chiseling or scraping ofif all that is practicable each time, until the root is clean and polished. The pockets should be washed out and treated antiseptically. Finally, when all the deposits are removed, a weak solution of chlorid of zinc may be injected as a stimulating astringent. It may be necessary to freshen the alveolar edges with a hoe excavator, or a safe bur, to induce new granulations. When there has been an effusion of coagulable lymph it should be protected, and not carelessly wiped or washed away. To this end it is necessary to know when to stop active surgical or operative measures, and to leave the rest to the vis nicdicatrix naturcc. Pursuing this course, the author has had the great satisfaction of seeing pockets that reached almost or quite to the apex of the root, and into which a considerable quantity of cotton could be packed, completely healed and filled with a new growth of bone through the action of a newly-formed perice- mentum. The prognosis of the third condition is almost inva- riably bad. It seems to be connected with some vicious consti- tutional condition that prevents eradication of the disease. There is frequently very little if any gingival inflammation. There is no thickening or tumefaction, and but little redness of the gums. Per- haps they may even be abnormally pale and bloodless. There are none of the pockets of the preceding conditions, but there is a steady wasting of the alveolus, a continual recession of the gums, with a constant and sometimes profuse discharge of pus from the sockets of the teeth. In the pocket form a single tooth may be 9 114 ORAL PATHOLOGY AND PRACTICE. affected, but in this state it usually spreads from tooth to tooth, until all or nearly all of either or both jaws become affected. There is no special pain, or any great degree of soreness until the later stages are reached, when the loss of the teeth seems imminent, and when the destruction of tissue goes on with such rapidity that it almost assumes the acuteness of alveolar abscess. There may be no deposits of any kind. The condition may occur in the mouths of those who are fastidious in the care of their teeth, and who regard its insidious but sure advances with horror. They fight it with every weapon at command. They may retard it for years, but it is seldom that it is entirely eradicated. The author has under his care instances in which it manifested itself twenty- five years ago, and though it has been kept in check, sometimes by the most radical measures, it still crops out occasionally, and he and his patient have never been long entirely separated. When a radical cure of this form of the disease has been effected, it has usually been because of some constitutional change in the general tone of the sufferer. It has ever been prone to attack anemic and atonic persons, though it is not confined to them, and when it has been eradicated it has been accompanied by a com- plete change in the bodily health of the patient, and a return to a tonic state. The treatment of this special condition must, to a con- siderable degree, be general in its nature. When tonics are required they should be administered. If there is any distinct diathesis with which it may be connected, that should be attended to. Antiseptics must be constantly used, and the mouth kept as free from putrefaction as possible. Stimulating, astringent mouth- washes should be frequently employed, and every hygienic pre- caution exhausted. The space between the gum and the tooth should be kept clean, and whenever necessary it should be wiped out with some mild cauterant, like lactic or trichloracetic acid. Massage should frequently be employed by rubbing the gum with the ball of the finger, using considerable force. The tooth-brush should not be too harsh, and washes rather than powders should be employed with it. In some instances the author has seen what he thought to be good results following the use of anti-gout and rheumatic remedies. The employment of lithia in some form, or of salicylic acid, has been especially recommended. Dr. E. C. Kirk has reported excel- FACIAL NEURALGIAS. II5 lent results from a persistent use of lithium bitartrate, in the form of tablets. If a tooth becomes very loose through destruction of the alveolar socket it is usually best to remove it, but when it is the result of an acute inflammatory stage, it may be held firmly for a time by weaving a ligature about it and the adjoining teeth. Sometimes there may be a decided amelioration following the burring away of the diseased edges of the alveolar process, with the use of antiseptics and stimulating astringents, but too often this is not permanent. \>ry little dependence can be placed upon the many specific methods and remedies offered by those who claim to cure the incurable. The best results will be attained by the practi- tioner who, to general medical intelligence, adds the most faithful, diligent, painstaking care in the line of treatment adopted. Of course, when the whole or nearly the whole alveolar socket of a tooth has been lost, further temporizing methods are useless. CHAPTER XXXI. FACIAL NEURALGIAS. Neuralgias are organic affections of a nerve, and may be either constitutional, functional, or local. Those first named arise from cachexia, and are associated with a constitutional diathesis. The second are due to disturbed nutrition and the consequent lack of tone, while the third originate in a direct lesion, or in some local irritation. An instance of the first is the general neuralgia of gout; of the second, that of miasmatic affections; while the third may be found in prolonged dental disturbances. Strictly speaking, any pain is a neuralgia, but the usual signification is confined to an affection of a nerve trunk, as distinguished from that caused by the irritation of a terminal filament. The continued pain arising from a neuromatous tumor is an instance of neuralgia from a true lesion of a nerve trunk. True neuralgias are principally confined to the afferent nerves, but they may be reflex and hence have their origin in the efferent or motor nerves. The facial neuralgias that form the majority of the afifections presented to the notice of the dentist are manifested in the trigeminus, and their most frequent cause is diseased teeth. Il6 ORAL PATHOLOGY AND PRACTICE. The irritation from caries may be so severe, or so long continued, that the trunk of the nerve is afifected and its function so modified that it remains in a permanently irritable condition. The diagnosis of this disorder is not always easy. That is, it is sometimes difficult to determine whether the pain arises from a mere local irritant, like the inflamed pulp of a tooth, or if it is a true degeneration or functional disturbance of the nerve tissue. In facial neuralgia the first thing to do is to look for the cause, and to determine whether it may not be mere odontalgia, or toothache. To this end the most minute examination of the teeth upon the affected side should be made. Cavities may exist beneath the gums which only the most careful search will reveal. Every test for in- flamed and irritated pulps should be tried, and in the great majority of instances the suspected neuralgia will be found to be mere tooth- ache. Every local cause having been excluded, the general bodily condition should be noted. If any distinct diathesis exists, like that of gout, rheumatism, syphilis, malaria, or catarrh, its possible connection with the disturbed neural currents should be looked for. If there is a state of anemia, or lack of nutrition, here may be its origin. The starved nerves are crying for the sustenance that they lack. All these sources excluded, a neuroma, or some other disor- ganization of the nerve tissue itself may be suspected. When this is the case and a true neuralgia is indicated, more minute in- quiries should be made as to the character of the subjective symp- toms. If neuralgic, the pain will be unilateral. Though not local, it will affect but one side, for bilateral disorders of this kind are something more than rare. The pain will usually follow the course of the trunk of the diseased nerve. That is, it may be recognized at different points in the route. It will be sudden in its attack. Its onset will not be a gradual approach, increasing in intensity until the climax is reached and then subsiding by degrees, but, from entire ease, in- stantly the victim is in the throes of the most agonizing torture. It will be of a darting, stabbing, boring character. It is not the steady, dull, throbbing, continuous pressure of a pus- gathering. FACIAL NEUIL\LGIAS. II7 It will be markedly intermittent. There will be intervals of complete immunity of greater or less length succeeded by- paroxysms that will end as suddenly as they begin. There may or may not be regularity in these attacks. In the earlier stages there is usually an increase in severity with each paroxysm, to be succeeded by decreas- ing violence. While the invasions are sudden in their attack and subsidence, there is a true paroxysmal character to their recur- rence, each one becoming more severe until the climax is reached, when the abatement will be as gradual. There is no functional disturbance connected with the attacks. The pulse will not be accelerated, nor will the tempera- ture rise. There is no fever or other general disturbance. This is an important pathognomonic symptom. In some instances, especially in cases of long stand- ing, there will be soreness along the track of the affected nerve. This may be especially marked at the foramen of exit. Anesthetic spots in the tissues supplied by the disordered nerve may assist in the diagnosis. Reflex symptoms in communicating nerves may be ex- hibited. There may be spasms and muscular twitchings. Tears may flow, the effect of reflex irritation, or salivary secretions may be markedly increased. Fatigue and depressing influences bring on attacks, or exacerbate them. The receipt of distressing news will be likely to provoke an attack. Sleeplessness or any unusually prolonged exertion will be likely to be followed by paroxysms. The clinical history is usually quite distinct and marked. Neurotic persons, and those with an unbalanced nerv- ous organization, are especially liable to attacks. Hence the neuralgias are frequently closely related to hysteria, migraine, sick- headache, hypochondria, paralysis, catalepsy, epilepsy, and other nervous and convulsive disorders. Clavus hystericus is but another special form of it. It usually accompanies or indicates an atonic, debili- tated condition. It is sometimes among the sequelae of a long- continued fever or other exhausting disease. It is especially liable to attack those who are suffering from malaria or miasmatic fevers. In such instances it some- times assumes the form of "brow ague." Il8 ORAL PATHOLOGY AND PRACTICE. The gouty and rheumatic diathesis seems especially provocative of different forms of neuralgia. Among these, sympathetic affections of the trigeminus, or fifth cranial pair, are not uncommon. Indeed, sympathetic pains along the course of communicating branches or nerves, or through those but second- arily connected by different ganglia, would naturally be anticipated from the very nature of the disorder. It could not well be other- wise than that reflected pain would be felt in perhaps distant tissues or organs. These may not be of a severe character, and they will probably be felt at the outset, or more likely still at the close, of a paroxysm. Yet their existence may be an important part of the clinical history, and should be carefully sought out. Treatment. A real neuralgia having been clearly diagnosed, the first thing will be to determine its cause and to remove it. If there is any local source of irritation it must be remedied. The hygiene of neuralgic patients should be carefully looked to. They must be guarded from sudden changes of temperature, draughts of cold air, etc. All sanitary precautions must be adopted, and if the patient suffers from malaria removal from the miasmatic influence is the first consideration. Plenty of out-door exercise must be urged, with a liberal, rather stimulating diet. Extreme fatigue should be guarded against, and bodily and mental rest is important. If there is a constitutional or general functional dyscrasia, it must be relieved. Nervous sedatives may be prescribed, and gen- eral quiet insisted upon. Potassium bromid, ten grains in water, from two to ten times per day, will be found useful, or tincture of valerian and gentian, equal parts in teaspoonful doses. During the paroxysm, digitalis, or veratrura viride in five-drop doses may be given, and aromatic spirits of ammonia in fifty-drop doses will be found useful. If there is a gouty diathesis, wine of colchicum in small doses, frequently repeated if necessary, should be prescribed. Muriate of ammonia fumes, arising from the burning of the salt upon a hot iron in the room, sometimes give gradual relief. If the neuralgia is of miasmatic origin, from three to ten grains of quinine should be administered, or P'owler's solution of arsenic and potash in ten-drop doses, two or three times per day. FACIAL PARALYSIS. 119 Hot moist applications to the affected parts are very useful, and massage sometimes gives very ready relief, although there are instances in which it will be found exacerbating. It must be gentle, and not too long continued at first. If the paroxysms are very violent, it may be necessary to allow the patient to inhale the vapor of ether or chloroform for a short time; of course, not to the point of entire narcosis. If none of the usual remedies are effective, and if the paroxysms are violent, resection of the affected nerve may be necessary. This will, with comparative frequency, be called for in neuralgia, especially in that of the inferior maxillary nerve. Pro- fessor Brophy, of Chicago, has greatly simplified this operation, and by his method it no longer presents any formidable difficulties. His resections of the infra-orbital from tne oral cavity also relieves that operation from many complications. CHAPTER XXXII. FACIAL PARALYSIS. Ix its etiology, this affection is closely connected with facial neuralgia, but differs from it in being the effect of lack of nerve nutrition ; the neuralgias are usually the result of over-stimulation of the nerve. It arises from disordered nerve function, and its treatment very properly falls within the province of the oral physi- cian, inasmuch as not infrequently it is the result of some oral lesion. Facial paralysis is the complete inhibition of efferent neural currents in the tissues affected, with usually a local anesthesia, more or less complete. It may be traumatic or idiopathic in its origin. If the former, ther' will be no difficulty in determining the fact, while in the latter case its source will be more obscure. It may be complete or incomplete. It is complete when there is a total loss, and incomplete when there is more or less diminution of function in the nerves. It is general when there is loss of power in both the upper and lower extremities, and local when it is limited in the number of muscles affected. Facial paralysis is local in its charac- ter, and as seen in oral practice it is usually but partial. Paralysis of sensation may be either loss of tactile sense — in- 120 ORAL PATHOLOGY AND PRACTICE. ability to receive impressions from external contact — or immunity to painful sensations. Thus the skin and the mucous- membrane of the mouth are endowed with both kinds of sensibilit}-. The capacity of these tissues to receive painful impressions may be quite impaired, or even lost, while the tactile or feeling response to external agents remains. But in these instances the impression made by ice, or a hot iron, will not materially differ from that derived from a piece of wood. Paralysis of the tactile sense is com- monly called anesthesia, while that of the sense of pain is denomi- nated analgesia. Reflex paralysis is a term that has been applied to cases in which a paralyzed condition of certain parts is attributed either to a wound or shock received from other and more or less remote parts, or to a local disease situated elsewhere than in the paralyzed region. Dr. Brown-Sequard supposed this to be induced through shock to the vaso-motor nerves, thus interfering with the nutrition of the nerve centers. The instances of paralysis that are of the greatest interest to the dentist are those of the fifth and the seventh pair of cranial nerves. The fifth, or trifacial, is the great sensory nerve of the head and face and the motor nerve of the muscles of mastication, while the seventh is the motor nerve of the muscles of expression. Com- plete paralysis of the fifth nerve results in the loss of sensibility of one side of the face, of the mucous membrane of the mouth, the conjunctival membrane, the anterior portions of the tongue, with the muscles of mastication upon the afifected side. The external manifestations are not so pronounced as in paralysis of the seventh nerve, because the resulting deformity is not so great. There is a loss of the special sense of taste, and sensation is absent. But if the aft'ection is unilateral, mastication may be carried on by the use of the muscles upon the sound side. The tongue and buccal tissues upon the paralyzed side are too frequently bitten and lacerated in the act of taking food, sometimes seriousl}', because the muscles are unable to keep themselves from getting between the teeth, and sensation being gone the patient is unaware of the injuries that are being received. Such paralysis may be induced by long exposure of the face to cold or a keen wind. Paralysis of the seventh cranial nerve is perhaps not so com- mon as that of the fifth, but it is much more readily observed, as it results in serious deformity. \Mth the loss of function in the nen'e all expression in the affected side is lost. In speaking or smiling FACIAL PARALYSIS. 121 the mouth is drawn toward the sound side through the loss of con- tractile power in the muscles of the affected side. The contractility of the orbicularis oculi being absent, the patient is unable to close the eye or to wink. The secretions of the lacrymal gland are not diffused over the conjunctiva owing to the loss of function in the orbicularis, and there is a more or less constant overflow of tears upon the cheek. The saliva dribbles from the angle of the mouth, and the pronunciation of certain letters of the alphabet is interfered with. Paralysis of the seventh is perhaps most often caused by intra- cranial disease. These cases will properly fall within the province of the general practitioner. But it may be the result of injury. The extraction of a considerable number of teeth at one time may produce a shock that will cause spasms of the muscles of mastica- tion, or even inhibition of function and paralysis, with jaw drop. The spasm may be clonic (paroxysmal) or tonic (continuous). The symptoms are too pronounced to be mistaken. There will be a drawing of the muscles of the face, due to their entire relaxa- tion, with a loss of mobility. The eye remains staringly open, and a smile is observable on one side alone. All expression upon the affected side is lost and the muscles are in a state of tonic relaxa- tion. This will be observed by the operator before the patient becomes aware of the lesion. If it is of a clonic character he may by gentle manipulation of the tissues relieve the spasm or tem- IDorary paralysis, and within a few moments have the satisfaction of seeing the muscles regain their tone. Of course he will remove the hand-glass from the reach of the patient to prevent the unneces- sary alarm and nervousness which discovery would cause, and which would only tend to aggravate the condition. Should the injury be more lasting in its character and assume a tonic form, the dentist should explain to the patient the probably temporary nature of the lesion and commence the proper treatment for relief of the condition. One of the most efTectual remedies for this condition is electricity. The faradic or induced current should ordinarily be used, and ifmust be gentle at the outset; nor should it be continued too long. The cathode or negative pole should be placed over the cerebellum, and the anode or positive electrode carried gently over the points of distribution of the affected nerve. Occasionally the pole may be changed, and if it is desired to stimulate the facial 122 ORAL PATHOLOGY AND PRACTICE. nerve alone, the stationary electrode may be placed immediately in front of the external auditory meatus, while the other is moved successively over the various terminal branches. This treatment,, if found beneficial, may be repeated every day, provided the cur- rent is not too strong and not too long continued. At the outset it should not be used so often. If the disorder has its seat in the ganglia, the magneto-electric interrupted current may sometimes be used with good effect, but it should be employed with caution, because it may still further tend to the inhibition of the neural currents in exhausted trunks or branches. Massage of paralytic muscles, if mild and properly applied, ^vill be of great benefit in many cases. The facial muscles may be gently manipulated with the balls of the fingers, and rubbed in the direction of their fibers with the palm of the hand. The hygienic condition must, of course, be carefully looked after, and out-of-door exercise with nourishing food directed. Vegetable tonics may be prescribed if indicated, and quiet and rest ordered. If the paralysis is the result of any trauma, such as the extraction of teeth, the wounds must be carefully examined to see if there are any loose fragments of alveolus or bone left, and all possibly irritating projections and spiculse should be removed. An aseptic condition must be maintained, and soothing applications applied. With these precautions, unless the lesion is very great, a gradual return of functional activity may be anticipated. CHAPTER XXXIII. SYMPATHETIC DISTURBANCES. The nervous system of the body holds all the various organs and tissues in correlation with each other, and secures harmonious functional action between them. Every organ works, not for itself, but for all the rest. There is but one heart to carry on the vascular circulation for all the tissues, but one digestive tract to provide nutrition for all, and but one pulmonary organ to furnish the neces- sary supply of oxygen. Hence the mutual interdependence is complete, and no tissue or organ can be properly studied aside SYMPATHETIC DISTURBA^•CES. I23 from its relation to the others. No oral physician, or dentist, is equipped for the practice of his specialty until he can show that he has made himself acquainted with the functions of other organs, and has learned their possible reflex agency upon those with whose care he is especially charged. A fair knowledge of the anatomy and the physiological function of every tissue in the body is essen- tial to the dentist as well as to the general practitioner, and with- out the basal facts upon w'hich all curative measures nmst be foimded he is as unfitted for his vocation as would be any other man who professes to practice any branch of the healing art. Any disordered condition of one organ affects to a greater or less degree all the others. The sympathy may not be as active in one case as in some others, but it is as certain. The dependence of one tissue or organ upon another may not be as complete or entire as that of others, or as may be the reciprocal reliance, but it surely exists. Proper functional activity of the brain may for some years be more disturbed by indigestion than would ensue to the stomach if the converse were the case, but no physiologist would assert that digestion could be properly and fully performed in cerebral conges- tion. The gravid uterus of the female will be more deranged by toothache than the teeth will be disturbed by metritis, but each reacts upon the other to the extent of its susceptibility, and their mutual relations cannot be lost to sight. The organs disturbed by diseases of the teeth and the oral tissues will be those to which they bear the closest relation. It is well known that the teeth sympathize with each other to such an extent that it is sometimes difficult to determine which one, and sometimes which jaw, is affected. Otitis media may exhibit itself as toothache, while on the other hand pains in the middle ear are very often mere reflexes of odontalgia. The eye sympathizes with the teeth to such an extent as sometimes to exhibit a profuse lacrymal discharge as the accompaniment of toothache, and alveo- lar abscess may be fliagnosed by the condition of the pulse. The otologist especially should be on good terms with the dentist, for mutual consultation is frequently desirable, owing to the intimate relations of the organs concerned. But that which most interests both practitioner and patient is the possible complications of pregnancy. Women have long been taught that the relations between the teeth and the impregnated uterus are so intimate that each must suffer from 124 ORAL PATHOLOGY AND PRACTICE. the faults of the other. "For every child a tooth," was a proverb long before the period of modern dentistry. That extraction is very liable to be followed by premature delivery is a part of the creed of every expectant mother. The impression resting in the minds of too many dentists that temporary disturbances may, within a short time, exhibit themselves in a softened or changed condition of the tooth structure, is perhaps responsible for a part of the general belief that the teeth decay to a much greater extent than usual during pregnancy. It should be remembered that nutritive changes in the dentin are exceedingly slow, while it is not unreservedly admitted that they take place at all in enamel. Hence, while functional disturbances in the teeth are quick to manifest themselves in allied tissues, the reverse is not the case. A continued fever may cause a great waste in many tissues, but it cannot in the teeth, because there are in them no absorbents, no lymph S3'stem. There is no active circula- tion in either dentin or enamel, through which progressive or retro- gressive changes may be readily and quickly wrought. The sup- posed divergence of the nutrient currents from the teeth to the growing child must, then, be largely imaginary, and there can be no sudden breaking down of these organs during pregnancy. And yet the general impression that the teeth decay more at that time than any other doubtless has some basis upon which to rest. One explanation may be found in the fact that at such times the pregnant woman has something else to take up her whole atten- tion, and often intermits the care that she is accustomed to give her teeth. Food is suffered to remain upon and between them, and fermentation does its perfect work. The pregnant woman sometimes has perverted or unnatural appetites, and takes into her mouth deleterious substances. Mineral tonics are frequently pre- scribed for her, and these may bring about destructive results. But there is little doubt that the fact that at least a year passes in which she is without the dentist's help is the principal factor in the result attained. Poor people, who never care for their teeth, find little difference between the period of gestation and any other. The fear that a visit to the dentist must result disas- trously is a mistaken apprehension. It is the true office of the oral practitioner to relieve pain, and not to cause it. Every woman who finds herself pregnant should visit her dentist, if he is a com- petent man, should tell him her condition, and place herself in his DISEASES OF THE MAXILLARY SINUS, I25 hands for such measures as are necessary. He will take special care to avoid giving her pain at such a time, not because it would always be immediately hazardous, but from the necessity for pre- serving her mental and nervous equilibrium to as great an extent as is possible. If there are cavities of decay that would be likely to bring about complications before the time for her delivery, they should be filled, usually with plastic materials. If there are troublesome teeth, so badly diseased as to forbid conservative measures, they should be promptly extracted. If the administra- tion of a general anesthetic is essential, she should be referred to her medical attendant. If from the performance of any such neces- sary operation, when carefully and skillfully done, any ultimate harm has ever occurred, it has not been made a matter of record, and the world is in ignorance of it. It should not be forgotten that the pregnant female is usually in a state of exalted nervous sensibility, but that does not necessarily imply that all operations upon the teeth are inhibited. That there is more toothache during gestation than at other times may be quite true, but there are often sympathetic disturb- ances, without real tooth lesions, that have their origin in the disordered nervous condition. Concerning the nutrition of the teeth of both mother and child, and the prevailing belief that these can be governed by any specially regulated diet, another chapter will have something to say. CHAPTER XXXIV. DISEASES OF THE MAXILLARY SINUS. The antrum of Highmore, or the maxillary sinus, is a cavity within the superior maxilla, connected by a small opening with the air passages of the throat. It allows proper contour of the face without the weight of bone that would be the consequence of solidity. It also makes the nutriment of the bone more easy, and obviates any necessity' for a large medullary portion. iBut its principal utility is in giving resonance to the voice. All musical instruments have a hollow chamber of some kind, to increase the reverberations and reflect the vibrations of the air. The perfection of the instrument and its quality and volume of tone depend very 126 ORAL PATHOLOGY 'AND PRACTICE. largely upon the particular form of this reverberatory chamber. Many years of experiment have not been able to devise any benefi- cial modification of the peculiar shape of the body of the violin, as it was fashioned by Guarnerius. Any departure from that model, whether accidental or intentional, has been found to change the character of the vibrations and impair the tone of the instrument. The antrum is the principal sounding-chamber of the human voice, and the wide variations in the character of the tones produced are due in a large degree to the size, shape, and condition of the cavity. The howling monkey, whose voice can be heard at the distance of several miles, has an additional chamber to reinforce the reverberations of the antrum. All are aware of the peculiar, hard, metallic, unmusical tone that is communicated to the voice in cases of empyema of the antrum, or in atresia of the communicating sinus. The size and shape of the antrum in different individuals varies as greatly as do the characteristics of the voice. In some it is large, and occupies the whole center of the bone. The two antra in the maxillae have even been known to be a continuous cavity, united by a communicating opening across the symphysis. Usually, how- ever, its anterior limit is the canine fossa. It is sometimes par- tially divided into a number of chambers by septa passing across its floors. The opening by which it communicates with the air passages is at the point of junction of the ethmoid and palate bones and the turbinated process of the superior maxilla. This is usually at or very near its highest point. Dr. M. H. Cryer, of Philadelphia, has, by his dissections and studies of the cranial bones, added largely to our knowledge of the structure and configuration of this cavity; and Dr. Thomas Fillebrown, of Boston, has given us yet further illumination. The commencement of the formation of this cavity is not until early childhood has been passed. Hence antral disorders are un- known in infancy, because there is then no maxillary sinus to become diseased. The mucous membrane lining the antrum is continuous with the Schneiderian, or that covering the bones and cartilage of the nasal cavity. It will therefore be liable to the same diseases and be materially affected by the condition of the air passages. In- flammations and degenerations of the Schneideriai: membrane, by DISEASES OF THE MAXILLARY SINUS. 12/ mere continuity may be communicated to the antrum, and a nasal catarrh may induce a chronic antral disorder. This will be the most fruitful source of the degenerated conditions so often present, and if what has frequently been asserted is true, that in the northern and eastern parts of the United States the person who is entirely free from catarrhal troubles is an exception, it must necessarily follow that most of the residents of those sections have disor- dered or inflamed antra, and this may account for the nasal tone said to be characteristic of their voices. The roots of decayed and devitalized teeth may sometimes penetrate the floor of this cavity and become points of irritation and of infection. It does not seem probable that any healthy root can actually pierce the floor. The very conditions of the formation of the apex demand its investment by the pericementum, and that being a double membrane its functional activity implies a septum of bone upon its ultimate surface. Accordingly, in the examina- tion of antra it is found that the apex of the root of a premolar or molar tooth that might otherwise be within the cavity is covered with a thin septum of bone that forms a distinct eminence upon the floor, and no tooth that reaches the level of the antral floor is with- out this. When, however, there is a devitalization of the pulp, with a consequent pericemental inflammation at the apex, the nature of that alTection implies an absorption of the bone that forms the septum; and then the end of the tooth might be within the antral walls, perhaps perforating the mucous membrane. Under such circumstances the apical pericementum would be lost, and the root to that extent denuded. If an abscess formed it might discharge into the sinus, but such a condition would not be likely to exist, because there must be investing tissues capable of affording a continuous supply of plastic lymph to form the basis of the pus discharge. As this would not be the case when the apex of the root actually lay within the antrum, penetrating the lining, a chronic abscess discharging into the antrum is not probable. The projecting root, however, could undoubtedly prove a continuous source of irritation to the lining membrane, and thus be the cause of a persistent inflannnatioii, which in flue process of time would induce a condition of degenera- tion of the mucous follicles, with ultimate breaking down of their structure. In this manner the roots of dead teeth may be un- doubtedly the cause of actual empyema. 128 ORAL PATHOLOGY AND PRACTICE. Traumatism is, probably, more frequently than many persons are aware of, the origin of actual degenerations. Teeth are too often extracted with a degree of violence that would never be condoned in the general surgeon. The fact that the alveolar walls are exceedingly vascular, and that injuries are healed more readily than in any other osseous tissue, alone saves the patients of many harsh dentists from most serious consequences. There are more fractures of alveolar walls, even to the depth of the maxillary sinus, than most people would imagine. There are few practitioners who have not seen cases, either in their own practice or that of others, in which a part or the whole of the septa of the molar teeth was removed, making a considerable opening into the antrum. The presence of foreign substances sometimes induces a diseased condition. Into a cavity, accidentally made, may penetrate some extraneous matter that will remain a source of irri- tation, or the root of a tooth may be forced into the cavity in extraction; and as long as this remains the degeneration will be kept up. It has been demonstrated that the infundibulum, through which the frontal sinus discharges its secretions, in a considerable number of instances at least, opens into the apex of the antrum instead of into the meatus of the nose. Normally, the opening is separated from the mouth of the infundibulum by such a thin septum that it is readily broken down by any diseased condition. In such instances any vicious secretions from the frontal sinus would form the initial point for degenerations in the antrum. Whatever their source of origin, the usual phenomena pre- sented by antral diseases are those of disordered mucous membrane. The probable steps in the degenerative process are, first, a hyperemia, to be succeeded by congestion and suppression of the mucous secretion. Then follows an active state of inflammation, with degeneration of the mucoid follicles, and perhaps a profuse watery discharge. This may continue for a time, when, if the irri-^ tation is continued, further degeneration takes place, with final breaking down or ulceration of the surfaces. The mucous mem- brane thus destroyed, and the periosteum devitalized, there is no longer normal nutrition for the bone, and a progressive caries of this tissue, or even necrosis, with a profuse discharge of pus, will be the consequence. DISEASES OF THE MAXILLARY SINUS. 1 29 S y:\iptomatology. The symptoms attending the early stages of catarrh of the antrum are not very marked or distinctive. There will be a feeling of dryness, with its characteristic pain in the antral region, and possible pressure. The latter symptom, however, more distinc- tively belongs to a later period. The general phenomena are those of catarrh of the air passages. These are perhaps succeeded by profuse watery secretions, which may quite fill the antral cavity and produce that feeling of pressure and the changes of voice that are so often observed in acute coryza. This will pass away with the other prodromata of empyema. Finally, ^Vith repeated attacks of the acute inflammatory pro- cess, there begins a degeneration in the follicles themselves; the disease assumes a chronic form, which results in the complete breaking down of the tissue and an empyemic condition. Pus may be formed in such quantities that the antrum is filled, with complete atresia of the natural opening, and a distressing distention is the result. The feeling of pressure under such conditions will be severe. There will be the usual septic fever, and the superincumbent tis- sues will be hot and irritable. If this breaking down of the tissue and the formation of pus continues, there will be dilatation and pro- trusion of the antral walls at their weakest point. This may be in the orbital region, and the eye may be actually forced partly out of its socket. It may be at the basal walls, in which case the pro- trusion will be above the roots of the teeth; or it may be at the palatal processes of the maxillary, and the protuberance be into the oral cavity. The general symptoms will be nearly the same if the origin of the disorder is other than that of nasal catarrh. If the frontal sinus is diseased, and its depraved contents are dis- charged into the antrum through a misdirected infundibulum, the prodromata will be more brief in their course, but the pathological changes will not materially difTer. The same may be said of the presence of foreign substances in the sinus. The character of the changes will be those that arc usual in inflanunations of mucoid surfaces. 130 ORAL PATHOLOGY AND PRACTICE. ■. CHAPTER XXXV. TREATMENT OF DISEASES OF THE MAXILLARY SINUS. The prognosis is usually good, provided all sources of irritation can be removed; and, as in all inflammatory processes, the first attention should be paid to this point. If the trouble is taken in its early stages of simple catarrhal inflammation, the usual remedies for that afifection should be employed. Nasal douches of erethymol, listerine, or borolyptol, diluted with from three to five volumes of water, may be frequently used for irrigating the nasal mucous membrane. If these cause pain, a little cocain may be added. For the ordinary colds, that seem likely to, run a chronic course, with first a dry, heated condition of the mucous membrane, followed by a muco-purulent discharge, the following may be used, as recommended by Dr. E. C. Kirk: 5 — Borolyptol, oj; Cocaine hydrochlor., gr. ij; Aquse dest., oiij. Sig. — Use as an irrigating douche. In the acute stage of coryza the following will be found useful: 3J — Acid, carbolici, oj/^; Alcoholis, 5ij ; Aq. ammonise fort., 3j ; Listerine, oiij. Sig. — Pour half a teaspoonful into a cone made of blotting-paper and inhale. In addition, for the relief of the antral congestion, a saline cathartic may be given, its operation to be followed at bed-time by one-sixth to a quarter of a grain of sulphate of morphin, dissolved in an ounce of acetate of ammonia liquor. With relief for the catarrhal inflammation the antral complica- tion will pass away. But if there is any filling up of the sinus, either hydromatous or empyemic, it must be opened. This is accomplished by penetrating the walls with a trocar. To obtain perfect drainage it is absolutely essential that this be done at the correct point, otherwise some of the cavity will continue to be bathed in the vitiated fluid. Usually the lowest depression is found just anterior to the first molar tooth, but this is by no means universall}^ the case. Sometimes the antral cavity does not reach anterior to this, and occasionally it lies considerably farther for- TREATMENT OF DISEASES OF THE MAXILLARY SINUS. I31 ward. If the thumb and finger are made to grasp the alveolar and palatal processes, and the oral region thus carefully examined, one may be able to determine the point at which the divergence of the walls marks the beginning of the cavity. If the first permanent molar has been removed, the best place tor making an opening will be at that point. If it be much decayed it will be wise to extract it and drill or puncture through the socket of its lingual root. Care must be taken to avoid following too far in the direction of the root if it diverge much from the others. The drill, or trocar, should be pointed in the proper line. The best instrument is a twist drill in the dental engine. The cavity once reached, the aperture should be expanded with a reamer imtil it is at least as large as a common lead pencil. An opening less than this will be likely to become closed. It is not usually a formidable operation, or one attended with a great deal of pain, but in most instances it will be advisable to administer an anesthetic. The opening once made, a little time should be given for its drainage, when it may be washed out with tepid water in which a little salt has been dissolved, thrown into the cavity with a syringe. This may be repeated until the cavity is quite clean, when a disinfectant, like peroxid of hydrogen or electrozone, warmed to blood temperature, may be substituted. Care should be taken to dilute it if peroxid of hydrogen is used, for if much pus remains, and it be injected pure or nearly so, violent and painful foaming may be the result. If the opening is of sufficient caliber and made at the lowest point very little treatment will, in cases uncomplicated with dis- charges from the frontal sinus or foreign growths or substances, be demanded. A disinfectant simply decomposes septic matter, and there is necessarily nothing therapeutic in its nature aside from this. It is better to wash out the pus than to decompose it, for its elimination will be more perfect and more readily brought about, provided the opening is completely patulous. The cavity having been cleansed, the next step will be to secure continual drainage. For this purpose the insertion of a drainage tube has been recommended, but this, it is believed, will seldom be found necessary; and there are conclusive reasons for its rejection, if that be possible. The drainage tube that has usually been employed is of metal. It is very difficult to retain in position one of any other kind, be- 132 ORAL PATHOLOGY AND PRACTICE. cause adhesive plaster bandages, and the methods by which such are usually held, are inadmissible in the mouth. A metal drainage tube must of necessity act as a continual irritant and become a focus of inflammation and of infection. It is almost impossible accurately to adjust its length, and if it should once be perfectly adapted it will not remain so. If the upper end projects above the floor of the antrum it will not afford perfect drainage, and if it does not it will fill and become stopped with granulations more readily than an opening without such a tube, because its irritant presence will stimulate hyperplastic growths. It will seldom be the case that a drainage tube will be needed if the opening is sufficient. Should the mouth of it not remain patulous, the granulations should be cauterized or cut away. This will be better for the disorder than to allow them to grow about a drainage tube. If the orifice is kept dehiscent, open and gaping, the drainage will remain perfect, and the diseased con- dition will not be perpetuated by retention and further degenera- tion of the septic product, even for an hour. Tents and plugs for the perforation should be avoided. They are an irritation, retaining within the antrum the septic products that should be removed or allowed to escape as soon as formed. Even a moment's restraint is evil in its tendency. The sole excuse for their employment is that they prevent the entrance of food, saliva, etc., from the mouth. There is no cause for anxiety from this source, for saliva will not enter against the force of gravitation, while food and debris can only penetrate when forced in, and these are usually spontaneously eliminated before fermentation can take place. But even if there is a liability to the intrusion of foreign matter through an unstopped orifice, the possible resulting injury could not be as great as that arising fro'm an impeded drainage. If the natural foramen of the antrum is closed the artificial opening must be kept unstopped, because com- munication with the outside air is a necessity. As well might one seal up the drum-hole as entirely to close the antrum, which, as has already been said, is a reverberatory chamber. The employment of tents and plugs has resulted in very serious injury at times. It will doubtless have been found by most oral surgeons who have had a considerable experience in the treatment of antral disorders, that the most obstinate and incurable cases were those in which a comparatively small aperture TREATMENT OF DISEASES OF THE MAXILLARY SINUS. I33 had been made, with the subsequent attempt to keep it open by- tents, distenders, and drainage tubes. It has become the common usage of those who have acquired skill by extensive practice in these cases, first of all. carefully to explore the antrum for lost plugs and dressings, or parts of such, which are certain to perpetuate the disease, Any^ oral surgeon can call to mind more than one in- stance of this. The author has never met with a case of persist- ent antral degeneration, in which it was possible to remove the source of irritation, which was not healed with comparative readi- ness if drainage was left free and unimpeded. He has frequently met instances in which no relief was obtained until a dressing or other foreign substance that had lodged in some depression in the floor had bee found and removed. In one case it was a piece of iodoform gauze more than six inches in length. Perfect drainage having been secured, there are com- paratively few cases that will demand anything more. The use of the drastic and irritating remedies and solutions that are so frequently injected is to be avoided. Cleanliness once assured, the z'is mcdicatrix naturcc will usually do the rest. A considerable number of instances from daily practice might here be cited, in which a profuse, long-continued, and exhausting empyemic dis- charge was entirely cured by a proper operation, the permanent removal of all plugs and tents and dressings, and a thorough wash- ing out and disinfection of the sinus. The irregularities in the shape of some antra insure the in- definite continuance of the septic state unless some further surgical interference than the mere perforation of the floor is provided. Occasionally septa will be found crossing the cavity, and dividing it into partially separate chambers. Depressions in the base will be encountered, which will retain septic matter. If the opening has been made suf^ciently large, a bent silver probe may be used to explore for any lamina and dividing walls, and for intrusive foreign substances. When their nature will permit, any septa should be broken down, and when this is not practicable the patient should be directed occasionally to incline the head in such a man- ner that any retained fluids may flow out toward the drainage open- ing. Care should also be used frequently to wash out such depres- sions and partial chambers, and to keep them thoroughly disin- fected. The author has in some instances found it impracticable to 134 ORAL PATHOLOGY AND PRACTICE. make an opening sufficient for all this work through the floor of the antrum, and has broken down the alveolar walls until the end of the finger could be introduced for exploratory purposes. Such an aperture gives entire access to every part of the sinus, and enables the operator to determine the presence of necrosed conditions, and to extirpate dead tissue, if it be not of too great proportions. There will be instances in which, from a general atonic or anemic state, some cachectic condition, or special degeneration like necrosis, there is not a speedy return to health. The inflammation may assume a low, subacute, or chronic stage, and the indolent tissues refuse to respond to the treatment indicated. In such cases more rigorous measures must be inaugurated. After disinfection a solution of three to five grains of chloric! of zinc to the ounce of water may be injected, and made to reach every part. This will act as an antiseptic and a stimulating astringent, and probably bring about an altered condition. If it be insufficient, it may be used in still stronger proportions, the production of painful and irritating symptoms being the guide for its limitation. If there is pain, it may be treated by an injection of dilute wine of opium. In case of a profuse discharge from an ulcerated mucous membrane, a solution of zinc sulphate, one dram to the ounce of water, may be used. When there is a great deal of fetor a solution of potassium permanganate, ten grains to the ounce of water, will be found useful. Carbolized solutions may be employed, the avowed aim being to produce a temporary aggrava- tion of the inflanmiatory symptoms, or to change the chronic con- dition to one that is more acute. If the degenerative process shall have proceeded so far as to involve the bony walls, an operation for the removal of the dead tissue will be necessary. Whenever the symptoms lead to the con- clusion that depraved secretions from the frontal sinus are dis- charged into the antrum, the opening should be kept patulous and the attention directed toward the other cavity that is the source of the disease. An opening through the bone of considerable size, that has served for the drainage of pus, w-ill not always entirely close. This will not materially matter, because there will usually be a formation of soft tissue and mucous membrane over it that will be sufficient for the exclusion of foreign matter. Even if this is not accom- plished little inconvenience is experienced, provided nothing is DISEASES OF THE FRONTAL SINUS. 135 kept in it that can retain food until it ferments within the sinus. It will not be in a worse condition than are the nasal passages in cases of cleft palate. It may be necessary periodically to wash out the antrum, but this can readily and easily be accomplished. CHAPTER XXXVI. DISEASES OF THE FRONTAL SINUS. This is another of the cavities connected with the air passages, and the reasons for its existence are the same, though of less importance than in the case of the antrum. As the cavity is much smaller, and as sometimes it is entirely absent, its pathological complications are less in number and of smaller import. As in the case of all other open cavities it is lined with mucous membrane, and its diseases will be the same as those of the maxillary sinus, except as they are modified by the dififerent environments. It is probable that they seldom originate in the sinus itself. Inflammations and degenerations of the lining membrane will comprise the most of these, and, while the presence of foreign sub- stances may be eliminated from the list of causes inducing them, the pathological changes will be so nearly analogous that a recapitulation of these is unnecessary. In edemas and empyemas the discharge is through the infundibulum that penetrates the ethmoid, and into the middle meatus of the nose. The diagnosis of these conditions must be through the tracing of this vitiated matter to its source, and from the sense of fullness and pressure that will inevitably be felt in the supra-orbital region. Local treatment will be impossible unless an opening is made, which will be from the lower border of the bone, through the supra-orbital prominence or ridge into the cavity, where it may be treated as in the case of the antrum. But this is a very unusual operation, and seldom called for except in cases of atresia of the discharging duct or canal, or when the discharge has induced a degenerated condition of the infundibulum, or is flowing into the maxillary sinus. That these latter conditions may exist and may induce serious complications, the following case in the practice of Prof. Truman W. iirophy amply demonstrates. Miss A. had for some years 136 ORAL PATHOLOGY AND PRACTICE. suffered from what was pronounced antral disease. Five opera- tions for its relief had been made by different surgeons, most of them consisting of the usual opening and flushing of the sinus with antiseptic and stimulating solutions. It was now determined to explore the cavity more completely than had yet been done, and to this end the maxillary walls above the roots of the teeth were removed until the finger could be introduced. No foreign sub- stance or growth was found, and the cavity was temporarily packed with antiseptic gauze. At a subsequent visit this was removed and the antrum critically examined. Near the apex purulent matter from some superior source was observed to percolate into the sinus. The connection of the frontal sinus with the diseased condition had not previously been suspected, but in the light of the then newly published observations of Dr. Cryer it was at once apparent. The infundibulum was discharging pus into the antrum, and the seat of the disease was either in the frontal sinus or in the ethmoid, and a further operation was at once determined upon. At the proper time the supra-orbital tissues were divided, the filaments of the supra-orbital nerve dissected out and an opening made into the frontal sinus, from which pus at once welled up. The opening was now extended the whole length of the sinus, until a probe could be thrust down through the infundibulum for a considerable distance, when its point was found in the maxillary sinus. Careful probing now demonstrated that the cells of the ethmoid were in a degenerated condition, and that the connecting passage was for a part of its length devoid of its membranous lining. With the properly shaped burs in the surgical engine the incision was carried along the course of the infundibulum until the center of the nasal bone was reached. A considerable opening was made in this bone, the degenerated portions of the ethmoid were removed, the surfaces of the discharging canal freshened and its mouth made to open into the nasal meatus instead of into the antrum. A drainage tube was now inserted into the frontal sinus, through which the whole terri- tory could be flushed, and the wound was closed about it. The dis- charge was for some time very profuse, but continued antiseptic treatment finally resulted in a complete cure. When the infundib- ulum was made to discharge into the nasal cavity the trouble in the antrum was at once relieved, and never returned, thus conclu- sively proving that the source of disease was not in this sinus, w^hich was only secondarily affected from the frontal sinus. CYSTS AND THEIR TREATMENT. I37 CHAPTER XXXVII. CYSTS AND THEIR TREATMENT A Cyst is a tumor containing a cavity or cavities filled with fluid or semi-fluid contents. In one sense, it is nature's method of isolating from the tissues any foreign or irritating matter. It is the only way in which extraneous substances can be permitted permanently to remain in the animal economy. When cysts consist of a single chamber they are simple, and when divided by membranous septa midtilocular. Should they contain teeth they are called dcntigcrous cysts. A cyst may also be the result of the stoppage of some duct, and the consequent retention of the secretion of the gland of which it was the discharging canal; or it maybe the mere collecting of a watery fluid in a previously existing serous cavity, the outcome of functional disturbance. A cyst co7isists of a membranous pouch, zvithont an opening, that envelopes the aliai substance when such exists, ami separates it from the tissues. In like manner a colony of bees, when some animal or offensive substance which they are unable to expel gains entrance to the hive, seal it up and segregate it by covering it with an im- penetrable coating of wax, within which it loses its repulsiveness. A cyst is filled with a fluid in which the offending matter floats or is contained, thus preventing its immediate contact even with the cyst walls. Cysts are developed in a natural cavity of the body, or within the substance of an organ. They cause a distention that with the continual gathering of the cystic fluid and the constant growth of the cyst sometimes becomes of enormous proportions. It is only through their expansion that they assume any dangerous character, for they do not otherwise cause functional disturbances. They may readily be distinguished, in most instances, through this peculiarity, and through their slow formation and the entire lack of pain tha*: accompanies their growth. The methods of distinguishing them from tumors are various. If they are accessible, the fluctuation of the fluid contents may readily be perceived. Sometimes, when they have existed for a long period without materially growing, a parchment-like crackling will be felt upon pressure, and it may even be heard with the ear. 138 ORAL PATHOLOGY AND PRACTICE. It sounds very much like the crepitating sound produced by the flexing or bending of bar tin. This is because of the inspissation, or thickening into a grumous, clotted mass of .the fluid contents, through their desiccation, or drying. In deeper cysts it is usually advisable positively to determine their character by aspiration, or the drawing ofif of some of the fluid contents, by means of an aspirating or hypodermic syringe, and its careful examination. This gives a positive method of diagnosis. An exploring needle should also be used, to determine the presence of any foreign or irritating substance. Park, whose "Surgery by American Authors" may be ac- cepted as the most modern expression of surgical pathological knowledge, divides these ordinarily benign tumors into four classes: 1. Retention Cysts. These imply a previously existing cavity, zvhose outlet is stopped up, and zvhose contents consequently accumulate and perhaps degenerate. This class will of course include those oral cysts which arise from an obstruction of the ducts of the salivary gland. 2. Tubido-Cysts. These are dilatations of certain functionless ducts in other parts of the body. They are largely developmental in their origin. 3. Hydrocele. This, as its name indicates, is a collection of zuatcry fltnd in some serous cavity, one zvhich has no discharging duct and no opening of any kind. Hydroceles are apt to be of congenital origin, and are most frequently found in the region of the neck. 4. Glandtdar Cysts. These grozvths are formed by the dilata- tion of certain glands. They may usually be classed as retention cysts, for the enlargement is most commonly induced by a stop- page of the ducts. They may, however, occur in connection with the ductless glands, and because of this there is a degree of pro- priety in distinguishing them from those which arise from the mere closing of a duct. Those which are of interest to the oral surgeon or physician are the first and last classes, tubulo-cysts and hydroceles not being likely to fall under his observation. Cysts in and about the oral cavity are quite frequent, a con- siderable proportion of them being caused by calcareous deposits within the salivary glands or in their discharging ducts, and the subsequent formation of a retention cyst. CYSTS AND THEIR TREATMENT. I39 Ranula is a retention cyst, caused by the stoppage of Wharton's duct, or one of the mucous glands beneath the tongue. A small cal- culus may be formed within the gland, and it will eventually become lodged somewhere in the duct, completely stopping it. The saliva or mucus is obstructed and forms a cystic pouch or pocket, into which more is continually flowing. The watery portion will be lost, and there will remain a thick, jelly-like mass beneath the tongue upon one side, which in some instances thrusts that organ quite out of the mouth. It assumes a peculiar mottled appearance, closely approaching that of a frog's belly, and hence it has received the name of ranula, from the Latin rana, a frog. Odontocelc or Odontoma is another comparatix'cly coninwn form of oral cncystmcnt. These are caused by the presence of an undcvcltped or misplaced tooth-germ. The former term more strictly applies to a cystic, and the latter to a degenerate formation, although both are due to the same cause and are of the same general character. They may appear at any point of the jaws, wdierever the undevel- oped germ may exist. They are easily diagnosed in most in- stances, not only by the means already laid down, but by the addi- tional fact of there being a missing tooth, and by their location where that might naturally be expected to exist. There are other forms of cysts arising from some functional disturbance in the smaller glands of the mouth and tongue. They belong to the strictly glandular class, and consist of an enlargement or dilatation of a mucous gland. Such an one is frequently found just at the tip of the tongue, where lies the so-called Nuhn's gland. These cysts, however, may be of the simple retention variety, due to a stoppage or closing of the duct of the mucous follicle. Dermoid or congenital cysts are also sometimes found in the mouth. Sometimes the cystic formation is within the antrum of Highmore, which it fills with cystic fluid. In this locality it is liable to be mistaken for an ordinary edema of that cavity. But after it has existed for some time it usually causes an absorp- tion of the walls of the antrum, when its true nature is revealed. This will most often occur at the external extremity of the antral cavity, where the alveolar walls are thinnest. At that point, beneath the cheek, fluctuation may readily be observed, and the peculiar fcceling of the cystic fluid may easily be detected. If there is yet any doubt, an aspirator needle may be intr(Kluced, and a little I40 ORAL PATHOLOGY AND PRACTICE. of the fluid extracted. If this is thick and glairy, with perhaps some flocculent matter floating in it, the diagnosis will be clear. There is a kind of cyst that is of a distinct interest to the dentist, viz, the ovarian dermoid. These dermoids are teratomatous groiuths, made up of matter that is developed from the epiblastic layer. Hence we find them containing epithelia. skin, hair, sebaceous glands, and well-developed teeth. If they should contain bone, muscle, or nerve tissue they would not be dermoids, because these are of mesoblastic origin. The author has in his possession a dermoid ovarian cyst that contains nearly forty teeth, some of them decidu- ous and some permanent, with hair rolled up into a ball and nearly two feet long. The treatment of cysts is usually quite simple. In most cases it is sufficient to first open the cystic tumor, and explore it for the presence of an irritating agent. This, when discovered, may be removed. The contents of the cyst should now be thoroughly evacuated, and the cavity washed out with a weak disinfecting solution, when the whole may be packed with iodized lint. Granu- lations will usually commence and complete the cure. It may be desirable to wash out the cavity with a stimulating fluid, and wait a little time to see that no undue inflammation succeeds, before the iodized lint is used. In cysts within the bone, or in the antrum, septa may- exist, partially dividing the cavity into two or more por- tions. These should usually be broken down, that the diagnosis m.ay be complete. This will be found especially true in the maxil- lary sinus. In ranula, it is desirable to remove the obstructing cal- culus and evacuate the cyst without cutting, if it be possi- ble, that the course of the duct may not be changed. A little careful manipulation will not infrequently be effectual in driving the concretion, if it is not too large, out through the course of the duct, when the contents of the cyst may be removed by means of the aspirator. Should the cyst again fill up, it may be necessary to open it, but the natural discharge from the submaxillary gland should be carefully provided for. There are instances in which it will be found necessary to dissect out as much of the connecting membrane as is possible. There is little danger from bleeding in any operation upon cysts, if carefully performed, and the only com- plications are those arising from the ordinary inflammations. TUMORS AND NEOPLASMS. I4I CHAPTER XXXVIII. TU-MORS AND NEOPLASMS. It is not the purpose of this work to enter upon any extended investigation of diseases not commonly encountered by the dentist, or which properly belong to the practice of the general physician, or that of any other specialist. But it would not be complete were not a sufficient knowledge of morbid growths imparted to enable the student intelligently to diagnose the condition, even were it essential for him to refer his patient to the general surgeon for any necessary operation. Hence, some general remarks will be at- tempted concerning the origin and pathology of the more common foreign growths. The term Tumor implies an abnormal enlargement of any part from any non-inflammatory cause, but usually from a morbid growth, which in its structure conforms to a greater or less extent to the tissue in which it grows, and which has no functional action. A simple inflammation is a tumor in one sense, but not in that which is surgically the accepted one. The term Neoplasm is more applicable to the conditions under consideration, because it implies an abnormal growth, which may be either normally or abnor- mally located. All neoplasms, or tumors, consist of tissue that belongs to the body, and that forms an essential part of it when properly devel- oped. But when any tissue of the body grows in a location that is foreign to it, or when it develops in an abnormal manner, or in excessive amount, it becomes a tumor or neoplasm. Every hyper- trophy is a tumor, because it is an excessive development, though of a normal tissue in a natural locality. If it is developed in an im- natural position, thfre is a greater departure. If fibrous tissue develops unconnected with other such tissue, or in a place in which fibrous tissue does not belong, it is a neoplasm. If osseous tissue develops in undue amount in connection with other bone, it may be but an hypertrophy or a hyperplasia. But if it is formed in an ab- normal manner, or in an unnatural location, it becomes a morbid tumor. A wart is the undue development or an hypertrophy of one or more of the papillae of the skin, and it is thus a form of benign tumor. A corn is the impaction of the epithelia in the tissue be- neath, but it is not a true foreign growth. When epithelia develop 142 ORAL PATHOLOGY AND PRACTICE. unduly in the midst of other tissues, they form a dangerous kind of tumor. Neoplasms may be of benign or of malignant growth. In the former case the tissue elements may form a mere harmless hyper- trophy, like hypercementosis, sometimes called exostosis of a tooth, while in the latter they are essentially foreign, and therefore irri- tants, and cause a degeneration and breaking down of tissue. All neoplasms, therefore, are composed of normal cells, abnormally de- veloped in number, as in hypertrophies; in position, as in warts, moles, etc. ; or in both location and histological arrangement, as in the malignant tumors. They are named according to the tissue in which they occur, or of which they are composed. An Epithelioma is composed of unduly developed epithelia. A Fibroma is composed of iindtdy developed Hbrous tissue. An Osteoma is composed of unduly developed osseous tissue. An Adenoma is composed of unduly developed glandtdar tissue. An Enchondroma is composed of undidy developed cartilage tissue. A Myoma is composed of unduly developed muscular tissue. A Glioma is composed of unduly developed nerve structure tissue. An Angeioma is composed of unduly developed blood tissues. A Myxoma is composed of undidy developed mucous and gelat- inous tissue. Tumors are also named from other peculiarities, as — Sarcoma; having the appearance of flesh. Encephaloid; having the appearance of a head. Myeloid; having the appearance of marrow. Melanotic; having a pigmented or colored appearance. Scirrhus; having a hard appearance or consistency. Medullary; having a soft appearance or structure. Tumors are also Homologous or Heterologous, the former con- sisting of tissue like, and the latter unlike, that in which it is im- bedded. Homologous tumors naturally are apt to be benignant, aiid heterologous tumors to be malignant in their nature. Malignant tumors are usually connected with some peculiar diathesis, and there is an hereditary tendency to- ward their formation. They are embryonic in structure; that is, not fully developed tissue, and hence quite unlike ordinary hypertrophies. They are apt to consist of a network of connect- TUMORS AND NEOPLASMS. 143 ing tissues, whose meshes are filled with abnormally developed cells. They may be diagnosed from their position, their his- tory, growth, pain, general appearance, etc. A tumor will usually first appear as a hard nodosity within the tissues. It may increase in size very fast, or its growth may be slow. It may be accompanied with considerable pain, or it may be without functional dis- turbance. There are a great many benign tumors to each one of a malignant character. As a rule, if the growth is slow and with- out pain, if there is no special reason for its appearance, if it can be attributed to no particular pathological condition and no functional disturbance is connected with it, little attention need be paid to it. It is probably one of the frequent hyperplasias of an innocent char- acter that may be found in almost every person. It is usually safe under all circumstances to allay the fears which such an appear- ance almost invariably excites, by the assurance that it is one of the numerous growths that can do no harm, and to endeavor to divert the mind from all thoughts of it. Nothing should ever be said that can excite apprehension. Even if the practitioner is in doubt con- cerning its true nature, he should not let the patient become aware of it. g He should keep it under observation until it has sufficiently developed to enable him to judge intelligently, but always without communicating alarm. The treatment of the homologous tumors is wholly local. They have no constitutional origin, and do not menace life. The chief reason for interfering at all in many such cases will be found in the fact of their causing inconvenience or disfigurement. The heterologous tumors represent a constitutional vice. They tend to infiltrate into and invade other tissues. Especially are they likely to affect the glandular system. Local treatment is entirely useless, and even if they are removed they are quite likely to re- appear. They never, like the homologous tumors, reach a definite limit of growth, but continue to increase and spread. Their treat- ment, aside from surgical interference, which is usually advisable except in the later stages, must be specific and sustaining. 144 ORAL PATHOLOGY AND PRACTICE. CHAPTER XXXIX. TUMORS AND NEOPLASMS (Continued). The term Cancer is one that is not usually employed by pro- fessional men. It is derived from the Latin cancer, a crab, and the name is given from the supposed crab-like appearance of the veins in this affection. The laity usually understand by it either of the malignant growths which are technically called Sarcoma or Carcinoma. Of these the sarcomata are composed of embryonic tissue from the mesoblastic layer, while the carcinomata are of epiblastic origin. Each is variously subdivided according to its character or development, and each presents separate physical and pathological characteristics. Sarcomas have a distinct hind of fleshy appearance, and seem to he specially vascular. They grow along the lines of least resistance, and are likely to penetrate into cavities and fissures of the tissues. They appear at any age, and are comparatively rapid in their growth, sometimes causing considerable pain. When they appear upon the surface they bleed very easily, and have in such cases sometimes been known as Fungous Hematodes. They are com- paratively frequent in the salivary glands, in the jaws and^other tissues of the mouth, sometimes penetrating to the antrum. They are quite common in some of the lower animals, especially the horse. Carcinoma is of epiblastic origin, and is connected zvith some form of gland tissue. It is rare in young persons, and it commonly involves the lymphatics at an early period of its development. It is usually rapid in its growth, and it may cause a very great degree of pain. It is very apt to attack the breast in women, but its seat may be in the sebaceous glands, the salivary glands, the prostate, liver, kidney, testicles, stomach, intestines, especially the rectum, or wherever glandular tissue exists. Hence its location will be an important guide in its diagnosis. Epithelioma, as its name indicates, is a degeneration of an epithelial surface, usually of the skin, and consists of masses of epithelial celh surrounded and separated by bands of connective tissue. It belongs to the malignant growths, though it does not necessarily assume their form. It is most apt to attack those beyond middle life, and is much more common in men than in women. It sometimes TUMORS AND NEOPLASMS. I45 arises upon the lip, from the long-continued irritation of a pipe. It is also not infrequently caused upon the tongue, or in the oral tis- sues, by the pressure of rough, sharp edges in carious teeth, which act as a continuous provocation. Its diagnosis is not usually diffi- cult. Its late and superficial appearance and the chronic ulcer with indurated edges forbid its being readily confounded' with any- thing else, unless it might be some forms of syphilis. Lupus is one of the many forms which tuberculosis assumes. It is strictly a communicable disease, and is due to an infection by the tubercle bacillus. It usually commences early in life upon the face, in the form of small red or dark spots, which are much softer than the inclosing tissue. They ulcerate in time, and, spreading with the deposition of more tuberculous matter, there is a steady erosion into the surrounding territory. The infection of the system with the tubercle bacillus is always a grave matter, and is liable to cause many complications. It is a question to be taken into careful consideration w'hen any surgical measures are contem- plated, because the appearance of miliary tubercle would interfere W'ith the healing process. It is impossible within the limits of a work like this thoroughly to consider the many phases which tuberculosis may assume, and the student who desires further in- formation is referred to works upon general surgery. Of the non-malignant tumors, those most commonly found in the mouth are the different forms of fibroma. These, as their name in- dicates, are composed of fibrous tissue. They are ordinarily dense in structure, and composed of bundles closely packed together, which are permeated by blood vessels. The Epulids belong to this class, as they are of fibrous origin. Lipomas, or fatty tumors, are the most frequent of any of th: neoplasms. The}' are of the adipose tissue type, and it is needless to say are harmless in their character. They are usually inclosed in a capsule, from which, if no vital organ is involved in these folds, they may readily be enucleated. They are easy of recognition, except when deeply located, and when once extirpated are not apt to return. The Osteomas are bony tumors, and arc by some believed to be chondromas, or cartilaginous tumors, zchich have ossified. They may be either compact or cancellous in structure. They are most com- mon about the cranium, and may be found in the frontal sinus, the external auditory meatus, and about the mastoid process. The 146 ORAL PATHOLOGY AND PRACTICE. compact forms are sometimes very dense and hard, appearing like ivory, and they may defy the finest steel instruments. Some forms of odontoma are classed with osteomas. The student will be especially interested in the methods by which tumors of malignant growth may be distinguished from those which are benign. This may usually be done by the clinical symptoms, although there are instances in which the most careful observation will be at fault. Some of the foreign growths will pre- sent misleading characteristics, but the following points of differ- ence may usually be relied upon: Benign tumors are common to all ages, while those which are malignant do not appear in early life. Benign tumors are slow in formation, -while the malig- nant are usually of rapid grow^th. Benign tumors do not spread and infiltrate into the surrounding tissues, while those which are malignant in- filtrate in all cases. Benign tumors are often inclosed in a capsule and are circumscribed, while malignant tumors are never thus limited. Benign tumors are rarely adherent, while malignant ones always are. Benign tumors rarely ulcerate, while the malignant ones always do when they come to the surface. In benign tumors the overlying tissue is not disturbed, w^hile in the malignant it is more or less retracted. There is no lymphatic involvement in the benign tumors unless they are inflamed, while malignant tumors almost alw^ays involve the lymphatics. The treatment of the tumors is almost exclusively surgical. Those which are benign seldom return when they have been extirpated. It is not so with the malignant ones. If they have made considerable progress, and especially if the lymphatic glands have become enlarged and indurated, they are very apt to reappear. Yet excision, even of the most destructive forms, will usually prolong life, if it does not permanently save it. There is but one safe method of removing them, and that is by the knife. The eroding plasters of the so-called "cancer doctors" are not only the most painful means of effecting removal, but are eminently dangerous, being very apt to hasten infiltration, and in some in- TUMORS AND NEOPLASMS. 14/ Stances they may convert a tumor of a benign aspect into a malig- nant type. The dentist will be mainly interested in the epulitic growths that are common in the mouth. The term Epulis means "upon the gums." Hence it is applicable to any abnormal gingival growth, and the hypertrophies that, proceeding from the gums, fill the cavities in decayed teeth are true epulids, though of a simple character. The couuiwn form of epulis is a vascular tumor that appears upon the gums. Its origin may be from the supciUcial fibers, from the peri- cementum of a tooth, or it may penetrate into and appear to have its root in the alveolus. Epulids may appear as erectile or as non-erectile tissue, and may have fibrous, myeloid, myxomatous or sarcomatous complications. The erectile epulids are vascular growths, whose size depends upon the vascular condition, and they vary with this. When dis- tended they appear tinged and dark. The epulitic tumors that spring from the periosteum perhaps invade the substance of the bone. They may be diagnosed by careful movements, and by the exploring needle, which may pos- sibly detect an opening into the bone. If the origin is from the pericementum of a tooth, a pedimcular connection may usually be traced, either through the alveolar walls or by the side of the tooth, in the direction of the pericemental membrane. For the removal of the superficial and erectile tumors, little more is needed than a ligature that shall cut off all circulation, with final cauterization of the place. An epulis that has its origin in the pericementum of a tooth will be cured by extraction. But for those which penetrate the bone, it will be necessary to remove as much of ^he alveolus, or even the body of the maxilla, as is affected, remembering that the extremity of the invasion must be reached. The wound should be dressed with iodized lint. If there is much inflammation the following may be applied: B — Plumbi acetatis, oij; Tinct. opii, 5ij; Aquje, 5xvj. Sig. — Pack the wound with lint wet with the solution. 148 ORAL PATHOLOGY AND PRACTICE. CHAPTER XL. OSTEITIS. Before entering upon the consideration of diseases of the bone it is necessary thoroughly to comprehend the pathological changes involved in the initial steps of the degeneration. Bone, which forms the framework of the body, is made up of an inorganic, or mineral portion, and an organic, or living part. The latter is con- tained within the meshes of the former, and communicates through the whole structure of the bone. This is accomplished by means of the peculiar formation of the inorganic part. It is through the organic or living portion that nutriment of the whole osseous tissue is carried on. The changes that occur in the inorganic portion, the waste and repair, are not, of course, as great as those of vascular tissue, yet they must be provided for in the economy of nature. The nourishment of the bone, like that of all other tissues, must primarily be derived from the blood, and it is carried on through the periosteum or investing membrane, the medullary marrow or central cavity in long bones, and the Haversian or penetrating canals which carry the blood to all portions of the thick bones. Around the Haversian canals, and along all the sources of nutriment, are arranged a concentric series of cells containing the essential living matter of the bone. These cells are the lacunae; and each of the zones of these so concentrically arranged cells is called a lamella. Connecting the several lacunae, and communicating with the nutrient source — the periosteum, the medulla, or the Haversian canals — are the canaliculi, the minute canals which carry the pabu- lum extracted from the blood to the lacunae, the immediate source of nutriment. , The living contents of the lacunae and the communicating canaliculi are of a protoplasmic or embryonal character, and contain the elements of the osseous tissue. If the nutrition of its structure is cut off, the bone dies as inevitably as does any other tissue under like circumstances. If a ligature is placed about the finger that is sufficient to prevent all circulation, and thus to stop all nutriment, the soft tissue will die and become gangrenous. If the ligation is so complete as to deprive the bone of its nutrient currents, that will also die from the same reason, and become necrosed. OSTEITIS. 149 If the stoppage of nutrition in the finger is through a progres- sion of the inflammatory' process, by hyperemia, congestion, and final stasis of the blood current in the part, the result is precisely the same as if it were through a ligature, or separation of all arterial sources of supply. It matters not by what the nutrition is com- pletely interrupted, whether by starvation, stoppage of food supply, either to a part or the whole of the body, by cutting ofif that supply through interruption of the channel of conveyance, or by such pathological changes as completely to prohibit assimilation of food products, death of a part or the whole of whatever is thus deprived of its food supply must be the inevitable result. In the soft tissues this may be called suppuration, ulceration, sloughing, or gangrene, and in the hard portions caries, exfoliation, or necrosis, but it is essentially all the same process. Each is but a different manifesta- tion of the universal law of death and decay whenever nutrition and progress cease. The instant that progression stops, retrogression commences. The contents of the lucunae and canaliculi of bone, the proto- plasmic embryonic elements, although they are not directly vas- cular, may be the subjects of inflammatory action. This process, differing from ordinary inflammation in some particulars because of the varying physical character of the affected substance itself, as well as of its environments, will arise from the same causes as do inflammations of other tissues, and may be studied from the same standpoint. The initial point will undoubtedly be in the tissue or organ that is the immediate source of food supply, — the periosteum, the investing or lining membrane of the bone. Disorders of this tissue must affect the living portion of the bone. Inflammation of the periosteum, if the degenerative process continues, ends in stasis of the blood currents, thus cutting ofif nutrition, with the consequent deterioration of the living contents of the lacunae and canaliculi. This inflammation, or afl^ection of the living portion of the hone, is that which we call osteitis, and it is usually the initial point of necrosed conditions. If the osteitis is relieved through the removal of the source of irritation and the re-establishment of nutrient currents, that is essentially the resolution spoken of in dealing with Inflam- mations. If it proceeds to the breaking down of tissue it will be caries or necrosis, the analogues respectively of suppuration and gangrene. 150 ORAL PATHOLOGY AND PRACTICE. Like all other inflammatory conditions, osteitis is the result of some irritant. This may be a traumatic lesion, the presence of pus or of a foreign body, or the interference with nutrition caused by some external impression manifested through the nervous sys- tem. Anything that would induce the inflammatory process in the soft tissues may in a less degree be provocative of osteitis in the hard. Probably there was never an acute pericementitis that did not induce a corresponding osteitis in the bony tissues in the imme- diate proximity. We know that an alveolar abscess causes a breaking down of the bone about the infected spot, and the forma- tion of a cavity of greater or less extent. We are also but too well aware that pus from an abscess sometimes infiltrates the bone, and will burrow to a considerable distance, forming secondary pockets and foci of infection, which sometimes make thorough sterilization very difficult. We know, too, that it takes considerable time to effect the complete healing of the pockets and cavities in the bone thus formed, and that until the embryonic or temporary tissue that is the result of the first reparative process shall have time tO' con- solidate and become permanent through further progressive changes, there is always danger that the metamorphoisis will take upon itself a retrogressive state and the whole again break down. All these conditions go to demonstrate the fact that osteitis, to a greater or less degree, is always present in pericemental complica- tions, and that in the treatment of such conditions its existence should be taken into account and care taken that it he kept in check. Symptomatology and Treatment. The diagnosis of osteitis as a separate infection is not readily made, and principally depends upon other known degenerative processes. The existence of an abscess in the immediate neighbor- hood of any osseous tissue must inevitably induce it. The mere presence of pus and of the micro-organisms of suppuration are sufficiently irritating to provoke an inflammation of periosteum, and that necessarily implies more or less of osteitis. But aside from such recognizable complications the condition does not pre- sent sufficient of pathognomonic symptoms to enable the observer always to detect it in its earlier stages. It may often be inferred, and in some instances perhaps determined, by exclusion of all other functional disturbances, but the pathologist must mainly depend upon associated disorders for his complete diagnosis. CARIES OF BONE. 151 The periosteal inflammation that is the cause of, or that accompanies it, will manifest itself by a red line, or red blotches upon the superincumbent tissues, provided they are not too thick, and this will be intensified if there is very much of osteitis present. But this cannot be depended upon as a certain diagnostic symptom, though it may be useful as an adjunct. The treatment of osteitis in its early stages should be abortive, and it will not materially differ from that laid down for the relief of inflammation in other tissues in the chapter (X.) devoted to that subject. Its presence once determined, every effort should be made to discover the source of irritation and to remove it. About the jaws this will most frequently be a diseased tooth, and when that is restored to a healthy state, unless the disorder shall have existed for some time or the lesions be unusually violent, the inflammation in the lacunae of the bone will subside with the rest. If, however, this is not the case, and the retrogression or degenera- tive action persists, it will result in either caries or necrosis of the bone; and these will be considered under their appropriate heads. CHAPTER XLI. CARIES OF BONE. This disease may be compared to suppuration or ulceration in soft tissues. It is the devitalization of bone, cell by cell, and its breaking down by a comparatively slow progression, rather than death in mass. It has its origin in perverted or interrupted nutri- tion, but the phenomena exhibited vary somewhat from those of necrosis. It may arise from local irritations, or it may be general and constitutional in its origin, as in the case of scrofulous subjects or those affected by the syphilitic virus. A frequent source of maxillary caries will be found in the diseased roots of teeth, which act as sources of irritation. Not infrequently, too, it is the result of excessive violence in dental operations. Long-continued wedging will be likely to induce a local osteitis so severe as to interfere with the nutrition of the thin septa of bone between the teeth, denude them of periosteum, and result in a wasting caries which will destroy that portion of the alveolar process by slow disintegration. It will be comprehended that this form of caries materially 152 ORAL PATHOLOGY AND PRACTICE. differs from that which is by surgeons usually denominated caries of the bone, both in its etiology and symptomatology. While it may be aggravated, or even induced, by cachetic conditions, it is not characterized by the substituted granulation tissue. It has its usual origin in a local rather than a constitutional irritant. It more resembles in its progression dental caries, but is quite distinct from the latter in many of its characteristics. This form of caries of the bone may be readily diagnosed, through careful examinations, by any one who is skilled in such matters or who has cultivated habits of close observation. Yet the earlier periods in these perversions are recognized by but few dentists, because their perceptions have not been sharpened by continual practice. Either they are not sufficiently instructed to know what to look for, or they do not extend their observations beyond the teeth themselves, and neglect everything save that which obviously demands mere mechanical or operative interference. Any localized congestion or inflammatory turgescence and swelling demands the attention of the practitioner. It may be indicative of a slight disturbance, or it may be the initial point of a serious lesion. The oral physician should be competent to determine which it is, and faithful enough to keep it under observation until it shall develop its true character; and the condi- tion should be recognized early enough to enable the practitioner to obviate the spontaneous formation of sinuses. True caries of bone will produce a marked change in the over- lying* soft tissues. There will in the incipiency be great determina- tion of blood to the parts, with congestion and tumidity. This will gradually assume a deeper color, until it approaches a purple hue and sloughing commences. In simple denudation caries of the maxillary process there will be very little of this, nor will there be any very considerable formation of pus. But there will be limited sloughing of the superimposed tissues, with denudation of the bone, more or less complete, beneath. An opening through the soft tissues will be found, and this may be discharging a small amount of pus, though without acute complications. If now a probe — the best one for such cases is a hatchet-shaped excavator — or an explorer of some kind be carried through this opening, the bone will be found quite denuded and softened. The point of the excavator will readily enter it, and small spicula from the roughened surface may be readily chipped off. There will be none of the smooth, solid, resisting sensation CARIES OF BONE. 1 53 that a healthy bone presents. To the educated sense of touch it presents characteristics that cannot well be mistaken. If there is ca.ies of the septum of the bone between the teeth, the result of traumatic violence, perhaps in filling, there will be a peculiarly- rough, gritty feeling, showing that portions of it have been thrown oflf, with destruction of the periosteum. There may be a distinct putrefactive odor from the diseased territory, showing that food is undergoing decomposition there, even if there is no appreciable formation of pus. The treatment of caries of the bone will be both local and general. If the degeneration is extensive, it will indicate a general debility that demands the use of tonics. If there are any acute symptoms, premonitory to a yet more rapid breaking down of tissue, the most active abortive measures should be instituted, and cathartics, diaphoretics, counter-irritants, with local depletion by means of scarification, or leeches, or cupping, should be employed. As soon as these are effective in reducing the acute phenomena, or if the condition is ascertained before such active symptoms are manifested, the dead and carious bone should be burred away with the dental engine, and, if necessary, the diseased surface carefully curetted or scraped. This process must be carried to the extreme limits of the dead bone, which, unless there is a carious sinus, will not be very deep. This done, and all debris carefully washed away, the surface of the affected bone may be saturated with aromatic sulphuric acid, which may be allowed to act for a few minutes, when the cavity should be thoroughly washed with water. That an acid, especially sulphuric, will exercise a selective action, dissolving only dead tis- sue, seems to be proved by the experiments of the late Prof. J. E. Garretson, who caused to be submitted to the action of a twenty- five per cent, solution of sulphuric acid, for three days, fragments of dead, of diseased, and of healthy bone, with the result that in dead bone a considerable proportion of the lime salts was dissolved, in the diseased bone a less amount, while in the healthy bone no such action took place. Great care must subsequently be exercised to keep the territory clean and aseptic, disinfectants or antiseptics being used if necessary. If the tissues seem indolent, they may be stimulated to action by the use of a weak solution of the chlorid, or iodid of zinc. Opportunity must be given for the formation of a new periosteum, 154 ORAL PATHOLOGY AND PRACTICE. and when the reparative process is once under way the forming tissue must be left undisturbed, except for occasional gentle irriga- tions with an antiseptic or stimulative solution when that is abso- lutely necessary. Many practitioners defeat their own efforts by uncalled for and meddling interference, by over-treatment when all is progressing satisfactorily. The preceding remarks apply more directly to caries of the alveolar process of the jaws. In caries of other bones there is almost always some cachectic condition, such as tuberculosis or syphilis, which induces the carious degenerations. If there is infection by septic organisms suppuration of course ensues, and the disease may assume a more active necrotic type. In dry caries of the alveolar process, which is the form most frequently met with by the oral practitioner, there is nothing of this kind, nor is there necessarily a constitutional dyscrasia, the local irritation being sufificient to induce the gradual wasting of the cancellous bony tissue, through the gradually progressive cutting off of nutrition. In oral practice, then, a distinction may readily be made between the carious disintegrations of the alveolar process of the jaws, that may not be accompanied by any specially inflamed conditions and in which there are few if any traces of ulceration, and the porous, abscessed state of true caries, which is surrounded by foreign, unhealthy granulations of the soft tissues. The one is merely a gradual disintegration, brought about by the deprivation of the nutrient supply, with denudation of the process by sloughing of the perios- teum, while the other is the breaking down of osseous tissue with the formation of fetid pus, which tends to burrow into the tissue. The first is due to simple lack of nutrition, usually the result of some injury, while the other is a cachectic state arising from some constitutional disturbance, the tuberculous deposit being its most frequent accompaniment. The only treatment demanded by the progressive crumbling of the alveolar process will be to remove any irritating cause, bur out the bone that is denuded of its periosteal covering and that is disintegrating, and then, by the use of stimulating astringents, to induce a new membranous growth. If there is an ulcerative condition, due to a dyscrasia, constitu- tional treatment will be demanded, and this will consist in the pre- scribing of nutritious diet, cod-liver oil, hypophosphites, syrup NECROSIS. 155 of iodid of iron, etc., with the local treatment previously recom- mended, and specific remedies when indicated. CHAPTER XLII. NECROSIS. Necrosis of the hard tissue is the analogue of gangrene in the soft. Its progress is not so rapid, because of the difference in the physical characteristics of the tissues themselves. But its origin is in an identical disturbance of nutrition, its course presents the same pathological changes, the termination is usually similar, and the treatment involves the consideration of cognate principles. Inflammation forms the initial point in its morbidity, and it is from that standpoint that the degenerate modifications should be studied. Necrosis differs from caries of the hone rather in degree than in essence. As gangrene is the death of soft tissues in mass, so necrosis is the devitalization of a territory having an osteogenetic origin. Like caries of bone, its cause may be either traumatic or specific, local or constitutional. It may attack any of the bones, but the maxillje are especially subject to it; necrosis of the lower jaw is four times as common as in the upper. In simple caries of the bone this proportion is nearly reversed. When not the result of an injury, its origin is in an inflammation of the investing or lining membrane, which spreads to the lacunae of the bone, thus producing osteitis, which eventually reaches the point of entire inhibition of nutrient currents, with subsequent death of a territory more or less extensive. Necrosis is usually an indication of a weak, anemic, or debili- tated condition. When all the functions of life are active and general nutrition is good, vitality in a part will be maintained despite unfavoring conditions. But when there are defects in the assimilative process retrogression is easy, and there is a predis- position to wasting diseases. The most fruitful source of necrosis of the maxillae will be found in the presence of decayed, diseased, irritating roots of teeth. These initiate inflammations, and exacer- bate them when once started, prevent nutrition, and hence provoke devitalization. When the suppuration of alveolar abscess takes 156 ORAL PATHOLOGY AND PRACTICE. place the pus may burrow beneath the periosteum of the bone, and, separating it, cut off nutrient currents from the territory beneath. This will be especially probable in the lower jaw, for drainage of its pus pockets is usually imperfect, while gravity constantly tends to bring about infiltration ; and this will in part account for the greater proportion of cases of necrosis in that bone. A fruitful cause for necrosis of the jaws -will be found in impacted teeth, arising from the lack of room for their proper development. This is especially true of the third molars, the body of the jaw between the symphysis and the ascending ramus often being too short to afford room for all the teeth. When the time comes for the development and eruption of the wisdom tooth all the space is occupied; it is imbedded in the tissues with- out power to advance, and becomes a source of violent irrita- tion. An inflammation is excited which assumes a peculiarly vicious character, and, the irritant still remaining, there is breaking down of tissue, infection, and suppuration. In the general degen- erative state this spreads to the bone, with consequent acute osteitis and necrosis. This condition, to which the upper jaw is not as liable, yet further accounts for the disparity in the relative number of cases in the two jaws. Necrosis may also be the result of injuries done by the dentist. Fractures of the alveolus in extraction are very com- nTon, but such is the recuperative power of these very vascular bones that nature usually buries the faults of the incompetent or reckless operator beneath new formations. If, however, the patient is suffering from any form of atony, the reparative process may not be sufficiently active to restore the normal condition, and retrogression may take the place of progression. In such patients the mere careless puncture of the alveolus to some depth by a sharp-pointed excavator, or plugger, or engine bur that has been infected by some septic product may induce a septicemia that will result in serious necrotic complications. Arsenous acid, when used in too great quantity for the devitalization of a tooth pulp, or if not securely sealed in the cavity of decay, may penetrate to the alveolus and produce a necrotic condition that will spread to other tissues. Many zymotic and exanthematous diseases sometimes have necrosed conditions among their sequelae. This is especially true of scarlet fever. Mercury, when given in large NECROSIS. 157 doses, may cause it. Syphilis is quite likely to attack the palate and nasal bones. People who, having dead teeth, work in match factories, are especially liable to a form of affection called phosphor- necrosis, caused by the fumes of the phosphorus used, which is supposed to penetrate through the root canal, and thus to come in contact with the pericementum which gives nutriment to the alveolar sockets. So universally is this special condition recog- nized, that in France every factory that uses phosphorus in the manufacture of matches must employ a dentist, whose duty it is periodically to examine all the inmates and forbid the employment of any that have dead teeth with unfilled roots. The diagnostic signs of necrosis are usually distinct and well marked. With the death of the bone, the overlying tissues with which it is invested become peculiarly turgid and inflamed. They finally assume a characteristic purple tint, and look exceedingly angry. This is increased as the tissue commences to break down beneath the surface, and suppuration ensues. There is little of the characteristic "pointing" of alveolar abscess, but the pus finds its way to the surface at a number of places, and the discharge is usually profuse and fetid. If now an explorer is passed into one of the sinuses until it reaches the bottom, the characteristic sensation imparted by dead bone will be plainly felt; or if the disease has been peculiarly active in its character deep cavities may be detected in the bone, with crumbling, disintegrating edges. Minute chips of the degenerated bone may be easily separated with any appropriate instrument. There will be the usual septic fever, and this may be decidedly pronounced. There will be a general malaise and loss of strength and vitality. The constant tendency on the part of nature is to get rid of the dead and irritating tissue. The very suppuration that accompanies all necrosed conditions is a part of this process. It is indicative of a disposition to slough away the diseased portion. Sometimes this is successful. There is a clear line of demarcation drawn between the dead and the living tissue, and the granular lymph acts as a kind of wedge to separate them. If this is accomplished, the dead part that is thrown ofif is called the sequestrum. At the same time there will perhaps be a successful effort on the part of nature to reproduce the bone, and this may be outside of and envelop the scf|uestrum. Such new enveloping bone is called the involucrum, anfl it may entirely prevent the exfoliation of the se(|uestrum. 158 ORAL PATHOLOGY AND PRACTICE. When there is extensive alveolar necrosis of a peculiarly active type it is not always judicious to extract teeth, even though they are plainly involved. There is a difiference of opinion upon this point among pathologists, but it must be evident to all that if the disease is the result of an acute osteitis, and the attachment of any part of a tooth is in live bone, its extraction will produce a wound that will be certain of infection; the inflammation will spread and a new focus will have been produced, which might have been avoided had the tooth been left to the slower process of exfoliation. On the other hand, if the tooth is a distinct irritant that is aggravating the situation it should be removed, provided it may safely be done. It will therefore be seen that it sometimes requires the nicest dis- crimination to determine this point. If there is a tendency toward the formation of a sequestrum, the dentist naturally desires to hasten this process. But here again good judgment must be employed. If it is violently torn away before the separation of the dead from the living tissue is completed by nature an open wound is produced, as in the case of extraction of a tooth; and at this point, minute though it may be, inflammation may begin anew and the diseased state thus be aggravated. But when a fissure of separation can be felt, a pledget Ct antiseptic cot- ton or gauze may be crowded in, and thus a little pressure made to assist the process of exfoliation. CHAPTER XLIII. TREATMENT OF NECROSIS. The treatment of necrosed conditions may be divided into three parts, — local, operative, and general. The first will consist of the use of disinfectants and depurators. There will be little occasion for antiseptics, because the flow of pus cannot be prevented as long as there is dead bone. But the whole diseased territory should be kept as carefully drained as possible, and it should be frequently and effectually cleansed with some good disinfectant. For this purpose electrozone, or meditrina, will be found especially useful, or peroxid of hydrogen, or a three per cent, solution of pyrozone may be injected with a syringe or applied with an atomizer. If TREATMENT OF NECROSIS. 159 the discharge of pus is into the mouth, that cavity should be fre- quently washed with an antiseptic gargle, and as much care as pos- sible should be exercised to avoid swallowing the septic products. A drainage tube, or strip of iodoform gauze to serve as such, may be introduced into the sinus if its location is such as to demand it, and this may be held in place, if necessary, w^th strips of adhesive plaster. Of course, neither of these will be appropriate if the dis- charge is within the oral cavity. Sulphuric acid may, in some instances, be profitably employed to dissolve out the dead bone. It may be used in such strength as the nature of the case demands, from a dilute aromatic solution to the chemically pure. Of course the latter will only be employed with caution. There is no danger to the soft tissues involved, unless possibly from the chemically pure, and even that involves no serious effect if it is properly used and washed away in time. Local stimulants may be employed to overcome the indolence if necessary. The operative measures to be employed will consist of those necessary to secure perfect drainage, and operations for the removal of the dead bone. Sometimes in the lower jaw a deep pocket will be formed in the body of that bone, through the enlargement by necrosis of the socket of a tooth which was the original cause of irritation. Drainage of this may be impossible, through the inability of the tissues to expel the pus over the borders. In one such case the author, against his own better judgment but at the solicitation of both the patient and the dentist who had referred her to him, attempted in vain the acid treatment after thor- ough burring out of the necrosed cavity. The pocket could not be kept clean, and reinfection from the retained pus was certain, until an anesthetic was given and an opening made from otitside the face and beneath the jaw into the cavity. A strip of iodoform gauze was then passed through into the mouth, drawn back and forth repeatedly, and the end finally left projecting from the external wound to assist in drainage. The result was a speedy and complete cure, without the use of any other agents. In some cases of necrosis of the upper jaw, operative measures may be necessary to open completely and straighten out the sinus of discharge. This may be readily done by a proper bur in the dental engine. The operation for the complete removal of dead bone l60 ORAL PATHOLOGY AND PRACTICE. in the maxillse may be of a formidable character, and its consideration may properly belong to the domain of oral sur- gery. It must be thoroughly done, if done at all. Half-way op- erative measures are of little account. The patieuL, having been properly fortified with nourishing food for a time, is anesthetized and placed in such a position as will afford complete command of the situation. The superincumbent tissues are laid back by the proper incisions, the blood checked by ligatures or the use of hemostatic forceps, and the territory carefully sponged and exam- ined. When the extent of the lesion is fully deterrnined, the proper steps are taken for the removal of the dead and diseased bone by the use of the dental engine, bone chisels, scrapers, and saws. When this is completed, all exposed edges of bone must be made smooth, every particle of debris removed, and the wound antisepti- cally washed and properly closed, with sutures if necessary, a drain- age tube inserted, the exterior dusted with iodoform powder, and the whole enveloped in the proper bandages and dressings. If the wound is wholly within the oral cavity, of course the iodoform dusting and the bandaging will not be called for. The desirability of working within the mouth when practicable cannot be too strongly urged, especially in the case of young women, that dis- figurement may not be the result; but the success of an operation should not be jeoparded in the effort to avoid minor disfigurement. A visible scar is better than death, or even the entire loss of a bone. General or systemic treatment is called for in almost every case of extensive necrosis. The disease is of such a wasting nature that, at the very least, tonics and a sustaining diet will be called for. The patient should be made to live out of doors as much as pos- sible, and every hygienic precaution be taken. If the lesion is the result of some cachectic condition, like syphilis or mercurialization, the general treatment proper to such condition must be instituted. For the former a strict course of specific treatment will be de- manded. The subject is presented in another chapter, and hence it is not necessary to pursue it farther in this connection. The tonics that are used in wasting diseases are of two kinds, — vegetable and mineral. The former consist mainly of the bitter barks of certain trees, while the latter are inorganic substances that exercise a peculiarly stimulant or alterant action that tends to pre- vent waste or assist nutrition. Of the vegetable tonics, Peruvian bark or cinchona, quassia, gentian, and wild cherry, with their alka- HYPERSENSITIVE DENTIN. l6l loids, are those most commonly employed; while the inorganic or mineral agents most used are preparations of iron, of copper, and of zinc, with such other remedies as subnitrate of bismuth and sul- phuric, nitric, hydrochloric, and oxalic acids. CHAPTER XLIV. HYPERSENSITIVE DENTIN. Were it possible to rob operative dentistry of the horrors too often its determined attendant in the pain and anguish that excava- tion of carious teeth causes, public health would be greatly con- served and human life would be correspondingly lengthened, be- cause of the greater care that would be bestowed upon those organs. \\'ould the public generally learn to look upon the dentist in his true light, — that of one whose mission it is to avert pain and suffering, — he would be regarded with much greater favor and would enjoy higher consideration. But the nature of his work is such that, like the general surgeon, in his efforts to forestall future anguish he too often brings present distress, and too many who should be his patients choose to postpone the evil day and hazard all the future rather thafi risk a moment of the present. Recognizing all this, dentists from the earliest period in the history of their art have been constantly striving to devise some- thing that will give exemption from pain in dental operations. Most of their efforts have been entirely empirical, and their experi- ments and labors have been conducted in a haphazard way that betokens anything but professional erudition or scientific knowl- edge. Those who have claimed to accomplish anything in the way of a solution of the problem, have not usually been those who^ were best equipped by education and professional attainments for the task. The practitioner who advertises "painless dentistry" has passed into a byword, and the term is a synonym for an impostor and a charlatan. Almost invariably those who have brawlingly boasted that they have discovered a universal panacea for all dental pain have been illiterate, undisciplined, unknown pretenders, whose sole object was to secure a dirty dollar by unprofessional methods, and to make profit out of that which should be public philanthropy; men who would, if possible, garner the sun's beams and peddle l62 . ORAL PATHOLOGY AND PRACTICE. them out for individual g'ain; who -would put holy things to an unholy use, and make of human benevolence a public prostitute. Of this character have been most of the widely advertised prepara- tions for the obtunding of the dental tissues, — quack remedies, pre- pared by dental quacks for quackish purposes. The student and practitioner should avoid them if he is an honest man, for he has no moral right to recommend to a patient, who pays him for special knowledge, any drug of whose exact nature and therapeutic value both are alike ignorant. In its normal condition dentin should be without sensation. There are no organized nerves to convey impressions, even were the tooth-bone subject to them. Yet the protoplasmic, albuminoid con- tents of the dental tubuli may, under special irritation, become the subjects of inflammatory conditions, in which they not only re- ceive, but readily transmit to the dental pulp, external impulses of a painful nature. It is true that the pulp of the tooth is supplied with nerves; yet they are without some of the characteristics of ordinary nerves, and, protected from all irritating shocks as it is in its normal state, even the pulp is not of itself responsive. Only when some of its protection is withdrawn, or when from some reflex source the pulp is subjected to external irritation, does it become impressible to outward agencies and convey disagreeable sensations. We know that it is a law that animals, and organs and tissues, adapt themselves to their environments and change their structure with varying conditions. Thus the fishes of rayless caverns lose their sight, and certain inhabitants of the greatest ocean depths are without the usual sensory functions. Both, by gradual transmis- sion to other surroundings, would develop special senses, as have other organisms. Continual subjection to external irritation may either weaken or develop the corresponding sentient perceptive- ness, through which alone can defense and security be obtained. That both dentin and dentinal pulp are without ordi- nary sensation ^vhen in a perfectly healthy and normal condition, is proved by the fact that when a healthy tooth is fractured and the pulp thereby completely exposed, it is irresponsive to external irritants for a short time. Healthy pulps are painlessly "knocked out" by a certain class of practi- tioners, provided the teeth are sound and the work is done quickly enough. But if there is the least inflammation in either pulp or HYPERSENSITIVE DENTIN. 163 dentinal fibrils the operation is anything but painless. There is not a practitioner who has not at some time cut into the dental pulp entirely without the knowledge of his patient, provided he was excavating in dentin that was completely or even compara- tively irresponsive. The source of sensitive dentin, or of impressionable pulps, lies in their continued subjection to irritation, by which responsiveness is developed. The freshly exposed pulp, or dentin, of a perfectly healthy tooth is without sensation. But a few moments of subjec- tion to external influences, the air and other irritants, are sufficient to produce a marked change in the tissues, and they become exquisitely responsive. A kind of inflammatory degeneration takes place, and ;iormal function is so altered that disagreeable currents are conveyed. This is in perfect harmony with the other known processes of Nature, for in the presence of danger she always develops means of defense by giving warning through the awakened senses. If, then, in the normal state the tooth tissues are without sensation, it follows that if a pathological condition is succeeded by one of perfect health, the immunity to pain should be re-estab- lished. This is undouljtedly the fact, for teeth that have been attacked by caries, and which under its influence have become painfully sensitive, have, when the broken continuity has been restored by a filling, lost that responsiveness and again became insusceptible to external impression. It is true that this is not always the case, because the very material that has been used to mend the broken place may of itself become an irritant and per- petuate the abnormal state. Were it possible to fill an ordinary tooth with something that w^ould be perfectly congenial to the tissues, there is little doubt that all filled teeth would be comfort- able, and herein may be found a reason why certain materials, aside from their lasting ciualities, make the best fillings. The test for the perfect success of an operation is the condition of the tissues which ensues, — because decay is not the first symptom of the failure of an operation. It may be found in the responsiveness of the dentin to external irritants; to its sensitive- ness to outward impressions. Not that it is always possible com- pletely to restore to healthy functional activity a tooth that has been subjected to operative filling. Usually only toleration with mild protest can be obtaincfl for llic foreign matter that is used 164 ORAL PATHOLOGY AND PRACTICE. for protective purposes, especially if it is of a metallic nature. When there is permanent denudation of any part, as in recession of the gums, normal conditions cannot even be approximated. One of the causes of the irritation in which is found the source of sensitive dentin is caries. This is of itself a pathological condition of dentin, and its progress necessarily entails other degenerative conditions. The disintegration of por- tions of the tooth-bone, with the consequent destruction of parts of the dental fibrillse, must affect that with which it is in connection; and so there will be an irritable, disordered condition of the whole of the dentin, with hypersensitiveness and inflammation of the protoplasmic elements of the soft fibrils, modified in manifestation by the character of the structure itself. With s^uch a destructive, deadly disorder as caries working at its vitals, no portion of the structure of a tooth can be in a healthy state, for although teeth have not the complex and vascular formation of the soft tissues, we cannot consider these organs as made up of dead, inert matter. Denudation of portions of the tooth, its loss of a part of that which should form any of its investing protection, must subject it to unnatural conditions. If the gum has receded at the neck, that simply means that the tooth is exposed to new environments and strange perplexities that cannot be other- wise than exasperating. Under the stress of their provocation it assumes an added susceptibility, and becomes more and more liable to attacks of external agents. All the dentin is thus affected, and it becomes tender, sensitive, responsive to any provocation. This, as in the case of caries, proceeds by continuity of tissue to the pulp, which also becomes irritable and inflamed, so that there is an immediate response to thermal changes, to the presence of acids or sweets, and even to the finger nail or quill toothpick. Metal toothpicks are almost always irritating to the teeth. Vitiated secretions are also a cause of sensitive dentin. That of the somewhat specialized mucous follicles at the gingival margin, through neglect of the teeth and the presence of fermenting debris, is sometimes of a degenerative type. This secretion becomes , acid, and in this state is highly irritative to the cervix of the tooth. Or the white deposit which is so frequently found surrounding the tooth at its neck, and which is made up of decomposing matter undergoing fermentation or putrefaction, may be the cause of the irritation. The resulting acid may dissolve out some of the lime TREATMENT OF HYPERSENSITIVE DENTIN. 165 salts at the cervix, where the enamel is very thin, and so lay bare the dentin, which will thus be made specially irritable. Some of the most sensitive dentin encountered by the operator is the result of this acid degeneration or formation. The teeth are sometimes set on edge by the use of acids. This means softening of the superficial portion of the tooth, and a hyperesthesia, or its analogue, of the dentin. The sensation referred to is not a distinct pain, and it usually passes away with the provocation, but it is a definite feeling of responsive- ness in dentin. The same kind of impression may be induced by reflex action, wdien a saw is filed or strong cloth is torn. CHAPTER XLV. TREATMENT OF HYPERSENSITIVE DENTIN. It has been affirmed that if a tooth that is in a healthy condi- tion is insensible, a return to that state after diseased action should carry with it freedom from responsiveness. While this may be true, it is not always possible in dental practice to secure this result. In cases of caries it is impossible to induce a healthy state except by excision of the diseased part, as in necrosis of bone; and it is from the pain of that operation that we seek immunity, hence the only hope of the dentist is in securing an artificial anesthesia of the part. This may be readily accomplished, as in the other tissues, by inhibiting and stopping all nervous currents through general anes- thesia. But such methods are prohibited by the circumstances of the case. We do not wish to obtund all sensibility, but only to overcome that of a small part. The ordinary local anesthetics might be employed, and they would completely answer all demands were that which we wish to make insensitive supplied with blood vessels and nerves. Unfor- tunately for our object, this is not the case with the teeth. Theirs is not the structure upon which anesthetics act, and hence the latter are of but doubtful utility. When cocain was first discovered it was believed 1)y many that the dental millennium had surely arrived, but that agent has Ijeen found powerless to benumb non- vascular tissues. This class of remedies may therefore be dismissed from consideration, because while they may under certain condi- l66 ORAL PATHOLOGY AND PRACTICE. tioiis inhibit nervous currents in tissues that have a nervous supply, the}' are inefficacious when that is lacking. Cocain will obtund a pulp that is exposed to its influence, but it is ordinarily powerless upon dentin. We are thus obliged to fall back upon specific remedies, or those whose therapeutic action is not thus limited. We know that the protoplasmic dentinal fibrils, when in an irritable state, or when made responsive by certain pathological conditions, will convey painful impulses along their course and deliver them to the terminal nerve filaments of a more or less inflamed pulp. If, now, these afferent waves of irritation can be cut off at any point before reaching the sentient centers, immunity from pain will thereby be secured. This can be done by a general anesthetic that paralyzes sensory filaments and trunks, or it could be accomplished by the application of a local anesthetic directly to the pulp itself. Both of these, for reasons already given, are impracticable, and it leaves the work to be done upon the only other connecting link between the dentinal periphery and the brain. If the dental fibrils themselves can he put in such a state that they will no longer carry impulses to the pulp, that tissue cannot transmit any to the afferent nerves which carry them to the nerve centers. There are two ways of accomplishing this, neither of which is entirely satisfactory in its results. The first is by producing some temporary physical change in the character of the fibril that will prevent its receiving an impulse, and the second by subjecting it to some medicinal agent that will paralyze its transmitting function. There are perhaps two other methods of acoomplishing the same thing which should be included in the list of methods to be employed, and they will be duly considered. They are, first, the exercise of such care and gentleness, with the use of such perfected instruments as shall arouse no irritating pain waves; and, second, the employment of such general prophylactic remedies and measures as will so fortify the system as to enable it to resist them, or steel it against their reception. The physical agents which are practicable w^ill be such as will temporarily change the material characteristics of the fibrillae, and of these the most important are heat and cold. Heat may act either by raising the temperature above the point TREATMENT OF HYPERSENSITIVE DENTIN. 167 of susceptibility, — which is impracticable because it is of itself a painful process, — or by so changing the matter of the fibrillse through desiccation, or drying out, as to make them incapable of conveying impulses. It is readily conceivable that, a cavity being isolated by the use of a rubber-dam, a current of hot air may be effectual in so changing the physical structure of a fibril, by abstracting a part of its water, as to debar all reception or trans- mission of nervous or other impulses. This is perhaps the most simple of all methods for obtvmding sensitive dentin. The use of cold, or refrigeration, will be equally effectual by benumbing or paralyzing the fibrillse. If an ether or rhigolene spray is directed upon the tooth cavity, or even upon the tooth itself, until the temperature is reduced sufficiently, it will be com- paratively irresponsive. This would without doubt be the most perfect obtundent, were it not that the effective use of the agent is of itself too painful in its application. There is also danger that the pulp tissue may be permanently injured through degenerative processes inaugurated by the shock of the cold. A severe inflam- mation may be the result of the application of the ether spray for too long a time. Hence this has never been widely used for obtunding purposes, except in extreme instances. The medicinal agents that have been employed in the overcoming of dentinal hypersensitiveness are almost numberless. General and local anesthetics, stimulants and anodynes, excitants and sedatives, acids and alkalies, with many drugs of altogether indefinite and unknown therapeutic value, have been persistently recommended. The whole matter has generally been one of empiricism. It would seem that, so far as our present knowledge goes, anesthetics, whether local or general, have little direct effect upon dentinal tissue. All such remedies have a selective power, and affect nervous tissue alone. The den- tinal fibrillse, while they do not contain any nervous filaments, yet comprise the elements of such tissue; and it cannot be positively affirmed that they arc not, under certain conditions, amenable to anesthetic action. But we know that they are not ordinarily so, and hence the agents referred to have proved as inefficient as might have been anticipated. Certain sedatives, anodynes, and narcotics, like prep- arations of opium, cannabis indica, and chloral hydrate, have been effective in certain instances, but it is not at all l68 ORAL PATHOLOGY AND PRACTICE. certain that they did not work through other tissues, and thus act indirectly instead of directly. Some cauterants are effectual, but to a limited depth. Thus nitrate of silver, or chromic acid, or carbolic acid, will obtund, but only to the limited depth to which they reach. They certainly destroy the fibrillse completely as far as their action extends, but that action is not really obtund- ing, it is extinction. In the harmless coagulation of the albuminoid contents of the dental tuhuli would seem to lie the surest road to success. There are coagulating agents that thus obtund, like chlorid of zinc, but it is too often at the expense of quite as much suffering as they save, leaving out of consideration the dangers to which the dental pulp is exposed by the use in its proximity of active escharotics. If coagulation could be accomplished •without per- manent injury to the tooth structure, and would reach deep enough to allow of effective excavation, the agent that accom- plished this without pain would be the long-sought desideratum. That drug has not yet been discovered, nor can we be sure that it ever will be. Certain it is that until it is sought for in an intelli- gent, scientific manner, it will remain a secret; for the illiterate, untaught ignoramuses who have in the past been mainly respon- sible for the quack preparations sold at an extortionate price, and who have not the pharmacal knowledge to save them from com- pounding the most glaring chemical incompatibles, are not likely to be the discoverers of that which so many competent men have sought in vain. Cataphoresis, which is the transfer of medicaments into the deeper parts of tissue through the diffusive povrer of an electric current, seems to promise something in this direction. It is not recently acquired information that has taught us that when a drug is applied to a tissue upon the posi- tive electrode of a battery, the negative being placed so that the current will traverse the organ to be affected, it will carry with it the remedy; this principle has been cjuite extensively employed in general medicine, and with good results. To make the remedy in cataphoric medication effective it is not sufffcient to carry it deeply into the dentin; it must be transferred to the pulp itself, and to the accomplishment of this the hard dental tissues present difficulties not met with in other organs, in their relatively low vitality and their comparative impenetrability. Yet practical TREATMENT OF HYPERSENSITIVE DENTIN. 169 experience seems to point to the indisputable fact that cataphoric transference does take place, but whether with sufficient readiness and rapidity to make it all that can be desired remains to be definitely established. No one will dispute the assertion that in the cataphoric transference of such topically applied remedies as cocain and morphin better results have been secured than in any other of the thousand profifered methods of obtunding sensitive dentin. But its employment requires a cumbersome and expen- sive apparatus, troublesome alike to operator and patient, and its results are by no means uniform. While, therefore, every progres- sive operator should use it, it is not now to be considered a finality. Its application must be simplified and its effects made positive by further experimentation before it can be so accepted. Good men are investigating it, and it is to be hoped that in it will eventually be found that which is so highly desirable. It cannot be forgotten, however, that good men have before this cried, "Lo, here! Lo, there!" only to meet final disappointment and defeat. Prophylactics have proved of great service in the den- tal operating room. They are of sedative nature, and reduce general nervous irritability, thus preventing or obtunding nervous shock. These have not been as much used as their merits demand, because most dentists have either been lacking in the medical knowledge necessary to their most intelligent use, or have not felt themselves warranted in administering general remedies. The first of these causes, if it exists, should be at once removed by study, and the last eliminated by a proper amount of self-confi- dence. The time for administering srch remedies is a few moments before commencing any painful operation, the exact interval depending upon the nature of the drug. A few whififs of chloroform or ether, not enough to induce any functional dis- turbance whatever, will frequently be of use, but their influence will not last long. Twenty-five grains of potassium bromid in water will be more persistent, and usually quite as effective. Syrup of lactucarium, in teaspoonful doses, has been employed with good effect; or tincture of belladonna, administering from five to twenty drops. Sulphate of morphin, in doses of from a quarter to half a grain, has been frequently used, but its action upon some people is a little uncertain. The fluid extract of Jamaica dogwood may be substi- tuted for this, and five to twenty drops given in a little water. I^O ORAL PATHOLOGY AND PRACTICE. The full dose of the drug is from a half to two fluidrams. The author has not for several years been without aromatic spirits of ammonia in his case, and whenever there is unusual nervous irrita- bility he administers from forty to sixty drops of it in water. If there arises the necessity, a hypodermic dose of from one-eighth to a quarter of a grain of morphin may be given. This is usually effectual in quieting all nervous excitability and making otherwise insupportable operations comparatively tolerable. The proper dose of this drug, combined with atropin or strychnin, may be readily obtained in tablet form, and should always be kept at hand. Hypodermic medication has not been as much employed in oral practice in the past as it should have been. But, when all is said and done, the main dependence of the judicious dentist will be upon a gentle hand and sharp instruments. It is barbarous to employ in a sensitive tooth any tool that is not in the best possible order; while the operative dentist who for a moment allows himself to forget the consideration that is due to a sensitive, timid, shrinking patient, ^^-ho will become in the least degree careless or callous, and thus give unnecessary pain, is unworthy his vocation. In excavating a sensitive tooth he should invariably put on the rubber-dam, and dry out the cavity as far as possible. Then he will find a great deal of relief in the employ- ment of many of the remedies already mentioned, and especially in the use of some of the essential oils, like cassia, cloves, or eucalyptus, securing penetration by means of the hot-air blast. A mixture of equal parts of sulphate of morphin and gum camphor may be found useful for this purpose in some instances. Or he may apply tincture of aconite dilute, or any other favorite remedy, always remembering that its effectiveness will be greatly increased by thoroughly drying the cavity of decay, and by the hot-air current. For those who wish a cocain preparation that is effective, the following is given. It should not be forgotten that this is a ten per cent, solution, and when used hypodermically less of it should be injected: B — Atropin, tV grain ; Strophanthin, Ys " Cocain mur., SO " Carbolic acid, 10 " Oil of caryophyllus. 3 minims. Dist. water, I ounce. SECONDARY DEXTIX, PULP NODULES, ETC. 171 The following formula has been recommended by Professor Peirce as effective : IJ — Cocain mur., 5 grains; Carbolic acid, 20 " Chloroform, Yi dram; Muriatic acid, 10 minims; Alcohol, 2 drams. CHAPTER XLVI. SECONDARY DENTIN, PULP NODULES, AND CALCIFICATIONS. These, although different manifestations, are parts of the same process. They have their origin in the same disturbed function. They are the result of deranged neural currents and of some per- version of nutrition which induces a formation of dentin in abnor- mal quantities or in an anomalous position, through the undue activity of the odontoblast cells under the excitement of just enough of irritation to act as the proper stimulant. All of these products have the general structure of dentin, although it may be considerably modified. They are not usually found as mere calcific, structureless calculi, but are organized by the unduly excited odontoblast cells, whose normal activity continues through life. The odontoblasts are not found exclusively upon the periphery of the dental pulp, any more than osteoblasts exist alone in con- nection with periosteum. The latter may be found within the body of the bone, and may be the initial points for new growths after operations or accidents. The former may exist enveloped in the pulp tissue, and under the special stimulus that was perhaps responsible for their formation, may commence functional activity, with the consequent organization of segregated spicules of dentin; and these may continue to grow until they assume the form of the usual pulp nodule. Sometimes this form of calcification may begin at many points within the pulp, and may impart to that of a freshly extracted tooth a gritty, sandy sensation when it is rubbed between the finger and the thumb. At other times there is an agglomeration into one or more large concretions. When the unwonted functional activity is at the peripheral pulp borders, the new formation will probably be attached to and 1/2 ORAL PATHOLOGY AND PRACTICE. form a kind of hypertrophy of the ordinary dentin of the tooth. Sometimes this will be so continued that it will almost entirely fill tip the pulp chamber, and even extend down into the root canal. An examination of an extracted tooth affected with this condition will show by its complete or partial attachment to the normal dentin, or by its independence of it, where was the commencement of the new growth. The "pulp stones," or formations of dentin that take place within the substance of the pulp, sometimes contain chambers not unlike the "interglobular spaces" of the tooth. These impart an appearance of bone, and the new formation is analogous to true "osteo-dentin." It may even have open canals that cause it to assume the appearance of vaso-dentin. As might be inferred from the circumstances under which it is deposited, its structure will be quite irregular and unmethodical. The canaliculi, or dentinal tubuli, will be involved, complicated, and irregular. There will be hyaline spaces, but the structure, when carefully studied, will be found to be essentially dentinal. The study of comparative dental anatomy will materially assist in a comprehension of these anomalies. In certain animals secondary dentin, or tooth-bone, is very common. This is especially the case with some of the monophyodonts. The per- sistent pulp chambers of the sperm whale (Physctcr macrocephalus) are very frequently lined or partially filled with secondary dentinal formations, and some of them make very beautiful objects when polished. The long incisors of the elephant, the so-called tusks, are frequently wounded by the hunter near their insertion, the bullets remaining in the persistent pulps. This may result in the destruction of the vascular portion of the tooth, but much more frequently the consequence is the deposition about the wound of secondary dentin, which perhaps will entirely inclose and segregate the original cause of irritation, and form septa across the pulp chamber. With the continuous growth of the tooth or tusk this is carried forward, until, perhaps many years subsequently, when the animal is killed and its tusk falls into the hands of the ivory cutters, the original bullet, with the secondary formation about it, is found in the solid ivory, perhaps two or three feet from the skull. Nature sometimes throws out a layer of secondary dentin to protect the pulp from slowly advancing caries, or erosion. The SECONDARY DENTIN, TULP NODULES, ETC. 1/3 formative cells at the periphery of the threatened portion of the pulp are by the irritation stimulated to increased functional activity, and a kind of hypertrophy of dentin is the result. Prac- titioners have sometimes seen this take place under a plastic filling that had been inserted over a nearly exposed pulp. In the course of a few years this perhaps became svifficient support for a solidly impacted metal filling. This is the result hoped for in all instances of ordinary capping. Fractured teeth have been known to be vmited by a secondary growth of dentin, though these instances are probably few in number. The formation of so-called pulp stones and secondary dentin is a much more common occurrence than is usually imagined. The examinations of the pulp chambers of extracted teeth in the teaching of operative technics in some of the colleges, shows that a considerable proportion of teeth are thus affected. Prof. A. P. Southwick believes that from sixty to seventy per cent, of extracted teeth show some form of it, but as this applies only to such as have been extracted for diseased conditions, probably it would not hold good universally. The formations within the pulp chamber are some- times the cause of considerable local irritation, but neither the objective nor the subjective symptoms of these condi- tions are sufficiently distinctive to afford reliable means of diagnosis. When they are of rapid growth the pain may be of an acute character, but they do not under ordinary circumstances induce any breaking down of pulp tissue; nor do they bring about any serious complications. Usually the suffering is of that sub- acute nature that is hardest to locate. It presents no special dis- tinguishing characteristics, and a diagnosis can only be safely made through exclusion. When it is certain that the pain arises from nothing else, it may be attributed to secondary formations. It might, by the superficial observer, readily be mistaken for facial neuralgia, but it is not, like that, paroxysmal or periodical. Nor is it so acute or so intense in its nature. The presence of pulp stones will not usually be suspected until they are discovered through pulp exposure. Not infrequently they will seriously embarrass the dentist in his efforts at pulp devitali- zation and extirpation. Sometimes in their presence it is with the utmost difficulty that even arsenous acid can be made to produce its characteristic effect. Why this should be the case to such a 174 ORAL PATHOLOGY AND PRACTICE. marked degree it is impossible to say, as the secondary formation does not usually make an entire septum in the pulp chamber. That it may completely bar the proper filling of the roots of a tooth is more conceivable, for the growth may be so attached to the ordinary dentinal walls as to make its removal very difficult. It may form such an obstruction in a root canal as will absolutely forbid the passage of an instrument, and hence devitalized tissue cannot be removed, except through the slow and, under the cir- cumstances, uncertain process of sloughing; while subsequent successful filling of such a root is a mere matter of conjecture. The presence of secondary formations will only be positively known when the pulp chamber is opened, and then it is too late for anything but removal, when this is practicable. If they are float- ing in the pulp chamber this will not be a difficult matter. But if they are attached to the dentinal walls it may be impossible. It is not a safe practice to attempt to drill them out, nor in all cases would this materially assist in the subsequent treatment and filling of the root. The operative dentist will be obliged to take them out by enlarging the opening into the pulp chamber when this is practicable, or to use si4fficient time thoroughly to sterilize any fragments of remaining pulp tissue; and then to fill as best he can, using some plastic material for the pulp chamber. CHAPTER XLVII. HYPERCEMENTOSIS. Hypercementosis is the analogue of hyperostosis, or exostosis, of bone. Technically it is a tumor, but always of benign growth. It is an hypertrophy of the cementum, and has its origin in some form of irritation that is just sufficient to stimulate the pericementum to an abnormal activity. It may be local, and affect but one tooth, or the irritation and stimulus may be so general as to induce an ex- cessive deposit of cementum in some form upon all, or nearly all, the teeth of either jaw. It may even be more comprehensive than that, and involve the osseous tissues. Instances have occurred in which hypercementosis and hyperostosis existed together, with not only enlargement of the roots of all the teeth, but of the whole alveolar process of the bone as well. Nodules of exostosed bone DISCOLORED TEETH. 175 may sometimes be felt along the alveolar portions of the lower jaw especially, and these are apt to be associated with expansion of the roots of the teeth from hyperccmentosis. The condition is not one that presents very special pathognomonic symptoms. Unless it is accompanied by hy- perostosis, there will be no external indications of its existence. Nor is it provocative of much pain. Hence its diagnosis is at times difficult, or even impossible. There may be a feeling of pressure and general uneasiness in the teeth afifected, but it will not be sufficient to furnish a diagnostic sign. There are no special complications, and hence the condition is not one of great patho- logical importance. Its chief import to the practicing dentist lies in its being an impediment to extraction, and when that is impera- tive may make it necessary to cut through the investing alveolar process before the tooth can be lifted out. This will only be called for at the cervdcal constricted portion above the expanded part of the root. There will have been a resorption of the investing bone sufficient to accommodate the hypertrophy itself, and the cutting through, or removal of a part of the constricted superficial alveolar process is but a simple operation, and is very much preferable to a long struggle to effect expansion in continued efforts to extract the tooth, with the liability to its accidental fracture under the forceps. Microscopical sections of portions of hypertrophies of thecemen- tum show that they have the true cemental structure, and there is no special line of demarcation visible between the new and the old formation. Pigmentation, or coloring, is not uncommon, its most usual form being a deep yellow or light brown tinge. The cemen- tum corpuscles are often unusually large, so that the nutrition of the hypertrophied and original tissue is very well carried on, for perhaps obvious reasons. A clinical and microscopical study of the pericementum in these conditions has not hitherto been made. When this is undertaken further light upon this interesting subject will without doubt be afforded. CHAPTER XLVIII. DISCOLORED TEETH. While the remedial measures for the relief of discolored teeth belong rather to operative dentistry, and are outside the scope of 176 ORAL PATHOLOGY AND PRACTICE. this work, yet a little may be said concerning the cause of dis- coloration, which may be due either partially or entirely to patho- logical conditions. People sometimes present themselves to the dentist with the request that an objectionable color of the whole or parts of the teeth may be discharged, when it is plainly evident that it is congenital. Some people have yellow, and some dark teeth naturally, and no skill is sufficient to alter this without material injury. The leopard cannot change his spots, nor the Ethiopian his skin. But there are pigmentary deposits upon the surface, and stain- ing which penetrates to a little depth, that it is possible to remove. Dead dentin, the tubules of which have become filled with pig- mentary matter, may be bleached by chemical agents. Usually these deposits, either upon or within the substance of the teeth, are of a yellow or dark color, but in some instances the teeth are turned to a bright blue, or even an intense green. Workers in dif- ferent metals may have their teeth stained by minute particles. This is especially the case with brass, nickel, and copper workers. When this is superficial it may be readily removed, but when it has penetrated the substance of the tooth it presents greater obstacles. It is not usually the case that a tooth containing a living pulp is affected by anything- beyond mere shallow exterior discoloration. There may be congenitally maculated spots, or atrophied regions that become pigmented, but any material changes of color are usually associated with a devitalization of the affected tissue. As the consequence of a sharp blow, and sometimes too protracted or severe dental operations, a tooth has been known to assume a bright pink appearance. This is, however, the result of death of the pulp. While the red blood corpuscles are much too large to enter the dentinal tubuli, they may become partially decomposed and their hemoglobin may penetrate the tubuli, giving the red tint. This is more apt to be the case in man than in woman, because the percentage of accidents is somewhat higher. After a few days changes analogous to those that take, place when one has a "black eye" appear, but as there are no absorbents to take up the decomposed blood, it remains a black or dark color. The dentinal fibrillge themselves may, instead of being sloughed out, remain, and after desiccation or drying undergo slow retro- gressive changes that leave the dentin a dirty yellow or dark abrasions; pitted and furrowed teeth. 177 brown color. Foreign matter may enter the tubuli, and there slowly become carbonized, and thus be the cause of discoloration. Substances used in filling may impart a stain to the devitalized dentin. Oxidation, or other chemical changes going on in metals used for posts to assist in the retention of fillings, may induce pig- mentation more brilliant than ornamental. Thus a piece of copper has been known to impart to a whole crown a beautiful green color, while nickel has given a color approaching turquoise blue. The most efifective means for the discharge of the yellow or dark colors is by the use of chlorin gas. Oxygen is really the active agent, but the most convenient way to generate it is by the use of some preparation that will liberate chlorin gas, and this, in the presence of water, unites with the hydrogen and sets free oxygen, which accomplishes the work. Peroxid of hydrogen and pyrozone, both of which loosely hold in solution an extra volume of oxygen, are also used for the purpose. It is sometimes neces- sary to repeat the bleaching a number of times, for the discolora- tion is likely to return until all the degenerative changes have ceased. As it is difficult to force the bleaching agent very far into the dentinal tubuli, it is usual to cut out all the discolored tissue that it is possible to spare before commencing the process. The bleach- ing interferes with the integrity of the tissue, and weakens the tooth. Large contour restorations, after this process, are therefore likely to fail; this tact, with the liability to recurrence of the pig- mentation, has made crowning rather to be preferred in most cases. CHAPTER XLIX. ABRASIONS; PITTED AND FURROWED TEETH. The ordinary wear of teeth presents no unexplainable phe- nomena. The tooth-brush may easily account for many channels and indentations. But aside from these, there appear occasionally furrows and concavities that are not congenital and that cannot be the consequence of any usual cause. Sometimes these occur as deep pits in the occluding surface of a molar, without a corre- sponding protuberance on its antagonist. The channels may be between teeth, where no brush could reach them. They are even 13 178 ORAL PATHOLOGY AND PRACTICE. found in the teeth of wild and domestic animals, the brush as a necessary cause being thus eliminated. Cases have been known in \yhich upper incisors, for instance, have the appearance of being regularly and evenly chamfered from the. cervical portion to the point, as if done with a flat file. One peculiarity of this condition is that the surface left is smooth, and in some instances apparently polished. Very frequently these abrasions are near the margin of the gum, and their edges may be too sharp and well defined to be caused by any form of attrition, in some instances presenting a distinct undercut. They may be confined to a single one, or may affect a series of teeth. Usually they are found only upon the buccal aspect, occasionally on the proximate, and very rarely upon the lingual surfaces. They do not seem to be necessarily connected with any special diathesis, for they are found in the teeth of people who show no indications of gout, rheumatism, or any of the dis- eases to which they have by some been attributed. No explana- tion has ever yet been presented that will account for all cases of abrasion. Chemical solution is not a sufficient explanation, because any acid sufficient to account for the abrasion of the surfaces of incisors must manifest itself in other ways; besides, abrasion at times occurs when the reaction of the oral secretions is not strongly acid. It has been attributed to electro-chemical cur- rents which produce electrolysis. The improbability- — nay, more, the absolute impossibility — of the existence of such currents in the mouth seems too apparent to need demonstration. There is no question that electrical currents are constantly being formed by the incessant chemical action and the different molecular changes that never cease in the oral cavity, but it must also be as true that they are as perpetually and as instantly dissipated. There can be no closed circuits, nor any such thing as accumulation; and hence, while theoretically they may be present, practically they must as inevitably be powerless for either good or evil, vanishing on the instant of their birth. It seems to be true that while the acid reaction in some instances of abrasion may be weak, so far as observation goes it always exists. It is well known that organic acids in their nascent state are most active. While, therefore, through fermentation or in a degenerative state of the mucous follicles an acid may by combination be formed in a circumscribed locality, and there, on the abrasions; pitted and furrowed teeth. 179 spot of its birth, have sufficient force to attack tooth substance, as soon as it becomes dihited and its affinities are partially satisfied it might give but a weak reaction when tested. In this fact may be found a partial answer to some phenomena. But acids would not probably be formed upon the most prominent labial surfaces of incisors, for instance, where they are most free from any foreign fermentable substance, and where they are constantly washed by the saliva and kept clean by the friction of the lips. A degenerative, acid condition of the secretions of the special- ized mucous glands at the gingival margins might, and probably does, account for much of the peculiar abrasion that exists in such localities, but it offers no explanation for that upon the occluding or incisive edges of the teeth. Vital depression, an atonic condi- tion that offers a decreased resistance to degenerative changes, are terms too vague and indefinite to be accepted as elucidations of such a condition as abrasion. We are simply reduced to the alternative of accepting explana- tions that do not explain, or frankly admitting that there is much in this condition which with our present knowledge is not com- prehensible. There are factors at work which we probably know not. That it is an external agent of some kind is proven by the fact that a protective filling, when well inserted, always screens the tissue that it covers. The wasting process may go on all about the filling, but it ceases beneath it. In the absence of definite knowledge of the etiology of abrasion, any positive prophylactic treatment cannot be laid down. Filling prevents penetration, but it does not in all cases debar extension. It forms the only effective operative treat- ment that can be pursued, for usually there is no polishing or cleaning to be done. If there is a distinctly acid reaction of the fluids of the mouth it shows that assimilation and nutrition are interfered with, and relief may be found in alterative remedies, and in change of climate, out-of-door exercise, or perhaps the use of tonics. Lime-water may be used as a gargle, and at night a spoonful of Phillips's milk of magnesia may be rinsed about upon the teeth and left there until morning, or until it is slowly dissolved ofif. Moderate friction of the gums with the brush, and massage with the ball of the finger, are always stimulating and useful. Congenitally pitted and furrowed enamel is usually attributed to the influfence of exanthematous or eruptive diseases during the l8o ORAL PATHOLOGY AND PRACTICE. formative period. What gives probability to this explanation is the fact that it is usually found upon those portions of different teeth which are in the same relative state of advancement as to growth. For instance, the summits of the first molars will be im- perfect, with the tips of the cuspids, while the incisors will present an abnormality in the shape of a furrow that is farther up on the face of their crowns. Another reason for the acceptance of this solution is that the abnormality never appears in the deciduous teeth, but is confined to the second dentition; and even then it is usually found upon the six anterior teeth and the first permanent molar, the premolars and the second and third molars, which erupt later, being free from it. The fact, too, that the enamel has an epiblastic origin would seem to connect it, though not necessarily so, with the various skin dis- orders. And yet this hypothesis does not offer a complete explanation of some of the phenomena presented. The enamel does not grow by additions at one point, but the whole of the enamel organ, as far as it is fully developed, will be building up enamel prisms at once. Any interruption of the function or any lack of nutrition would therefore be likely to present enamel that was imperfect over its whole surface, instead of at a few isolated pits, or in a narrow fissure across the face. In some instances this is the case, but it is by no means the rule. There may be but a minute pit, which extends well into the dentin. There may be a fissure that is longitudinal, rather than transverse; and one tooth alone may be imperfect, the others, which erupted simultaneously with it, being unaffected. The fact that the child had measles, or scarlet fever, or chicken- pox, during its early years, proves nothing; there are but few children who are exempt, and thousands suffer with no visible effects upon the teeth. That these congenital marks are the result of some imperfection or disturbance of the enamel organ during its functional life must he the case. It is probable that often this may be an eruptive dis- ease, but there must be other factors. It is readily conceivable that a restricted field of the ameloblasts might be functionless from structural causes, and this would account for isolated pits and imperfect places. Interruption of nutrition might account for others, and thus a number of causes may be active in bringing about the general result. REPLAXTATIOX; TRANSPLANTATION; IMPLANTATION. l8l As it is impossible to make any diagnosis until the teeth are erupted, with the consequent destruction of the enamel organ, any preventive measures are out of the question. The trouble being structural, it is beyond the domain of medicinal agents, and the only remedy lies in operative proceedings. When the teeth are sufficiently advanced they may, if the pits or fissures are superficial, be ground down smooth and polished. Deep pits may be filled, or even "jacket" crowns may be placed on them. It is a matter that must be left to the knowledge, judgment, and skill of the operator. CHAPTER L. REPLANTATION; TRANSPLANTATION; IMPLANTATION. Replantation and transplantation are the insertion of an extracted tooth in a natural, and implantation in an artificial alveolar socket. Replantation is the replacing of a tooth in the same place from which it was, either accidentally or purposely, extracted. Transplantation is the removal of a tooth from one mouth to another. In each case the success must depend either upon the reunion of sundered tissues or the growing of new. Transplantation was originally performed by placing the donor and receiver in the same room, and then extracting a diseased or decayed tooth from the latter and immediately substituting it by one extracted from the former, without any special preparation. But the unfortunate inoculation for a communicable disease in some instances of transplantation brought the operation into dis- favor. With the advance in pathological knowledge, more especially that of bacteriology, better methods for its performance have been devised. Replantation is called for in instances in which teeth have been forced from their investment by accident, or ex- tracted by mistake, or taken out in special conditions. There is no bone that heals so readily as does the alveolar process of the maxilla, and even though there are compound fractures the parts readily unite if nutrition can be kept up in them. A tooth may be knocked out by accident, and may even remain out for a consider- able number of hours; and if it is simply washed of¥ and placed back in the socket it may readily unite again. But if no antiseptic l82 ORAL PATHOLOGY ANU PRACTICE. precautions are taken the probabilities are that an alveolar abscess will be the consequence. It is sometimes good practice to extract a tooth in the expectation of replacing it, A broach may have been forced through the foraminal opening, which it has been found impossible to remove. In a number of such cases that have presented them- selves to the author he has promptly extracted, removed the broach, given proper treatment, and reinserted the tooth, always, so far as he knows, with success. Cases of persistent and un- accountable pain that was located in the tooth have been so remedied. In instances of incurable alveolar abscess, perhaps due to secondarily infected pockets, or to foci of infection along the side of the root where there were Haversian canals penetrating to the pulp through the dentin, or in which the inflammation was of that low, indolent, subacute nature in which neither resolution nor active suppuration could by any usual means be brought about, the author has frequently extracted the tooth, and after proper treatment and preparation replaced it. Sometimes the mere trau- matism of the extraction was sufftcient to induce an active, acute inflammatory stage, in place of the sluggish one. In all cases of plantation the most careful antiseptic measures must be employed. When the tooth is extracted, or as soon as possible after its violent removal by accident, it should be placed in a warm bichlorid of mercury solution for sterilization. It should be handled with a clean napkin, and in any subsequent manipulation should be frequently returned to the sterilizing solution, which may be kept warm by placing the vessel containing it in a larger one holding warm water. The pulp chamber should be drilled open, and its contents, with those of the root canals, care- fully removed. After sterilization and drying they should be thoroughly filled, any openings, foraminal or through the body of the root, being especially looked to. The apex must be made smooth, and if the tooth ends in a sharp point it is well to cut this off, carefully polishing the exposed extremity. If the perice- mentum which comes away with the tooth appears red and con- gested, it should be removed without any injury to the tooth itself. Placing the prepared tooth in the sterilizing solution, atten- tion should now be directed to the socket. This must be thoroughly washed out by syringing with an antiseptic solution, either of the mercuric chlorid i : 2000, or some other effective one. replantation; transplantation; implantation. 183 If pus is present, a disinfectant like peroxid of hydrogen or pyro- zone should first be used. All these should be employed at blood temperature, or about lOo'' F. If there is any specially septic con- dition the alveolar socket should be minutely examined with a probe, to determine the existence of secondary pockets, which should be thoroughly sterilized. If it is a case of transplantation, the tooth should now be tried in the socket, when if necessary the latter may be deepened or enlarged. Xo fear of any specially threatening consequences need be entertained, because the formation of new bone is probable and desirable. \\'hen everything is ready the tooth should be taken from the sterilizing solution, and quickly and firmly carried to place. A little subsequent pain is to be expected, because of the presence of fluids in the socket; these will be gradually absorbed into the tissues. Care must be taken that the tooth shall not, for a few days, occlude with any antagonist, and thus keep up an irritation. It must be held firmly immovable by some specially devised apparatus, or l\v the use of a ligature woven about the planted tooth and a few of the adjoining teeth. It is surprising how well the ligature, when skillfully adjusted, will hold a tooth. No surgeon would attempt to reduce a fracture and then neglect the adjustment of a splint to hold everything immovable. The ligature is frequently the best splint that can be employed for loose teeth. The only subsequent treatment necessary will usually be to see that all remains aseptic. If necessary, careful irrigation with a sterilizing solution should be kept up until new tissue has begun to form. If there is the least sign of infection, or of breaking- down, it is usually better to remove the tooth, search for any irritants, more carefully sterilize, and insert it again. Implantation has become an accepted method of prac- tice with many oral surgeons. It had been successfully per- formed, but pul^lic attention was never called to it until Dr. W. J. Younger repeatedly demonstrated its entire practicability. The operation consists in the forming of an artificial socket in the alveolar process, and the insertion into it of a tooth ])reviously extracted. Xor is it essential, although it is advisable, that the implanted tooth shall have been recently extracted. Successful ojierations have been made with teeth that have been lying about 184 ORAL PATHOLOGY AND PRACTICE. the office for years. A very superficial comprehension of the con- ditions involved will, however, convince any one that such an operation will give very much less promise of permanence than when a tooth not full of cracks and checks is selected. It does not need much physiological or pathological knowledge to demon- strate that, other things being equal, the better and fresher the tooth to be implanted the greater the chances for lasting success. The first thing, when implantation is contemplated, is the selection of a tooth. This should be done with an eye to tempera- ment, size, and form. The proportion of the length and thickness of the root to the depth and breadth of the alveolar process should be observed, so that proper adjustment may be possible. The' directions given for the proper preparation of a tooth for replanta- tion are applicable to cases of implantation, and need not be repeated. The formation of the artificial socket in the alveolar process is done by laying back the gum and periosteum from the selected place, through the means of a crucial incision. Then with the proper instruments the socket is cut to a sufficient depth and enlarged as is necessary, the previously prepared tooth being occasionally lifted from the sterilizing solution in which it should be kept, and tried in to determine the direction, as well as the depth and size of the hole, which should not be so large as to permit the root to be loose. Finally, the tooth is inserted, and a proper splint or ligature used to hold it immovable. The operation is really but a simple one, as there are not likely to be any complications, unless in very rare cases tetanus might be induced. Should there be any indications of this, ten to fifteen drops of belladonna may be administered every four hours. There are no arteries to be avoided, or nerves to injure, if common prudence is employed. The point of greatest interest lies in the possibility of permanent attachment and the character of the changes that are involved. It does not seem possible that there can be any revivification of tissues that perhaps have long been dead. As for the enamel, the proportion of living matter which it con- tains is too small to be taken into account. The dentin is in precisely the same state as in other devitalized teeth in which the root canal has been successfully filled. It is not at all in relation with any of the other tissues of the body, being completely enveloped and segregated by the overlying enamel and cementum. replantation; transplantation; implantation.. 185 The latter tissue, with the pericementum, are the only ones to be considered, and a little examination into their probable state may be profitable. Osteoblasts may exist anywhere in the substance of the bone, or mav be developed at any point where the artificial socket is made. Some of them must necessarily be encountered, and they will serve as the initial points for the growth of new bone. A new periosteum (or in this case pericementum) must be developed to form the nutritive organ of the new tissue. The inflammation developed by the trauma results in the effusion of the lymph neces- sarv for these new growths, and thus the cavities in the bone are filled with granulations as the consequence of the development of a new pericementum, from the dipping down or primary additions to the oral mucous membrane. Without the growth of new perice- mentum it is difficult to imagine either the formation of new tissue or the nutrition of that already in existence. Under favoring con- ditions this is as readily organized as any other tissue, and it would appear that its formation must be the initial step in all these conditions. Thus we can readily account for the reconstruction of perice- mentum and bone. The cementum of the tooth structure is already formed. No instances of any further growths to it in these cases have been brought to professional notice. If any such do exist they must appear as hypertrophies, brought about through the formation of cementoblast cells and their physiological activity, a process that does not seem possible. Osteoblasts may be found, for there is living bone, but there is no vivified cementum. What, then, is the probable condition of the cementum of an implanted tooth that had for a long time been extracted? Such examinations as it has been possible to make in the very few implanted teeth that have fallen under observation have indicated resorption rather than growth. It does not appear that the cementum lacunae have ever been refilled with living matter, but that the extent of revivification has been the penetration of the cementum by the transverse fibers of the pericementum, which thus holds the tooth firmly in place, for a time at least, and pre- serves it from retrogressive changes. Under these circumstances that which might naturally be expected too often takes place, and any unusual irritation, or perhaps some nutritional derangement, l86 ORAL PATHOLOGY AND PRACTICE. results in the formation of osteoclasts, with the resorption of the cementum. This is the usual process by which an implanted tooth is lost. There being no formation of living matter within the cementum cells, but simply the penetration of the pericemental fibers, the tooth only remains in a state of tolerance. The usual period of retention, when the work is skillfully done, is sufficient, however, to justify the operation, when no special service is demanded aside from the preservation of appearances. CHAPTER LI. SYPHILIS: THE PRIMARY STAGE. . Syphilis is a constitutional, infections disease, which may be acquired by direct contact or by inheritance. When inherited it is exceedingly virulent in its character, and, next to tuberculosis, is probably responsible for more diseased conditions and morbid degenerations than any other disorder. But it is quite as true that there is none which so directly and unmistakably yields to properly directed medication. Indeed, it is the great stumbling- block to those who insist that drugs have no immediate remedial action, but that all cures are through vis medicatrix naturcc — the recuperative or healing force of nature. There is no disputing the fact that syphilis is primarily influenced by certain remedies. The infectious character of the syphilitic virus is that which makes the study of the disease so important to dentists. Some of the lesions manifest themselves in the oral cavity, and it is possible for the discharge from them to be carried by instruments to the mouths of innocent persons and thus to inoculate them with a loathsome disorder. It is therefore important that the oral practi- tioner should comprehend the nature of the disease, and be able promptly to recognize the indications of its presence. It is from this standpoint, rather than that of its successful treatment, that it will here be considered. It is only when acquired by inoculation that syphilis presents all its characteristic phenomena. When it is congenital, i.e., inherited from syphilitic parents, it does not pass through all the incubative stages, and is without the initial lesion or sore. Our attention will therefore primarily be directed to acquired syphilis. syphilis: the primary stage. 187 Although usually a venereal disease, it is not necessarily so. The virus may be communicated to any abraded surface, by any means. Thus the primary sore may be upon the lips of the person afifected, and he or she may communicate it to another by kissing. Surgeons are sometimes infected when dressing syphilitic ulcers or \vhen operating upon syphilitic patients. An instrument that has been used in such instances, if not yery carefully sterilized, may carry infection. But the usual source of contagion is through sexual congress. The primary sore which is produced by inoculation with the syphilitic virus is called the Chancre. It is located at the point of infection, and is single. It does not make its appearance imme- diately after infection, but there is a period which varies in length from ten to sixty days, during which the specific virus is insen- sibly working, before an unmistakable lesion is seen. This is called ''the period of first incubation." The chancre, or primary sore, presents certain characteristics which, while not affording an infallible criterion in diagnosis as to its nature, yet when linked with the whole clinical history should prevent any egregious errors. But it should not be at once sus- pected that every sore in the mouth, upon the lips, or even the genitals, is of syphilitic origin, without confirmatory testimony. Many an innocent person has rested under suspicion because of the appearance of a papule, vesicle, or pustule upon some portion of the body. Dentists should be especially careful in their deductions, and should not precipitately pronounce a lesion "specific" until it is unmistakably proved such. It is a very delicate matter for a practitioner to whom applica- tion for professional services is made by a respectable person, in whose mouth or upon whose lips there exists a suspicious sore, to ask any pointed questions as to its origin. And yet it is of the utmost importance, not only to the dentist personally, but to his other patients, that he should know the truth. He cannot com- mence any special inquiries until he has something definite upon which to found them, for an innocent person is likely to consider it a mortal ofifense if he or she is suspected of infection with so loath- some a disorder. I'Vjrtunately, it is not usual for lesions to make their appearance in or about the mouth until the existence of the disease is well known to the patient, and before that time arrives he or she has probably been under the care of a physician. Know- l88 ORAL PATHOLOGY AND PRACTICE. ing the exigencies of the case, they will then in most instances be ready to respond at once to guarded inquiries. But it should be comprehended that these remarks do not apply when the chancre originally appears about the mouth. It is only when the oral indications are secondar}^ that the patient himself will comprehend their character and significance. The first prerequisite to the identification of a syphilitic sore will be fonnd in the history of the case. If it appears upon the genitals, there must have been an exposure through an impure connection. It is needless to say that while the physician patiently listens, without expressing any dissent, to tales of water-closet infection, he will in his mind give them just the weight to which they are entitled. If the primary sore appears about the mouth there must have been a history of infection in some way, and that may be even less creditable than when the inoculation is through natural sexual intercourse. On the other hand, it may be by entirety innocent means. It may tax the ingenuity of the practi- tioner to discover some way in which to determine this point. The chancre, which is positively indicative of syphilitic poison- ing, presents these three distinguishing features : a. An incubative period preceding its appearance. b. Certain special characteristic appearances. c. Glandidar enlargements and indurations. The period of incubation, as has already been stated, is an average of about twenty-one days. But it should not be under- stood that symptoms of infection will always manifest themselves after exposure. Some people seem to have almost an entire immu- nity to ordinary inoculation, and may escape when another would not. There are conditions of the system in which one is more liable to infection than in others, as is the case with other commu- nicable disorders, so that a person may possibly pass through the fire more than once without being burned. Very old and very young persons are especially liable to infection, because of their weak resisting powers; and the same may be said in anemia, malaria, alcoholism, and other atonic conditions. The first appearance of a chancre is usually as some form of an erosion. It may be quite inconspicuous, and so remain for a time unnoticed. When recognized, it will be observed as a roundish, oval, or irregular macule, or spot, resting upon a slightly indurated bed, and feeling to the touch like a piece of parchment or cartilage syphilis: the secondary stage. 189 let into the tissue beneath. In size this varies from a pin's head to that of a dime, or even larger. Its color is a dull red, which has been aptly characterized as that of "raw ham," and this hue seems almost pathognomonic. It may be level with the neighboring skin, or its edges may be slightly raised and its center depressed. It may be dry and glazed, or slightly moist, secreting a thin serum, which in drying glues to the surface any dressings, clothing, etc. This serum is very infective. The chancre rarely suppurates or degenerates into an ulcera- tive stage, save when macerated, as by the fluids of the mouth. After ten days or so it is apt to break down and make an abraded sore, but it is not painful, nor are there any special functional dis- turbances attending it. ^But any superficial irritation may develop an ulcerative condition, either shallow and superficial or deep and crater-like. In all cases the distinctive indurated base, which is characteristic of the primary syphilitic sore, will be observed, and it is upon this sclerosis that one will largely rely for his diagnosis. The chancre may persist until the appearance of the indications of systemic syphilis, but it usually disappears without leaving any scar or other local indication of its presence. It is in this primary stage that mercury is peculiarly useful. Under its influence the chancre usually heals readily, and the progress of the systemic infection is slightly checked. It is usually given in as large doses as is possible without producing too profound mercurialization. CHAPTER LII. SYPHILIS (Continued): THE SECONDARY STAGE. With the disappearance of the primary sore the uninformed person might imagine the disease cured, but this is by no means the case. The virus is active in the system, though without any outward manifestation, until the period of secondary incubation has passed, when the indications and symptoms show that it is no longer local in its nature. Closely connected with the appearance and progress of the chancre there is an affection of the glands in the immediate neigh- borhood. This consists in an enlargement and induration, or thickening and hardening of neighboring lymph centers, without igO ORAL PATHOLOGY AND PRACTICE, special soreness or other change in them. It may be considerable, or it may be so slight as scarcely to be noticed. It is not a manifestation upon which the practitioner can confidently rely in making a diagnosis of primary syphilis, but it may in some in- stances materially assist. It is to be classed with other inconstant symptoms and indications, all of which are to be grouped together, and the absence of any one of which neither proves nor disproves anvthing. It should be understood that in case of the appearance of this indication it will only affect the lymph nodes that are in nearest anatomical relation with the primary sore. If this is upon the genitals the chain of glands in the groin will be the limit of affection, while if it is about the mouth the probable boundary will be the cervical glands. The second period of incubation is that between the appearance of the initial sore and the manifestations of constitutional disturb- ance. These consist of the so-called syphilides, or eruptions upon different portions of the body. As has been already stated, the chancre is local in its character. The secondary eruptions indicate that the virus has permeated the whole body. The first period of incubation is that in which the diseased condition is obtaining its limited hold. During the second it is disseminating its baneful influence and fastening its grasp upon all the tissues of the organism. Its general progress may be marked by the glandular involvement, for it is through the lymph system that the degenera- tive influence spreads. The second period of incubation varies from twenty to one hundred and fifty days, fifty being about the average. As the chancre is the characteristic indicative of the primary, so these syphilides are the most constant manifestations of the secondary stage. They consist of eruptions of various character, which appear upon different parts of the body. The first is usually a kind of roseola, or blush, or redness of the skin, not unlike that of scarlet fever. It commonly covers the thorax, occasionally the abdomen, and sometimes the whole body, but seldom includes the face. It is symmetrical, appearing about equally upon both sides of the body. The first eruptions are almost always superficial, and are accompanied with no pain or itching, and spontaneously disappear after a variable period. After the first or superficial eruptions shall have run their course, they are succeeded by, or degenerate into, those of a papular syphilis: the secondary stage. 191 or pimple form. These show a deeper affection of the skin, but they may begin with the roseolar or superficial variety. Not in- frequently the papules may be seen invading the erythema, or blush eruption, and becoming more and more pronounced. The color of the eruption may change from the pinkish hue to a brown or yellowish red. The pimples or papules vary in size from that of a pin's head to a pea. They are sharply defined, circumscribed, and project above the level of the skin. Sometimes they break down and suppurate, but more frequently they heal without a scar. , During this process of healing they frequently exfoliate in the form of scales, forming the squamous syphilide, which may be readily mistaken for psoriasis, or itch. Another form which the syphilodermata, or syphilides, assume is that of the pustule. Pustules occur most frecjuently on the lower extremities and the scalp, as cone-like elevations, which give rise to large, irregularly shaped ulcers, secreting a bloody pus that dries up and forms dark brown or black crusts. The ulceration goes on beneath these crusts and about their edges, the secretion overflowing and forming a superimposed and larger crust, and thus in time a kind of corn is produced, consisting of successive layers. These appearances are not usually observed until at least six months have elapsed. During all this time the enlargement and induration of the glands has been increasing and extending. At this period they may probably be plainly felt along the posterior border of the sterno-cleido-mastoid muscle, the other cervical glandular regions, and those of the supraclavicular and epitrochlear localities. They vary in size from that of a pea to a pigeon's egg, are round, hard, and painless. At the same time the constitutional disturbance begins to manifest itself in fever, the temperature rising perhaps to 102° F., in pains of neuralgic or rheumatic character, and in severe head- aches, with sleeplessness and restlessness. All of these are worse at night. It should always be borne in mind that the characteristic secre- tions of the syphilodermata are infectious in the highest degree. 192 ORAL PATHOLOGY AND PRACTICE, CHAPTER LIII. TERTIARY AND HEREDITARY SYPHILIS. Tertiary Syphilis is the final result of the specific infection. It is a breaking down of the tissues under the degenerative process, and is characterized by a worse series of syphilides, by necrosis of the hard, and ulceration, sloughing, and perhaps gangrene of the soft tissues. It is a process of general destruction, and some of its forms are repulsive in the extreme. The discharges are not, however, of such an infectious nature, and hence it is of less interest to dentists than the earlier forms of syphilis, but it should not be imagined that they are wholly without danger. The syphilides in the tertiary stage take the usual form of gummata and condylomata. The former commence with circum- scribed, firm nodules beneath the skin or mucous membrane, vary- ing in size from a small cherry to that of an orange, or even larger. At first the skin is uncolored, but later it changes to livid, or purple, becomes thin at the apex, and finally ulcerates. They are not ordinarily numerous, seldom exceeding three or four in one subject. They usually leave a deep and abiding scar. The condylomata, or venereal warts, are morbid growths, the result of syphilitic infection in its later stages; but, as their observa- tion will seldom come within the province of the dentist, they need not be considered here. There are also tubercular deposits and complications, whose chief interest in this connection is that their presence may sometimes prohibit surgical operations. The chancroid, or soft chancre, is a sore which does not carry in its train any of the constitutional complications of the true Hun- terian chancre. It is of a pustular nature, with a secretion that is peculiarly infectious, but which, unlike that of the true chancre, is auto-inoculable; that is, it infects the person in whom it exists at any new point with which it comes in contact, making another chancroidal sore. Hence chancroids are usually multiple, while the chancre is single. Chancroids very rarely appear elsewhere than upon the genitals, and produce no oral lesions whatever. Hereditary Syphilis. The infection of hereditary syphilis may be transmitted through either parent, or by both. In the father the spermatozoa TERTIARY AND HEREDITARY SYPHILIS. I93 are affected, while in the mother it is the ovum. If a mother acquires syphiHs after her impregnation, she may transmit the disease to the fetus through the placental circulation. A healthy mother who gives birth to a child inheriting syphilis from the father may herself be infected, although the disease will be likely to assume a modified form. When there is impregnation, either of the parents being afflicted with recent syphilis, it is usually fatal to the fetus, either before or shortly after birth. The longer the time between the infection and the impregnation, the less will be the chance of transmittance, or the milder the form that the disease will take, especially when the parents have been under treatment. The prognosis in inherited syphilis is much more grave than in the acquired form. From one-third to one-half of all syphilitic children die before reaching adult life. The first symptoms of inherited syphilis, the early syphilides, usually appear within the first three months. If an infant arrives at the age of six months without exhibiting any of the indications of syphilis, it may be safely assumed that it is healthy. Syphilitic children are poorly nourished and anemic, and do not develop normally, either physically or mentally. They possess little ability to resist disease, and too often fall early victims to different disorders, Hutchinson first called attention to a peculiar formation of the tissues of the teeth that he believed to be indicative of hereditary syphilis. This, he declares, is confined to the permanent superior central incisors. When erupted these teeth are thin, narrower at the point than at the base of the crown, with a crescentic depression of the central part of the cutting edge; that is, they are longer at their mesial and distal cutting angles than in the center. Hutchin- son declared that when deafness, interstitial keratitis, and notched teeth are present in the same person, hereditary syphilis is positive. It is not probable that either alone is pathognomonic, and the notched teeth certainly are not an infallible indication, as they may be the result of other causes. 14 194 ORAL PATHOLOGY AND PRACTICE. CHAPTER LIV. SYPHILIS OF THE MOUTH AND TONGUE. It was necessary to investigate the pathological changes that take place in syphilitic affections before its manifestations could be comprehended, or recognized when seen. If the nature of the syphilides is not learned, the student will not be prepared to under- stand their import when he meets them in practice. But it will be the oral phenomena that will chiefly concern him, and hence these should be awarded special attention, because of the possibilities of the transmission of the disease through his instrumentality. The practitioner has already been cautioned against jumping to the conclusion that every mucous patch in the mouth, or every indurated sore, has a specific origin. Any excoriation of the mucous surface may be greatly aggravated by special irritants that are common in the mouth. The chewing and smoking of tobacco, the holding of pipes, cigars, and cigar-holders, the drinking of hot and iced fluids, may intensify a local irritation until it assumes a very suspicious aspect. In the same manner syphilitic sores of the mouth may take upon themselves an irritated character or appearance. But it should be borne in mind that these aggrava- tions do not in essence differ from the same morbific changes occurring in other parts of the body. Chancres occurring upon the tongue, the lips, or the tonsils, although somewhat modified by their surroundings, present the same distinguishing characteristics as when they appear elsewhere. The same may be said of the maculae or roseola, the papules, pus- tules, and ulcers which have already been considered. Rough or carious teeth may aggravate them, and modify their appearance, but they will not destroy their leading characteristics. As a rule, the syphilitic lesions of the mouth are of a moist rather than a dry nature, and mucous patches are of greater frequency. In the early stages of secondary syphilis, the eruption may appear in the mouth as well-defined areas of a dark red color, upon the soft palate, tongue, pillars of the fauces, and along the gingival labial borders. These may be of any size, from mere points to blotches covering the whole surface. But they will retain the sym- metrical appearance of the cutaneous eruptions, and will usually be seen upon both sides of the median line. Like those of the surface, SYPHILIS OF THE MOUTH AND TONGUE. 195 they may disappear after proper treatment, or they may form the basis for further degenerations. They usually become eroded to a greater or less extent, this probably being due to local irritation. The papular syphilide of the cutaneous surface is represented in the mouth by mucous patches or moist papules. These may be single or multiple, and they are usually well defined, varying in size from a single point .to that of a quarter dollar. They are at first red in color, but soon assume a whitish appearance, looking as if the mucous membrane had been cauterized with nitrate of silver. They are often raised above the general level, and are more or less painful. Two of them may perhaps be seen facing each other on membranes that are in contact, like the surfaces just back of the last molar tooth, or those of the cheek and the alveolar wall. Upon the dorsum of the tongue the papules may become confluent, giving the characteristic "toad's back" appearance. Not infrequently the tongue is swollen, and presses against the teeth until its edges appear serrated, or scalloped. The ulcerative lesions are usually the further breaking down of the mucous patches, and their deep erosion until they form con- siderable caverns in the tissue, which are exquisitely painful. Thesi may follow along the lines of the tongue, thus giving rise to deep fissures, or they may burrow^ into the crypts of the tonsils, or form circular pits on the posterior wall of the pharynx. Not only are fissures formed in the tongue, but they make their appearance at the corners of the mouth or the centers of the lips. An acute glossitis or inflammation of the tongue is not infre- quently the result of syphilitic infection. There may be first an hypertrophy of the organ, with subsequent contraction, thus caus- ing deep transverse or longitudinal furrows. There may be an indurative or hardening change in the muscular fibers, with a consequent partial loss of function, the speech becoming thickened and indistinct. Along the borders of the tongue dry or squamous lesions sometimes may l)e seen. They are not moistened by the usual secretions of the mouth, and in color are of a grayish or bluish white, sometimes having a glistening appearance. These patches are specially marked among users of tobacco, particularly those who aie smokers, and there is a distinct variety that has been called "smoker's patches." They are not by any means confined to the borders of the tongue, or even to the tongue itself, but they may appear anywhere in the oral cavity. 196 ORAL PATHOLOGY AND PRACTICE. Gummata of the mouth may develop during the later stages of syphilis. Their initial appearance is as nodules beneath the mucous membrane, from the size of a pin's head to that of the end of the thumb, usually single, but sometimes multiple. After a time they break down into ragged ulcers, and their degeneration is usually rapid. Perhaps one appears in or near the center of the vault, and when it breaks down a probe will detect necrosed bone, which is soon exfoliated, thus causing a perforation of the hard palate. The syphilides of the mouth assume a variety of forms, and sometimes their diagnosis is impossible, except with the aid of the history of the syphilitic infection. They may pos- sibly be mistaken for other affections. The roseola may be con- founded with a follicular stomatitis, and the ulcers with cancrum oris, or noma. Epitheliomata may be almost indistinguishable from some of the syphilitic lesions, though ordinarily they are much slower in their progress. Mercurialization may usually be distin- guished from syphilitic disturbances by the fetor of the breath, and by the distinct metallic taste. But there may be innocent ulcera- tions upon the tongue or oral tissues, which the experienced syphilologist might mistake if he were to depend upon their appearance alone. The only safe course is to group the various symptoms, examine for glandular indurations, and carefully and deHcately inquire into the history of the case when suspicious appearances are observed in the mouth, all the time observing caution to guard- against possible infection, for if there happens to be, as is frequently the case, any abraded or wounded point in the fingers, it is possible for syphilitic inoculation to take place from a secreting mouth-plaque. It is perhaps unnecessary to say that some form of iodin is the specific remedy for constitutional syphilis, more especially potassium iodid, exhibited if necessary in heroic doses and continued for an indefinite time. CHAPTER LV. PHYSICAL DIAGNOSIS. The oral physician should be competent to make a proper examination of a patient, for the purpose of ascertaining the ability to withstand an operation, to take an anesthetic, or to determine PHYSICAL DIAGNOSIS. I97 the probability of constitutional complications. When the regu- lar physician approaches the bedside of a sick person for the purpose of making" a diagnosis he first takes the pulse, that he may determine the condition of the circulation. He next looks at the oral tissues, especially the tongue, because upon it he will find reflected any disturbance of the digestive tract. When he has learned to read these aright he has the key to the state of the two most important functions of the body upon which, more than any others, health depends. To be able to interpret correctly the utterances of the pulse, of the breathing, or of the oral tissues, it is essential that the physi- cian know the language in which they speak. The technically un- instructed man may feel the pulse, but to him it tells nothing except that the heart is beating more or less regularly. The accomplished physical diagnostician with his eyes shut will at once pronounce whether the patient is strong or weak ; is nervously excited or depressed; is in a fever or rigor; whether the disturb- ance is functional or organic; whether in the brain or extremities; whether there is or is not narcotic or other poisoning, with many other matters that it is essential to know. The principal methods for determining the state of the internal viscera in physical diagnosis are auscultation and percussion. Auscultation is the dctcnuinafion of the coudition by listening to the sounds ivhich arc produced in normal or diseased functions. It is called immediate when the ear is applied directly to the part, and mediate when a stethoscope or other instrument for conducting the sound is employed. Percussion is the striking liglitly upon any part of tlu' body, especially the thorax or abdomen, ivith the riav of determining diseased conditions by the resonance or lack of resoiuincc of the sound. It is called immediate when made direct with the fingers, and mediate when a plcximeter or some instrument is used to increase the sound. L'sually immediate percussion is employed by laying the first two fingers of the left hand upon the part, and striking them with the ends of the first two fingers of the right hand. Perhaps the dentist may not need to become an expert, but he should at least know the most important expressions of the heart, the lungs, and the digestive tract, as expressed in the pulse, the breathing, and the oral tissues. 198 oral pathology and practice. The Pulse. To be able to recognize the pulse in disease, it is necessary to know what it is in health. It varies in different individuals, and changes with their condition. It is not the same during growth as in maturity, and every pliysical state has its appropriate expres- sion. There is a difference of five to six beats per minute between tlie pulses of men and women of relatively the same general physi- cal condition otherwise. A difference of from five to ten beats is made by change of posture from lying down to sitting, and from sitting to standing. By violent running, or any excessive exercise, the rate may be doubled. It is higher in infant than in adult life, and it decreases yet more in old age. The pulse may be felt at any accessible artery, the larger and nearer the heart the more distinctly. It is usually exam- ined at the point of nearest exposure of the radial artery, in the wrist, but dentists should be able to read the pulsation of the facial artery, where it crosses the inferior maxilla, because it is more convenient, especially in the administration of anesthetics. It may also be taken from the carotid artery in the neck, or the temporal beneath the ear. If the pulse is taken at the radial artery the tips of the first tw^o fingers should be used, w^ith the second finger nearest the heart. The strength is determined by pressing with the second finger until the pulse cannot be felt with the first, and taking note of the amount of force required to compress the artery. The number of pulsations are computed by counting. The pulse should never be taken when the patient is in any state of excite- ment, because its true reading cannot be obtained at that time. When first placed in the chair, or if a view of the instruments is obtained, the pulse may be raised several beats, and will be changed in its character. The best time will be after the patient has entered the ofiice and sat for a few moments, until all nervous excitement shall have passed away. Then, in the midst of conversation and without intermitting it, the hand may be taken and the pulse examined. Of course, no alarming display of instruments or apparatus will be permitted. At birth the pulsations are from a hundred "and twenty to one hundred and forty per minute. The rate gradually diminishes until at seven or eight years it is about ninety. In adult life it is from sixty-five to seventy-five, while in old age it sinks to sixty. Some PHYSICAL DIAGNOSIS. I99 people have normally a very slow pulse, while others have one that is rapid ; hence it is essential to have some knowledge of what is the normal rate. But an experienced physician will tell by its reading" whether the slow or fast pulse is the result of some dis- turbing influence, or whether it is normal. In disease the pulse presents certain modifications that depend" upon the kind of disturbance. In the principal changes certain definitions are given which are definite in their meaning. For instance, there is a marked difference between a rapid, a quick, and a frequent pulse, and each conveys its ow'n tale. The principal modifications are as follows: A frequent pulse means one that is diminished in foree, but increased in frequency. It is the result of and indicates debility. Thus before death it may be so frequent as almost to be beyond counting, and so weak as to be almost indistinguishable. The muscle of the heart is losing its contractile force. A quick pulse is abrupt, jerking, and may be moderate or frequent in its rate of pulsation. It indicates some irritable state of the heart, which may be only of a temporary nature. TJie slozi' pulse (unnaturally so) occurs in narcotic poisoiung and in apoplexy. It will be found in compressions of the brain from accident, and in unconsciousness from opium or liquor. This characteristic enables the physician to determine malingering, and the simulation of unconsciousness. Another method to detect counterfeiting is to press the ball of the thumb with considerable force on the supra-orbital foramen for one or two minutes, gradu- ally increasing it. No conscious person can long withstand this. The Jtard pulse seems to indent the finger, and is ivJiat the name indicates. It shows great excitement of the circulation, with high tension and rigidity. The soft pulse is the direct opposite of this, and indicates lassitude. It is easily compressed, though it may not be readily extinguished. The febrile pidse is an increase in the rate of pulsation, and usually of force also. It is found in active fevers and inflamma- tions of an acute character. The feeble pulse is nearly synonymous zvitJi the soft pulse, but is more easily extinguished. It is indicative of great debility and exhaustion. The thready pulse is one that gives beneath the finger the sensation of a vibrating thread. It is allied to the zciry pulse, which is an 200 ORAL PATHOLOGY AND PRACTICE. exaggerated condition. Both are sometimes present in very great debility. The irritable pulse is one that is both frequent and hard. It will be found when a debilitated person is subjected to some kind of excitement. TJie intermittent pulse is one that nozv and then loses a beat. It is indicative of either functional or organic disease of the heart. It should not be confounded with the weakened pulsations of exhaus- tion. The irrcgidar pulse is one that varies in both frequency and force. It may be very slight, or it may be extreme. It is generally found in heart disease, but it may be the result of the use of tobacco or strong coffee or tea. The inordinate use of stimulants may also produce an irregular pulse. The practitioner should lose no good opportunity for the study of the pulse, both in health and disease. He will find that his comprehension of it and his ability to detect variations will greatly increase with practice. He must learn to read it as he would Greek, by first conquering its alphabet, and then slowly and patiently acquiring the combinations. He will discover that he can acquire real skill and facility in reading the one about as easily as the other. It should be comprehended that all these modifications are not produced simply through changes in the force exerted by the heart in its pulsations. The readings depend upon the condition of the coats of the arteries quite as much. Their resilience, or elasticity, is governed by the vaso-motor nerves, and hence any nervous shock or neural depression will be readily manifested in the arterial walls, in the manner indicated in the section on Inflammation. Thus the "hard" pulse and the "soft" pulse will mainly depend upon the tension of the muscular arterial coats, while the "slow" pulse and the "frequent" pulse will be the result of the condition of the heart, or the rate of its pulsations. A "feeble" pulse indicates that the force of the heart-beats is lessened, and at the same time the tension and resiliency of the arteries themselves are reduced. The "soft" pulse, on the con- trary, simply implies a change in the coats of the vessels, without any special heart complications. The "hard," or "wiry," or "thready" pulse shows an undue tension of the arterial coats, and this will be induced through some nervous impression acting through the vaso-motor system. PHYSICAL DIAGNOSIS. 20I It may thus be seen that the pulse gives a very clear indication of the state of the nervous system, and reveals any neural shock or depression; and that at the same time it is indicative of the state of the blood column and of the functional activity or languor of the heart. CHAPTER LVI. PHYSICAL DIAGNOSIS (Continued). The Respiration. The various sounds made in breathing, as well as those of the heart, may be determined by the use of the stethoscope, or by placing the ear to the chest, not more than one thickness of cloth intervening. The breathing is termed either abdominal or thoracic. That is, the muscles chiefly used may be the diaphragm or the costal and superior thoracic. The breathing in man is mainly abdominal, while in woman it is thoracic. In forced and labored respiration yet other muscles may be brought into action, as the trapezius, serratus magnus, and the sterno-cleido-mastoid. In health, the respiration is from thirteen to twenty-five per minute. In the dyspnea of pneumonia it may rise to from thirty to fifty per minute. The normal respiration should be without effort, deep, and unhurried. There* should be no unusual noises or rales, and the natural murmurs of the passage of air through the bronchial tubes should be present when the ear is placed to the chest. The amount of air respired by each individual is about five hundred cubic centimeters, and, of course, the same amount is exhaled. But it should not be understood that all the air is expired at any one time. After the fullest expiration there will still be left in the lungs fifteen to eighteen hundred cubic centi- meters. In forced expiration, or exhaustion, most of this air may be forced out. The purification of the l:)lood is through the process of respira- tion. Oxygen is taken in, and carbon dioxid, water, and various organic matter are exhaled. A great deal of efifete matter is eliminated from the pulmonary surfaces. In the administration of anesthetics they are usually taken into the lungs by inhaling the 202 ORAL PATHOLOGY AND PRACTICE. vapor, and thence pass directly into the blood; in their elimina- tion it is chiefly the lungs which throw them off. They circulate with the blood until they again reach the pulmonary surfaces, when they are given up. Hence, in the recovery from the anesthetic state, it is of the first importance that the breathing be maintained evenly and regularly, as otherwise the poison remains in the system. In diseased conditions the respiration may be either faster or slower than the normal. When it is very much accelerated it will probably be superficial, shallow, and gasping. This will be the case when it is above thirty-five, in pneumonia, pleurisy, obstruc- tions in the trachea, or any kind of dyspnea. It will be retarded and will be deep in narcotic poisoning and in cerebral compressions, falling as low as twelve to the minute. When the lung is filling up, becoming consolidated, it will be interrupted, broken, and irregular. Bronchial breathing will be marked by blowing, as through a tube, and it will have a high pitch. This will be the case in advanced phthisis, in exudations, hemorrhages of the lungs, etc. The sounds that are heard as the air rushes through the various passages may be moist or dry ; may have their location in the larynx, the trachea, the bronchi, the air vesicles, or in cavities that may have been formed by disease. The bubbling sound may be coarse or fine. The coarser it is the higher up it will be, and the weaker will be the patient. It means the presence of water or moisture in the passages. Gurgling, like zvater boiling, may he heard in pulmonary cavities at times, and indicates an advanced state of phthisis. Splashing sounds upon succiission, or shaking or striking the chest, in the pleural organ indicate hydro- or pyo-pneumothorax — zvater or pus, with air, in the pleural cavity. Loud zvhistling or zvheezing that may he heard at a distance in the larynx or trachea indicates stenosis, or constriction, and is heard in croup. Lozv-pitched snoring in the larger hronchi means spasms, or nar- rozjjing of the hronchi, as in asthma. A crackling sound located in the air vessels of the lungs shozvs a sticking of their zvalls, and is heard in pneumonia. Creaking, grazing sounds are heard in plc^irisy, and indicate exudations upon the surfaces of the pleura. PHYSICAL DIAGXOSIS. 203 Metallic, tinkling sounds in pleural or pulmonary cavities mean pneumothorax, or the escape of air into some cavity. The rales (French "raler," to rattle) are the sounds caused by the passage of air through impediments in the lungs or bronchi. They are divided into the dry and the moist. Dry rales ivill usually he induced by a condition of the air passages in zcJiicJi they are not lubricated zvith the normal mucous secretion, or zi'Juvi it is inspissated or thickened; hence they are usually of a crack- ling or li'histling character. Moist rales arc produced zvJien the obstruction is fluid, and are apt to be of a bubbling nature. Peculiar conditions may, hozvever, modify either of tJu^se, and special puhnonary diseases have their ozx.ni specific rales. Caz'crnuus rales arc obscrz'cd Ziehen there is a cavity filled zvith pus. Crepitant rales are the crackling souiuls symptomatic of the first stage of pneumonia. Mucous rales are the bubbling sounds produced by the passage of air through broncliial mucus. Sibilant rCdcs are those that have a sharp, hissing souiul, as zvhen air passes through a contracted moist passage, or through foaming fluids. Sonorous rales are the stertorous, snoring sounds, as if the air zi'cre interrupted by some vibrating substance. Friction rales arc the creaking sounds heard zvhen, zvithout the lubricating fluid that is natural to them, tzvo surfaces rub upon each other. Vesicular rales are the fine crepitant sounds heard in tJw vesicles of the lungs in the early stages of inflammation. Subcrepitant, or tracheal, rales are heard zvhen mucus accumu- lates in the larger bronchi, or the trachea, and they form zvhat is called the ''death rattle,'' usually a premonitory symptom of dissolution. Other sounds heard in auscultation are called murmurs, and they are caused by the friction of moving currents of air or fluid. SoiiKlinics the r>cnch term bruit, having the same sii^nification, is employed. The arterial murmur is the .sound nnule by the arterial current, ami it may be normal or disturbed. The cardiac murmur is the union of the systolic (contracting) and diastolic (dilating) sounds produced by the musadar actions of 204 ORAL PATHOLOGY AND PRACTICE. the heart and the passage of the blood through its auricles, ventricles, and valves. Hemic murmurs are the sounds due to changes in the quality and amount of the blood itself, and not to modifications in the vessels or valves. Respiratory murmurs are the sounds produced by the passage of air through the lungs and bronchi in inspiration and expiration. The venous murmurs are the so-called "bruit de diable" of the French, produced in the common jugular in anemia, lead-poisoning, etc. Artificial Respiration. The dentist will not infrequently be called upon to use artificial respiration, and a few plain, uncomplicated directions are necessary. Many persons each year are lost whose lives might readily enough be saved if this subject was better understood. No one should be pronounced dead as long as there is the very slightest flutter of the heart, or when there is any vital warmth present. People have been restored after hours of unremitting efforts, unrewarded by even a gasp until near the end. Artificial respiration has held death at bay for days before any voluntary efforts could be induced. In cases of cessation of breathing' not an instant should be lost ill. getting the patient into a prone or recumbent position, if he is not already so placed. All clothing should be loosened and the tongue seized with a pair of forceps, or a tenaculum, and forcibly drawn forward, at the same time raising the head a little to insure the opening of the glottis. Something should then be placed under the patient's shoulders to raise the chest. The coat of the operator is excellent, if nothing else is at hand. The most simple and easily comprehensible method of pro- ducing artificial respiration is that called "Sylvester's," and either this or some other that is ecjually efTective should be at once employed. The operator will place himself at the head of the unconscious person and seize the wrists. Then by a sweeping motion the arms should be extended, and at the same time hori- zontally carried to their fullest extent above the head. After an instant's interval they should be carried back by reversing the motion until they rest across the body just below the diaphragm, when firm pressure upward and against the body should be exerted. These motions should be continued about fifteen times per minute for an indefinite time, at the same time keeping up the bodily heat by the use of hot-water bottles, hot flannels, and chafing of the extremities. THE ORAL TISSUES IX DIAGNOSIS. 20$ When there is sinking after the giving of an anesthetic, or in cocain or opium poisoning, artificial respiration may be necessary; but if breathing is once established the patient should be exercised as violently as practicable to assist the circulation and to aid in the elimination of the drug. A hypodermic injection of brandy may be administered, or one of ammonia. Strong cofifee is an excellent antidote, as is any stimulant. Cocain poisoning- will be manifested by symptoms very like those due to opium. People do not die of cocain poisoning except after the lapse of some hours, and the narcotic effects are plainly visible for some time before death ensues. The instances in which it is related that death occurred within a few moments after the injection of a cocain solution were doubtless errors of diagnosis. The patient probably died of something else than narcotic poisoning. CHAPTER LVII. THE ORAL TISSUES IN DIAGNOSIS. All gastric disturbances are reflected in the tissues of the mouth. The tongue especially is very expressive, and the oral physician or dentist should learn to read its indications as he would an open book. In health, the tongue is of a delicate whitish pink color, smooth and moist. Any departure from this appearance, either in the tongue or the other oral tissues, means a pathological state that demands the attention of a doctor. In another chapter, local inflammations with their symptoms have been described, and it remains but to give the appearance in general functional disturbances. The tongue is at times covered with a coating called "fur." This always indicates defective circulation of some kind. I-"ur consists of the unrcmoved epithelia of the nuicous membrane, of the thickened, inspissated mucus, of the debris of food, or of some deposit. In pathological conditions the furring of the tongue is by regular gradations, commencing at the base and spreading toward the tip. In clearing up this is reversed, the clean spots first aj)pcaring at the end and sides, and spreading toward the base, so that by watching the progression or retrogres- 206 ORAL PATHOLOGY AND PRACTICE. sion of this process a fair knowledge of the progress of the disease may be obtained. Generally speaking, a dull wMtish color of the tongue indicates a hyperacid condition; while red, with fur, points to an alkaline or inflammatory state. A delicate zvhitish tint of the tongue zvithin tzvo hours after eating means that digestion is not completed. This tint should not be con- founded with disease indications. If the tint remains for more than four hours it means arrested digestion. White, zinth a thin coating, means acidity. A yellozvish zvhite, acidity zvitJi biliary irritation. A very zvhite and thick coating ("'flannel mouth'') means intense venous congestion, as in cerebrospinal meningitis. Red, a delicate pinkish tinge, indicates that digestion is completed. Red of a deeper hue means arterial congestion. ■ Red, a very deep and dark tinge, means the last condition very much exaggerated. Red, bright in color and razv or glased, indicates paralysis of the sympathetic — approaching fatal exhaiistion. Brozvn, or brozvnisJi red, zvith a thick dry coating, means prostra- tion; arterial congestion; carbonic acid poisoning — a sign of danger. Black, or blackish, not deep, means blood poisoning — pyemia; sepsis. Blue, or a bluish tinge, indicates lack of oxygen; cyanosis. Humidity of the tongue means atony (lack of tone), zvith anemia. Dryness means nervous irritation; debility. Flabbincss, fullness, tremulousncss, indicate great debility. Imperfect muscular moz'ements, difficult artiadation, means cerebrospinal irritation; drunkenness. The tongue may be furred in health, as in excessive smoking. A dry tongue may be due to fever or to loss of sleep, or to some deep nervous impression. In old age the tongue loses its diagnostic value to a great extent. In scarlet fever the desquamation may cause what is known as the "strawberry tongue." It is generally accompanied with des- quamation of the kidneys, etc. Depressing nervous impressions may cause a tremulousncss and dryness that is but temporary, as in fright and great anxiety. Pleasurable sensations, the sight of food, etc., may induce a temporary humidity. "The mouth waters." THE ORAL TISSUES IX DIAGNOSIS. 20/ A red line, or red blotches, along the gums at a little distance front the margin is a diagnostic sign of pericemental or periosteal irritation. A still deeper red color, with e.vcessive flozv of saliva, is found in ptyalism, or mercurialisation. A blue line along the gums at the margin is indicative of lead poisoning. Great sponginess, sloughing of the gums, z^'ith fetor, indicate scurvy. Dark red gums, puffiness, everted edges, zvith oozing of pus, are ■found in pyorrheal conditions. Purple glims, zuith a piirident discharge at more than one point, are indicative of caries or necrosis of bane. Glims hot and szvollen, very tense, zvith a determination tozvard one point, mean suppuration, alveolar abscess, phlegmon. Gums inflamed and soft, zdth fluctuation, indicate the pressure of pus, zi'hich should be evacuated. Szcollen gums, fetid discharge, mucous patches, shallozv ulcers under the tongue, eruptions about the mouth, skin, and scalp, gums everted, zvith fetid matter about the necks of the teeth, the tongue per- haps szL'ollen and flabby, zvith the edges scalloped by the pressure of the teeth, zdll be found in syphilitic conditions. It should be compre- hended that not all these symptoms or appearances will be found in one mouth, but any one of them should stimulate the dentist to further examination and inquiry. The indication of imminent danger as presented by the tongue are a tremulous action, dryness, blueness, very red, shining, or glazed aspect, heavy furring, dark or black hue — the so-called "black tongue." In considering the tongue and the oral tissues as diagnostic organs, the indications are not to be taken alone. The appearance should always be studied in connection with other symptoms, which may be the dominant ones, and may reverse the usual signi- fications. The oral tissues are to be considered as auxiliary, and not in every case pathognomonic. The diagnosis is to be reached by grouping all together, and reading one sign by the aid of the others. 208 * ORAL PATHOLOGY AND PRACTICE. CHAPTER LVIII. WOUNDS AND INJURIES. A wound is a solution of continuity in the soft parts, suddenly produced. It is a rupture of the tissues by sorne form of mechanical violence, and may be produced by a direct or an indirect applica- tion of force. A wound may be a complete separation, with exposure of the tissues to external influences, or it may be a mere contusion, with- out any breaking of the integument. Wounds have their own train of symptoms, which are usually quite pronounced, so that, except in certain instances of deep- seated injuries, their diagnosis is comparatively easy. Wounds are distinguished by pain, hemorrhage, loss of function, shock, and, in injuries of the head, concussion. The pain is characteristic, and is usually proportional to the amount of the injury. When the tissues are crushed and there is deep contusion, the pain is sometimes very severe. The hemorrhage varies greatly with the vascularity of the tissue afifected. All wounds must have some hemorrhage, for all soft tissues are supplied with blood. Even in case of a wheal, which is merely a stripe or a ridge upon the skin, such as follows the cut of a whip, there is usually more or less capillary bleeding. Loss of function differs with the location. It may be merely local or it may be general, varying with the extent of the injury and with the tissue involved. A single small muscle may be cut, as for instance the extensor of one of the digits, in which case the function of but one finger would be interfered with; or there may be such laceration of the muscles of the hand as to inhibit the action of all the fingers. The amount of shock depends upon many things. The physical condition of the patient at the time of the injury may be such as to make this very profound, or there may be a high condi- tion of tonicity that will minimize it. The lesion may be in such vital organs that the constitutional disturbance will be great, or while considerable in extent the wound may be in tissues that react but feebly. The age of the patient makes a material differ- ence in the amount of the consequent shock, and sex is an important factor, women suffering from it much less than men. WOUNDS AND INJURIES. 209 Wounds are incised, lacerated, contused, punctured, per- forating, g-unshot, or poisoned. All incised z<.'ouiid is one made zcifJi a sharp instrument. Its diagnosis is not always as easy as might be imagined, for a blow with a bludgeon may cause an incised wound if it be delivered over a bone with a sharp edge, in which instances the incision will be from beneath, and not from the surface: or the impact of a blunt instrument may be at such an angle as to produce a sharp rupture of th-e tissues. A lacerated zcound is one in z^'hich the tissues are pulled apart. They are torn and ragged, and it is usually the result of an injury from compound causes, such as being caught in complicated machinery. A contused zcound is one z^'hich is made z^'ith a blunt zueapon. There is usually crushing of the tissues, without breaking of the skin. In such instances the connective tissue, with its enclosed vessels, always suffers. If but a few vessels are injured it is com- monly called a bruise. The hemorrhage consequent upon a con- tused wound is slight, and is usually limited to mere ecchymosis, or infiltration of blood into the tissues. The ordinary "black eye" is an instance of this. The extravasated blood assumes the dark venous hue, changes to a purplish black, then to a brownish green, finally assumes a yellow tint, and is absorbed. A punctured zvound is one that is made into a cavity of the body. The gravity of a punctured wound depends upon the cavity that may be reached. Punctured wounds of the abdominal, the thoracic, or the cranial cavities are usually of a serious nature, owing to the danger of infection. A perforating zvound goes entirely through an organ or a tissue. The terms perforating and punctured are occasionally confused, some pathologists defining punctured wounds as those made by a pointed instrument, and perforating wounds those which reach to and open a cavity of the body. Gunshot zvounds are those made by the discharge of fire-arms. Works on surgery usually consider these as a distinct class, because of the special compHcations in which they are apt to be involved. Xot infrequently in gunshot wounds foreign substances are carried in, such as portions of the clothing, debris of the explosion, etc. Thus the danger of infection is greatly increased, and the irritation produced is much more violent. The impact of 15 2IO ORAL PATHOLOGY- AND PRACTICE. bullets, from their great velocity, increases the probability of shock, and at the same time too often disengages splinters of bone, which bring on new complications. The rotation of the rifled bullet adds to the amount of destruction of tissue, so that the track left by its passage, while very difficult to follow with a probe immediately after the injury, is peculiarly liable to be made manifest subse- quently, through the breaking down of the tissue. A poisoned zuound is one that is infected with some mineral, vegetable, or animal poison. The most common of these are the bites of poisonous. reptiles or insects, the stings of bpes, wasps, etc., and the effects produced by the poison ivy, oak, and other toxic vegetables, as well as by bites of men and animals and infections by dirty tools. Wounds may be of a septic or aseptic character. In the former they have become infected with septic organisms, and there will be breaking down of tissue with suppuration, or the formation of pus. The septic bacteria are the greatest enemies the surgeon has to encounter in the treatment of wounds, and hence his chief efforts are directed toward the establishment of an aseptic, or sterile condi- tion. Wounds are healed by primary union, or, as it is often called, First Intention, by granulation or Second Intention, and by Third Intention. They are united by means of the fibrinous plastic exudate which is the result of the inflammatory process, and which eailier or later in the progress of healing agglutinates or unites the severed walls. Primary union or First Intention is the healing without infection. There is no retrograde metamorphosis, or breaking down of tissue. There are no acute symptoms of any kind, and no granulation occurs. Granulation, or Second Intention, is the healing of a wound by the regular progessive additions of papillary or grain-like growths. Capillary loops form at the bottom of the cavity of the wound, and through them new tissue is developed. Upon the summit of these, new capillary loops appear and new granulative tissue is formed, which follows the type of that from which it originated or to which it is to be joined, and this process is continued by "healing from the bottom," until the waste tissue is restored. Third Intention is the direct union of two surfaces on TREATMENT OF WOUXDS. 211 which granulation has already taken place. In fact, it does not in essential character differ from second intention, the granular or capillary loops being formed in the same manner, but there is less of cicatricial qr scar tissue as the result. It should be borne in mind that this system of nomenclature is rather arbitrary, and in part founded upon hypotheses which are not fully accepted by modern pathologists. All healing in one sense is by a kind of granulation, but as this phenomenon presents certain distinct phases, and as the old system of nomenclature will doubtless be insisted on for some time to come by State examining boards and others, it has been retained with this explanation. When granulation becomes too exuberant it may continue above the surface, and is then commonly denoted "proud flesh." Usually, when the capillary loops reach the level of the surface, the fibrous exudate contracts and cuts off the blood supply, and the process is stopped. There is a proliferation of the epithelial cells, or a growth of the investing tissue over it, and it is thus covered with the dermal appendage, and the process completed. But, as has been stated, this may not take place, and in that case the result will be a hyperplasia, or excessive formation. CHAPTER LIX. TREATAIENT OF WOUNDS. The healing- of a wound is induced and incited by cleanliness and an aseptic condition. In treatment the first step, in the case of an open wound, is to remove any foreign substances. Especially in incised, lacerated, and gunshot wounds should careful examina- tion and, if necessary, exploration be made, to determine if any extraneous matter has been carried in by the instrument of injury. If this is suspected, the wound must be carefully laid open to its extremest point, and thorough exploration made. There can be no healing so long as any particle of irritating foreign matter remains. In the case of a lacerated wound, the tissues should be carefully examined to determine the probability of the maintenance of the vascular supply in them. If the blood vessels are so thoroughly destroyed that circulatifjn will be completely cut ofif, such injured 212 ORAL PATHOLOGY AND PRACTICE. tissue must be removed, to obviate the dangers of gangrene. They cannot recover unless they are supplied with pabulum, and this is carried by the arteries. Hence, if there is no chance for the restoration of circulation in the part, amputation or excision is imperative, and should not be delayed. The destruction of an artery or vein does not by any means imply that circulation is entirely prevented, for it may be carried on through the collateral supply. It is only when all, or nearly all, the communicating tissue is so injured that its vessels can no longer convey a supply of blood that its removal is necessarily demanded. It is not sufficient if only the interior of a wound is thus cleaned. The tissue about it should be carefully washed with an antiseptic fluid, and all foreign matters removed. If the edges are surrounded by hair, this must be clipped or shaved off, that it may not harbor any impurities, and everything that might cause irritation must be heedfuUy eliminated. The wound should be irrigated, and thoroughly washed out .with a disinfecting and sterilizing fluid. It is sometimes necessary to use a great deal of judgment in selecting this. If the injury is very recent it is not well to use a mercuric chlorid solution, because this may induce mercurial poisoning. Nor should carbolic acid or iodin be employed, as they may bring about carbolic or iodin poisoning. Preparations of hydronaphthol, formalin, or boric acid are preferable. If, however, there is an infected condition and pus is present, the stronger germicides, like mercuric chlorid i part to from 2000 to 4000 parts of water, may be employed. No operations about a wound are permissible without the most stringent antiseptic precautions. All the sponges and cloths used must be sterilized. The hands of the surgeon must b6 thoroughly washed with aseptic soap, all matter under the nails being removed, and finally they must be drenched with an antiseptic mixture, or washed with ground mustard used in place of soap. A broad and shallow vessel partly filled with a solution of car- bolic acid, hydronaphthol, formalin, or some other good anti- septic, should be provided for all instruments used, and these must frequently be dropped into it. Especially if any instrument or sponge should happen to come in contact with any unsterilized body, as by an accidental dropping upon the floor, must it be given a bath in the sterilizing tray. TREATMENT OF WOUNDS. 2I3 If the hemorrhage from a wound is light in color, or if it issues by distinct spurts, it is arterial. If dark in color and steady in its flow it is venous; if merely oozing it is capillary. Either may be controlled by means of the hemostatic forceps, and by ligatures. Enough of the former instruments should be kept in the sterilizing solution for any emergency. With one of these the mouth of a bleeding artery or vein is seized, the handles are locked, and it is allowed to remain in position until the close of the operation. If the bleeding has not then been stopped by the contraction of the muscular coats, a ligature may be passed about the vessel and the ends allowed to protrude from the wound. When the bleeding is capillary, it may be necessary to pass a ligature around a portion of the tissue for the purpose of arresting it. \Mien it is venous, it is sometimes sufficient to seize the mouths of the vessels with one pair of artery forceps, draw them out sufficiently to allow of grasping them with a second pair, and then to accomplish torsion by twisting. For controlling the hemorrhage caused by the severing of important arteries, the only effective means is the liga- ture, the application of which sometimes demands expert knowledge and judgment. Great injury may be done by unskill- ful ligation. In the larger vessels, the arteries, veins, or nerves may be within the same sheath, which is but an enfolding of the fascia; and there may be more than one vein. .Before ligating, the sheath should be opened and the vessel to be tied dissected out. The ligature should be passed about it, and fastened with a square knot to prevent slipping. The knot should be drawn firmly, but not too tight, lest the outer coat of the vessel be cut. and sloughing and secondary hemorrhage be the result. An artery should not be drawn out of its sheath any farther than is necessary to allow of tying, because in so doing its future nutrition may be interfered with, through separation of or injury to the vaso-motor nerves. Immediate or mediate compression may be used for stopping the flow of blood temporarily when it is excessive. Immediate compression is accom])lislH-d by packing the wound with lint, and then ai)plying a compress or bandage. Mediate comj)ression is when i)ressure is made upon the artery between the wound and the heart. Any firm substance is placed over the artery, and then a bandage or tourni(|uet is twisted very firmly al;out the i)art until the bleeding is controlled. 214 ORAL PATHOLOGY AND PRACTICE. The control of bleeding by acupuncture is sometimes neces- sary in aged persons, the muscular coats of whose arteries are too weak to withstand the ligature. This consists in transfixing the tissues with an acupuncture needle, and then winding about it a ligature in such a manner as to produce local compression. Aneurisms may be formed through injuries to arteries, when some of their coats are divided and there is dilata- tion of those which remain unpunctured. In their earlier stages aneurisms may be diagnosed by the distinct pulsations within them, but later this may be masked by the thick felt of blood coagulum which forms within. A tumor in the immediate neigh- borhood of an artery should be opened with extreme caution, lest it prove of an aneurismal character. The ligating of an artery, when skillfully done, does not deprive the tissues dependent upon it of their vascular supply, as sufficient collateral circulation is soon established. This takes place through an enlargement of the communicating and anasto- mosing smaller arteries given, ofif above and below the wound, until they are sufficient to convey the volume of blood originally carried by the divided vessel. A wound having been cleansed and irrigated, and the hemor- rhage having been completely controlled, the next step is to close it. If the gaping is considerable, it may be necessary to sew it up. This is done with sutures of catgut if it is deep, or with silk if more shallow. The stitches are made with suture needles of differing shapes, which may be passed by means of needle forceps. All ligatures or sutures must be thoroughly sterilized before using. The depth of the stitches must be proportioned to the depth of the wound. If this is considerable, it may be advisable first to insert a few catgut sutures to hold in place the deeper tissues. The final closing ones are always superficial, and they should be near enough together to prevent any gaping of the edges. The closing stitches should be carefully made, so that there will be no drawing of the integument, the borders of the wound being left in smooth coapta- tion. They are to be removed as soon as there is sufficient union to prevent the separation of the edges. This will be within a very few days, if all goes well. Sometimes it is necessary to use deep retentive sutures to prevent undue tension upon the closing stitches. They have their insertion at some distance from the margin of the wound, and each end is attached to a button, so that they will not be likely to cut through the tissues. TREATMENT OF WOUNDS. 21 5 If the wound has become infected with septic organ- isms, or if there is good reason to suspect that it will be im- possible to keep it aseptic, it may be necessary to insert a drainage tube before completely closing it. This may be of sterilized rubber, or of decalcified bone; or it may be only some strands of silk or gauze, carried to the deep portion of the wound and allowed to come to the surface; and its size should be propor- tioned to the amount of probable discharge. The drainage tube offers a ready means of escape for pus or sanious matter, secretions of glands, or the products of inflammation. If the tube penetrates to a cavity of the body, some efifective means, like a ligature or the insertion of a safety pin, must be employed to prevent its being drawn into the cavity. To retain it and keep it from slipping out, it may be held by the external dressings, by adhesive strips, or other convenient means. The drainage tube is to be left in place as long as there is a necessity for its presence. Sometimes it is of great convenience in irrigating or washing out the wound. The final dressing of a wound should be with antisep- tics. After terminal washing" and cleansing of the exterior with an antiseptic fluid the surface is usually dusted with aristol, acetanilid, or iodoform. A piece of antiseptic gauze is then superimposed, and upon this sterilized cotton batting, in quantity sufBcient to make a thick pad. The wounded organ may then be bandaged, and placed in a sling or support if required. The dressings may be removed when necessary, but should not be disturbed by med- dlesome interference. Poisoned wounds that are of a serious character, such as the bites of venomous serpents, should be immediately ligated to pre- vent the spread of the poison in the blood, and then be thoroughly cauterized. The latter may be effected by the actual cautery or by cauterizing agents hke silver nitrate or chromic acid. An effectual though not agreeable way is to burn gunpowder upon the wounded surface. This may be practicable in case of accidents when no other cauterizing agent is at hand. The after treatment of wounds consists in the exercise of the most watchful care to avoid septic infection, or to combat it when present. All dressings must be kept clean and in place, and changed if necessary to accompHsh this. But meddlesome inter- ference must ])C avoided, and no dressing should l)e removed unless there is good cause for it. When the organizaljlc lymph has been 2l6 ORAL PATHOLOGY AND PRACTICE. effused it must be protected and kept aseptic. Every sanitary precaution should be observed, and the patient sustained with a nourishing diet. A wounded Hmb must be kept quiet and muscular action prevented, except so far as motion of joints, etc., is required to prevent ankylosis. CHAPTER LX. EXCESSIVE BLEEDING. There is nothing in dental practice that is more alarming, especially to the young practitioner, than to have follow an opera- tion an unusual flow of blood which cannot readily be checked. Too many lose their presence of mind at such times, become con- fused and distracted, exhibit this in their manner, and thereby alarm both patient and attending friends. A physician is perhaps called, who assumes direction of affairs, and the dentist is relegated to a subordinate position. As a consequence he is humiliated and loses the confidence of all who are witnesses. Exaggerated accounts of the matter are circulated from mouth to mouth, and his profes- sional reputation may thus be irretrievably injured in the commu- nity. All this may at any time be the consequence of lack of knowledge, or a deficiency in professional self-confidence. In any sudden emergency the most important requisite on the part of the doctor is self-possession, and the entire command of his own powers. The first thing to consider in cases of hemorrhage is whether it is arterial, venous, or capillary. If the former, the blood will be a bright red, and will issue from the wound in jets, synchronous with the heart-beats. If it is venous, the blood will be darker in color and will well up continuously. If it is capillary, there will be a slow oozing from the edges, which will appear again as it is wiped away. This, while the least alarming in appearance, is really the most threatening, because it may be the result of a hemorrhagic diathesis. Arterial bleeding may always be checked by ligation of the artery. Usually, however, unless the vessel is an important one, it will be sufficient to wipe away the blood with a sponge until the mouth of the severed vessel is found, when it should be grasped « EXCESS1\'2 BLEEDING. 21/ with a pair of artery forceps, which are at once locked upon it. In their absence the mouth of the artery or vein, with a Httle of the surrounding tissue, may be seized with any suitable pliers, and the whole twisted and pinched until the coats of the vessel contract sufficiently to stop the bleeding. Sometimes a fvaxed silk ligature passed around it and closely tied is preferable. If the bleeding is from the socket of an extracted tooth a pledget of cotton, or lint, or sponge that has been dipped in tannic acid, or, in its absence, in powdered alum, or red pepper, or in a solution of iodin, turpentine, capsicum, or even dilute stdphuric acid, should be closely packed at the bottom, and on that a cork, cut to a conical form that shall lit the socket, should be placed in such a manner as to project sufficiently for the occluding tooth to shut firmlv upon it. A two-tailed bandage may be now used to firmly press up the lower jaw and hold the cork in position. This should be left for some hours at least, when the bandage and cork may be carefullv removed, leaving the cotton until it loosens itself. If the bleeding is distinctly venous the same methods may be employed, but the emergency will not probably be as great. Arterial bleeding will be certain to receive attention, but the smaller veins may continue open, and there may be a steady loss of blood for hours, which will gradually weaken the patient. If this is the case, an examination should be made to determine whether the bleeding is from the small veins or is distinctly capillary. If the former the points of its issue may be readily determined, but if it is the latter there will be a slow oozing from the tissues without any distinct point of exit. If it is capillary hemorrhage, the condition will demand the most care and cause the most anxiety. Strips of cotton wet with a tannic acid solution or a ten per cent, solution of antipyrin, or with one of the other hemostatics named, should be adjusted over the wound, if on the surface, and bandaged to place if possible. Monsell's solution of perchlorid of iron should not be used in the mouth, nor should any active cauterants be employed. Tannic acid, in doses of one to four grains, may be administered in water every two hours in extreme cases. Or, of the acjueous extract of erigeron from five to ten grains may be administered every two hours. Or from fifteen to thirty drops of tinct. of ergot may be given every hour until the bleeding ceases. The feet should also be placed in hot water for half an hour. Vcratrum 2l8 ORAL PATHOLOGY AND PRACTICE. viride, as an arterial sedative, in doses of two to five drops every two hours, will frequently prove useful. In the so-called hemorrhagic diathesis the tendency toward capillary bleeding- is due either to some abnormal condition the result of a distincfflyscrasia, or to a lack of tone in the system. It seems to be idiosyncratic with some. When either of these is the cause it may demand more than a general knowledge of the sub- ject, and the family physician should be called to learn whether there exists any special cachectic condition. If this is the case it will, of course, be turned over to him. Anemia, purpura, scrofula, typhoid, and other diatheses tend to induce excessive bleeding, and in their presence great care should be used. If there is any special idiosyncrasy the patient will probably know of it, and should warn the dentist before any operation is commenced. CHAPTER LXL FRACTURES AND THEIR TREATMENT. The consideration of fractures should properly be taken up in connection with surgical procedures. But, as cases of injury to the jaw and head may at any time fall into the hands of the dental practitioner, this work would be incomplete if their pathology was not in an epitomized manner given some attention. More than this is not attempted. A fracture is a solution or rupture of continuity in bone or cartilage. What wounds are to soft tissues, such are fractures to the framework of the body. They form one-seventh of all the injuries to which human beings are liable. They are ten times as frequent as dislocations. They are of all degrees of severity, from the mere indentation or irregular depression of a flat bone to the complete comminution of long bones. The character of the frac- ture will depend upon the force which produced it and the shape of the bone itself. Thus, in irregular bones the fracture is usually a compression, while in long bones it is likely to be a complete separation, with more or less displacement of the fragments. Fractures may be produced by external violence or by internal muscular action. Probably a much greater proportion of them are caused by the latter than would be readily imagined. FRACTURES AND THEIR TREATMENT. 219 The Strength of bones, and therefore their abiHty to with- stand injuries, depends upon their texture. Compact tissue is stronger than that which is cancellous, and the bones of different individuals greatly vary. So also does the strength of a bone alter with the physical condition, certain diatheses predisposing to weakness, until perhaps in some extreme instances they yield to comparatively slight muscular exertion, and break almost spon- taneously. The shape of bones has also much to do with their strength, the long and flat being more liable to fracture than the irregular. The bones of males are stronger than those of females, but they are more exposed to accident. Age has much to do with the resisting power of the different parts of the skeleton, those of older people being more brittle. Weak points, or curves, largely deter- mine the course of fractures, especially when they are the result of muscular action. Fractures may be Simple, Compound, and Complicated. A sunplc fracture is one in zvhich the skin or mucous nieuibrane is not ruptured, and there is no serious injury to the investing tissue. A compound fracture is one in zcJiicli there is a coinniunication through the skin, or exposure of tlic bone to the air, zcitli the possibility of infection. A complicated fracture is one in zi'hich ofJwr tissues are involved in the injury. Fractures are also Complete and Incomplete. A complete fracture is one in which there is a separation of the body of the bone into two or more fragments. Complete frac- tures may be divided as follows: A Transverse Fracture is one that is at right angles to the axis of the bone. An Oblique Fracture is one that is at an angle of ten or more degrees. A Longitudinal Fracture is one that is at an angle of nwre than scz'cnty degrees. All Epiphyseal Fracture is a fracture of the cartilage z^'hich unites the epiphysis, or extremity, to the shaft of a bone. Of course it can only occur in young persons. A Multiple Fracture is one in ivhich the bone is separated into a number of fragments. An Impacted Fracture is zchen one fragment penetrates another, thus preventing their free nu)7'enn'nt. 220 ORAL PATHOLOGY AND PRACTICE. A Comminuted Fracture is one in which the bone is shattered, or separated into fine particles. An incomplete fracture is when there is not an entire separa- tion of the body of the bone, but either it stops short of that or consists in the breaking off of a portion. Incomplete fractures may be classified as follows: A Fracture of the Apophysis is the separation of that process from the shaft. A Detached Fracture is the separation of a fragment, as by a cutting instrument. Fracture of the Malleolus is a separation of the hammer-shaped head of a bone, the body or shaft remaining intact. A Green-stick Fracture is zvhat its name indicates: the splintering of a bone zvithout its entire separation. This is necessarily mainly coniined to long bones, and to young persons. A Fissured Fracture is the opening of a crack in one plate of a bone, as in certain fractures of the crania. A Depressed Fracture is zvhen a dent is made in the table of a bone, a part being thus displaced zvithout entire separation. The diagnosis of fracture, although usually easy, may be ex- ceedingly difficult. The symptoms presented are both objective and subjective. They may be arranged under the following heads: History of the predisposing or immediate cause. This should always be carefully inquired into, especially if the force seems inadequate to the production of the injury. Localised pain and tenderness. This may be determined by pressure and digital manipulation. Crepitus. This is the grating of one fractured end upon another, and is determined by careful movements of the parts. In impacted fractures this means of diagnosis is eliminated, and hence it may be difficult to arrive at a conclusion. Abnormal mobility. It is sometimes almost impossible to determine this in the neighborhood of joints, unless crepitus is present. Deformity. This may be partially or completely masked by the swelling consequent upon the injury. Comparison of tzvo sides. This is very important in determin- ing the deformity, but a possible asymmetry may lead one astray, unless caution is used. When the deformity is reduced it zvill not remain so, but the parts FRACTURES AND THEIR TREATMENT. 221 zcill separate and reproduce it. This will distinguish a certain class of luxations from fractures. Anesthesia is sometimes necessary in making a diagnosis, owing to the resistance of muscular action. Treatment of Fractures. Bones very readily unite when their injuries are properly treated. Reduction is the first thing to be accomplished. If there are no complications, and if the fractured ends are firmly held in apposition, there will be a deposit of plastic lymph — in this instance usually called provisional callus — about the injured ex- tremities. This assumes a cartilaginous form, and in due time ossifies and firmly unites the fragments, the process demanding from four to eight weeks. There will necessarily be some tem- porary enlargement and deformity, which will greatly depend upon the amount of displacement. In time, as the newly formed tissue becomes fully organized, the projecting portions will be resorbed, and the irregular surfaces thus made more symmetrical. Before the final reduction any muscular injury must be at- tended to, and if there are complications, such as involvement of a joint or injury to a contained organ, or comminution of the bone, these must be looked after. The greatest obstacle to reduction and retention will be the muscular contraction consequent upon the injury. This must be controlled by traction and counter-traction. A steadily applied, moderate force must be brought to bear upon the muscles until they gradually yield. Violence will only increase the contraction, but a gentle, persistent force, like that of a weight, will after a time tire the muscles out, when they will readily give way. Oblique fractures usually need only extension for their reduc- tion. Transverse fractures with displacement require also manipu- lation. When reduction is accomplished, the parts are usually held in place by splints or bandages, Aljsolutc immobility is not required, as slight motion is beneficial, owing to the fact that it is a stimulus to functional activity. In the treatment of compound fractures, the wound must be considered as an open one, and the instructions given in Chapter LIX., Treatment of ^A/^ounds, should be kept in mind. Thorough asepsis must be secured if possible. 222 ORAL PATHOLOGY AND PRACTICE. An anesthetic may be administered and the injury thoroughly ex- plored for the removal of all comminuted fragments, blood-clots, and foreign matter. A drainage tube may be inserted if desirable, and the wound left open at its center. Delayed union, or non-union, may exist when the plastic exu- date is not promptly thrown out, or being deposited is not organized. Perhaps the circulation or nutrition is impaired. This condition should be attentively looked after. The ends of the bone may be rubbed together if necessary, to stimulate functional activity. Delayed union may result in the formation of a "false joint," or a fibrous union. In such instances it will be neces- sary to break this up, and perhaps to bore the ends of the bone, or scrape them, to induce a new osseous formation. Non-union may be the result of a neglect properly to reduce the fracture. The ends of the bone may become rounded off by resorption and the medulla be closed. The remedy in such instances is to open the seat of the fracture, saw off the ends of the bone, and depend upon a new formation after reduction. In fractures of the long bones, shortening is likely to be the result of muscular contraction and the overlapping of the ends of the fragments, unless extension is used. CHAPTER LXII. SPECIAL CASES OF FRACTURE. Fractures of the nasal bones may be determined by the deform- ity, by the infiltration or emphysema of the investing tissues, by crepitus, and through obstruction of the nasal passages by blood- clots. They are not dangerous unless the injury is at the base, when the cribriform plate of the ethmoid may be injured, and a shock thus given to the brain. The adjustment must usually be by means of directors or needles thrust up the nostril, and the parts are held in place by adhesive strips. Fractures of the superior maxilla and of the alveolar process may be met with. If they are incomplete and there is no special deformity they have little significance. The nasal and alveolar processes are frequently broken. The former may be a complica- tion of injuries to the nasal bones. The latter may be broken in SPECIAL CASES OF FRACTURE. 223 careless extraction of the teeth. It very readily unites, and usually requires little attention unless a small fragment is displaced, in which case it should be removed. •* Fractures of the body of the superior maxilla may result from great violence. There is no bone which so readily unites, and all that is usually necessary is to reduce the fracture as completely as possible, and retain the parts in apposition by bandages and ad- hesive strips. When the injury is considerable, the adjustment may sometimes be made by getting the teeth in alignment, and retaining them by ligatures, gold bands, or even an artificial palatal plate. The antrum may be involved in fractures of the superior maxilla, and this may introduce a complication that may embarrass the treatment. In such a case the directions given in the chapter (XXX\'.) on Diseases of the Maxillary Sinus should be observed. The hemorrhage in fractures of the maxilla is not usually serious, and it will not be difificult to control. Fractures of the inferior maxilla are three times as common as those of the superior. This is because of their increased liability to accident through their greater exposure. The fractures are most often those of the body, although the ramus may be the seat of the injury. The diagnosis is easy, except when the injury is to the coro- noid process or the ramus. The symptoms are pain, deformity, mobility, and crepitus. The teeth form a most important auxiliary in both diagnosis and treatment. Observation of the position of the jaws and the occlusion of the teeth, if the latter are present, will ordinarily be sufficient to determine the amount of injury and the best method of reduction. The treatment of all such cases is best accomplished by the dentist, because he is familiar with the normal condition of the organs involved, and he has the mechanical skill to construct the appliance which will best reduce the displacement and retain the fragments in proper apposition. Too often the proper function of the teeth is lost through lack of the knowledge how to secure their proper alignment, or so to retain the fragments that normal occlu- sion will be secured when healing is complete. Various forms of splints have been devised by ingenious dentists for the treatment of fractures of the inferior maxilla. Some have held the fragments in apposition with the upper jaw by 224 ORAL PATHOLOGY AND PRACTICE. banding the opposite or occluding teeth on each side of the Hne of fracture, and then holding them together firmly by means of a connecting screw or clamp*. Various devices for wiring the teeth together have been pro- posed. The general surgeon has in the past mainly depended upon this method of retention. Skull caps, with fixed or elastic bandages passing around the lower jaw, have been employed. But perhaps the most effectual method is the employment of some form of the interdental splint. An impression of the frac- tured jaw is taken in some plastic material, without any attempt at replacement of the fragments. A cast of this is made in plaster-of- Paris, which gives a counterpart of the deformed jaw. Another impression and cast of the occluding jaw and teeth is secured. A fine saw is run through the cast of the broken jaw at the point or points of injury, and the pieces placed in proper apposition with the cast of the superior teeth, when they are fastened by running plaster-of-Paris about them. They are placed in an articulator and a wax model of a splint is made for the lower jaw which will properly occlude with the teeth of the upper jaw, so that mastica- tion may be possible during the process of healing. The wax model is reproduced in vulcanite, and when the frag- ments of the broken jaw are adjusted to it they may be retained in various ways. In the case of one such fracture of the jaw of a noted pugilist treated by the author, which had remained unre- duced for some weeks, nothing more was needed than the insertion of four gold screws through the outer plate of the splint, which obtained their hold in the V-shaped space between two teeth that were close together. Although this case demanded a subsequent operation from the outside for the removal of comminuted frag- ments, it was not found necessary to remove the splint until healing was complete. In another case, one of fracture of both the upper and lower jaws in a boy of fourteen, the splint consisted of a gutta-percha impression of each jaw, trimmed to proper shape. After their prep- aration, and immediately before their insertion, the occluding sur- faces were warmed so that they would adhere together when reduc- tion was accomplished, an elliptical opening between the anterior teeth being made for the purpose of feeding. The adjusting of the parts and the insertion of the splints, with the necessary band- DISLOCATIONS AND SPRAINS. 225 aging, was accomplished under chloroform. The whole work, in- cluding the taking of the impressions, the fashioning of the splints, and the reduction, occupied less than an hour, although three very competent physicians and an accomplished surgeon had vainly kept the boy under an anesthetic for more than four hours previously. Their failure was solely due to their inability to construct a splint that would hold the parts in apposition when they had the different fractures reduced, and not of course to any lack of surgical skill or knowledge. The judicious and ingenious dentist will readily devise an appliance that will be sufficient to retain the fragments in any form of injuries to the jaws. No two cases present precisely identical conditions, or require the same treatment, and he will vary his appurtenance so that it will meet the required ends. It is no part of the scope of this work to give instructions for the mechanical manufacture of splints, interdental or otherwise. CHAPTER LXIII. DISLOCATIONS AND SPRAINS. A Dislocation is the complete or partial separation of the articu- lar surface of one bone from that of another, or the displacement of an organ from its natural position. Joints or articulations are movable and immovable, or fixed. If movable, they are complex in their structure and are united by flexible ligaments. If slightly movable, they are usually connected zvith fibro-cartilage, which is tough, elastic, and pliant. If immovable, they arc connected by mere membranous sutural ligaments. .•Sometimes the union of fibro-cartilage is so firm that only a fracture can cause displacement. The ends of articulated bones, if the joint is a movable one, are enlarged and made up of compact tissue, the lamella; differing from those of the other parts, being without Haversian canals. The nutrition thus being less complete, they arc more apt to die. Articular cartilage covers the ends of bones, and, as has been said, fibro-cartilage separates certain of the joints, such as the i6 226 ORAL PATHOLOGY AND PRACTICE. vertebra. A man is half an inch taher in the morning than at night, because during the day, when he is in an upright position, the interarticular fibro-cartilage becomes compressed. A ligament is a band of compact membranous tissue connecting the articular ends of bones, and sometimes enveloping them in a capsule. It is not the office of the ligament to hold the bones together; that is the function of the muscles, the ligament merely limiting and restraining the motion, preventing it from going too far. The synovial membrane is a short membranous tube enclosing the joint, attached at the edges of the cartilage, and secreting the synovia, or synovial fluid, for the lubrication of the joint. When there are many muscles and great flexibility is de- manded, as in the wrist, there is very seldom a dislocation. Dislocations are traumatic, pathological, or congenital. Traumatic dislocations are the result of external violence or of muscidar action. They are by far the most frequent of any. Pathological dislocations are the restdt of the destruction of a part of the articidation by disease. Congenital dislocations are those in zvhich some essential part of the joint has never developed, and hence they are irreducible. Dislocations, like fractures, may be simple, or compound, or complicated. A simple dislocation is one in zvhich there is displacement, without injury to any tissue. A compound dislocation is one in which there is a wound that exposes some part of the articidation to the air. A complicated dislocation is one in which important nerves, blood- vessels, or other tissues are involved in the injury. Complicated dis- locations are fortunately infrequent. The symptoms of dislocation are much the same as those of fracture. They are as follows : Deformity. This will be evident from the unnatural position of the bone, and from the tumor which will be the result. Pain. This may be quite severe, and it will be located at the position of the joint. It will probably be of a dull, sickening character, and it is worse than that of a fracture. Rigidity. This will arise from the fixation of the parts, the voluntary movements being entirely absent or very much limited. New position of the bone. This may often be traced through the tissues by digital, or even, in some cases, ocular examination. DISLOCATIONS AND SPRAINS. 22"] The axis of the bone is altered and all its relations are modified. Usually there is lengthening" or shortening, as in fractures. Dislocations are dififerentiated from fractures by the immo- bility of the former, the absence of crepitus, and by the general appearance, the character of the pain, etc. Dislocations are treated first by reduction. This is best secured by manipulation, whenever that is possible. If the ligaments are badly torn and the luxation is thus com- plicated, manipulation may cause exceeding pain, and an anesthetic may be necessary. Sometimes in old dislocations there have been exudation and partial organization of the product, with perhaps more or less of bony ankylosis; or, more probably, fibrous ankylosis may have been formed, so that it is impossible to obtain reduction without surgical help. In these cases it may be necessary to open the joint and break up the union. This must, of course, be done under the strictest antiseptic precautions. Dislocation of the inferior maxilla may be unilateral, involv- ing but one side, or what is more frequent, bilateral, with forward displacement. It consists in a slipping forward of the condyle from the glenoid fossa, over the eminentia articularis. It occurs only when the mouth is widely opened. The external pterygoid muscle becomes violently flexed, and draws the condyle forward upon the surface of the bone. The temporal muscle becomes rigid, and helps to hold the condyle in its false position. The interarticular cartilage is carried forward with the condyle, but the capsular ligament is not usually torn. The symptoms of luxation of the inferior maxilla are a rigidity of the jaw, with inability to move it or to close the mouth. There is a marked projection of the chin, and the condyle may be felt for- ward of its normal position. If it is unilateral there is a deviation of the jaw toward the uninjured side. The reduction of the dislocation is effected by support- ing the symphysis, and at the same time depressing the angles of the jaw, the object being to carry the condyle downward and backward until it will slip over the articular eminence. The operator should stand in front of the patient, and, the thumbs being protected by wrapping around them a handkerchief, the jaw is firmly grasped with both hands, the pro- tected thumbs being j)laced far back over the molar teeth. Then, 228 ORAL PATHOLOGY AND PRACTICE. by pressing down with the thumbs and supporting the symphysis with the ends of the fingers, the jaw may usually be carried to place, the condyle slipping into the glenoid fossa with a distinct snap, and the jaw closing with considerable violence. Sometimes it may be necessary to use a round piece of wood between the back teeth as a lever to carry the condyle down and back, the angle being supported with the hand. This method will be found especially useful in unilateral luxations. Some kind of a pad should always be placed between the teeth of the two jaws, to prevent their being broken with the violence of the closure when the reduction is made. Dislocation of the lower jaw backward sometimes occurs, but only as the result of great violence, and is necessarily accompanied by fracture of the borders of the fossa. The dislocation in this case becomes of less importance than the other injury, and its reduction is subordinate to the other treatment. A Sprain is a self-reduced dislocation, with consequent soreness from the violent strain upon the muscles and tendons, and with, pos- sible laceration of the ligaments or attachments. It is characterized by severe pain, much increased by movement, with rapid swelling and heat in the joint. Sprains are usually treated by either hot fomentations or cold applications, whichever seems indicated. The former will be likely to bring about resolution, while the latter will be demanded when there is a great deal of heat and an intense hyperemia. If the swelling is very great, through excessive effu- sion, it is well to bandage with cotton, and to^ secure immobility by means of a plaster-of-Paris bandage, after the swelling shall have subsided. CHAPTER LXIV. SHOCK— COLLAPSE. Shock is the depression that is caused by severe injuries, surgi- cal operations, or great mental disturbance. It is the result of reflex nervous action, and may be slight, like the temporary faint- ness which soon passes away, or so severe as to induce a vital depression that is almost instantaneously fatal. It has already been shown that it is not the bullet in the heart that kills, but the impres- sion upon the whole nervous system which is its consequence. In SHOCK — COLLAPSE. 229 such an instance the shock is the direct result of the impact. But no less fatal may be the indirect efifects of a mental impression. It is related that the janitor of a medical school had made himself so obnoxious to the s^tudents that even his life had been threatened. As the result of a conspiracy among them he was captured one night, conveyed to a sepulchrally draped room, shown a block and ax, and informed that he was to be executed. Amid the solemn and impressive surroundings he was seized by the masked men, his neck bared and placed upon the block, when the executioner struck with a towel wet in ice-water. The victim was taken up dead. The shock was as complete as though the actual ax had been used. There is a wide difference in the susceptibility of different persons to shock. Some are of an emotional nature, and compara- tively slight mental impressions of a depressing kind produce pro- found effects. Others are more stolid and apathetic, and lose their nervous equilibrium less readily. It is well known that an unim- portant mishap will, in some instances, produce fatal efifects, while in others the system will successfully withstand the gravest injuries. The immunity of drunken men to the results of accident is proverbial. Their intoxication so exalts or stupefies the nervous system as to fortify it against or exempt it from shock, the usual result of injury. The shock that is caused by mere mental impression is more fre- quent and often more profound than that produced by actual vio- lence. Especially is this the case with nervously susceptible people. The mere sight of a dentist's instruments too ostentatiously paraded may induce a depression and shock to a nervous female that will be absolutely more injurious than the contemplated opera- tion. Any incivility of manner or unnecessary roughness of method on the part of the operator may, to a timid child, be worse than the real pain, because it can induce a more profound shock. In the light of these truths it is easy to comprehend why the gentle, suave, sympathetic dentist is al)le to perform with comparative ease to the patient operations that another finds absolutely imprac- ticable. It is because of the limiting of the primary shock that operations under the influence of an anesthetic are possi- ble and safe, that otherwise would be fatal. The benefi- cence of these agents and the glory of the discovery of anesthesia 230 ORAL PATHOLOGY AND PRACTICE. is not confined to the immunity from pain which they give, but they have saved Hves almost innumerable through their making feasible operations that before were impracticable. The usefulness of prophylactic remedies, to be employed before dental or oral operations, lies in their ability to pre- vent shock to the nervous system, either by stimulating it so that it can successfully ^vithstand disagreeable impres- sions, or so stupefying it as to make it insensible to them. In either case the primary shock is correspondingly lessened or inhibited. The entire confidence of a patient once secured, especially that of a child, the nervous system will without injury undergo, or even be insensible to, pain that under other circum- stances would be unbearable, because the deadly influence of shock is avoided. It may readily be conceived, then, that the subject is of paramount importance to the operative dentist, and that it is his bounden duty to study it with care. In this connec- tion, the remarks upon nervous influence in the chapter on Hyper- sensitive Dentin will be found useful. The distinction between shock and collapse is one not easily made plain, nor is it necessary here to draw a fine discriminating line. It is sufficient if we consider shock as the result of either mental or physical violence, while collapse is the final consequence of continued exhaustion. Thus the impact of a bullet may induce shock, but the slow bleeding that may succeed it will finally end in collapse. Shock may not only be the result of different kinds of injury, physical or mental, but it may assume different forms. For con- venience these may be classed as torpid, excitable, and delayed. In torpid, or apathetic, shock the symptoms may be almost entirely referred to vaso-motor paralysis. The circu- lation is materially modified. There will be a pallor of the skin and of the mucous membrane, with coldness, especially of the extremities, and the patient may be covered with a cold perspira- tion. The expression of the face is changed or lost, the pupil of the eye is dilated and does not respond readily to light. There is irregularity of the action of the heart, with a weak, thready, and perhaps almost imperceptible pulse. The respiration becomes slower and more superficial. There may be partial or complete insensibility, mental inactivity, and loss of control of the voluntary muscles. There will be depressed bodily temperature, perhaps to SHOCK COLLAPSE. 23 1 be followed by a corresponding rise, and in some instances nausea, and possibly vomiting. In excitable, or erethistic, shock the patient is restless, irritable, easily disturbed, perhaps uncontrollable. There is found a disordered pulse, with irregular breathing and dilated pupils. Notwithstanding the actually depressed condition, there will be the appearance of unnatural activity. The sufferer may perhaps exhibit an impatience with and opposition to the institu- tion of the proper remedial measures, or the continuance of any necessary operation. To the operative dentist, these symptoms are often premonitory of a more profound impression, and are not to be disregarded. Upon their appearance he should use redoubled care to avoid further nervous injury, and should promptly administer an anodyne. Delayed shock is the condition in which the symptoms are only manifested some hours after the injury or nervous impression has been received. They do not materially differ in reality, and may be of either the torpid or the excitable char- acter. They may be the result of a slow and concealed hemor- rhage. This type is often observed after dental operations that were not of a serious nature, but which were considerably pro- longed. The patient probably has not incurred any material harm, aside from the bodily depression that ensues, and the character of the symptoms will be rather of the excitable than the apathetic kind. The physical condition will not be materially different, no matter what the cause of the shock or the nature of the early symptoms. If it is serious the torpid state will gradually deepen into coma, and the excitement as progressively subside into entire insensibility. The bodily heat may steadily become less, the breathing more superficial, the pulse weaker and more rapid, until death closes the scene. Sometimes this will be an unexpected end, the injury or nervous impression seeming totally inadequate to j)roduce it. As has already been affirmed, the result often depends more upon the physical condition of the patient, and the bodily ability to resist or sustain the deadly depressing influence, than upon the nature or extent of the injury itself. 2,2)2 ORAL PATHOLOGY AND PRACTICE. CHAPTER LXV. TREATMENT OF SHOCK. The treatment of shock consists in the institution of measures to bring about a reaction. But these must be cautiously approached if the depression is very profound, or if it arises from or is accom- panied by any great loss of blood. There is danger that the reaction may be too great and exhaustive, or that recovery from the syncope or coma may be followed by a fatal return of the hemorrhage. Hence, in case of accident the precise condition should be determined before any extreme measures are attempted. Sometimes great difficulties are encountered in using the usual remedies. This is especially true in that common form of nervous shock called syncope, or fainting. Consciousness being lost, perhaps the patient cannot be made to swallow, and if fluids are forced into the mouth they will not be taken down the esophagus, but may go into the trachea and cause suffocation. If the shock is so profound that the circulation is arrested, there will be little use in attempting hypodermic medication; and. if* the breathing is suspended, inhalations of volatile stimulants will be impossible. There will, of course, be cerebral anemia, and this should be at once combated by laying the patient in a recumbent position, with the head as low as the rest of the body, or even lower. All obstruction to a free circulation, like clothing that is too tight or a violently flexed position of any limb, should be remedied. The lower extremities may be raised, and pressure used to press the blood out of them toward the head. If there is blueness of the lips, it may indicate that the head is too low, or that there is some obstruction about the neck. As soon as possible, warm stimulating drinks should be given, such as dilute whiskey or brandy. Volatile stimulants may be applied to the nostrils, such as ammonia, nitrite of amyl, etc., but care should be observed to avoid their being so unduly strong, or so persistently applied, as to cause suffocation. If the body is cold, external heat should be applied by wrapping the patient in hot blankets, or by laying bottles filled with water, not too hot, in the axillae and about the body. Chafing the extremities should not be resorted to until consciousness has returned, lest it draw away the blood from the head, where it is most wanted. TREATMENT OF SHOCK. 233 Artificial respiration should be used if the breathing is sus- pended and is not readily resumed. This may be continued as long as is necessary, but it should not be violent. Every precaution should be taken to avoid the deepening of the shock. It is need- less to say that in the unconsciousness resulting from drowning, the violent rolling of the body upon a barrel or other object is the surest way to extinguish whatever of vitality may remain. If the stomach will not retain remedies, or if the patient can- not swallow, stimulating drinks may be administered as enemas, and alcoholic dilutions, or strong coffee, with carbonate of am- monia, etc., will be almost as useful as when given by the mouth. Hypodermic medication is very useful when the circulation has been maintained or restored. The activity of the heart may be stimulated by strychnin and digitalis. The respiration may be strengthened by atropin. These remedies should be given in large doses. Park recommends that in one hypodermic injection there should be given one c.c. of tincture of digitalis, with one-twentieth of a grain of strychnin and one-hundredth of a grain of nitro- glycerin. This to be repeated as often as necessary, or digitalis alone may be administered at frequent intervals. In case the shock takes the form of extreme nervous excitement, anodynes should be given. Opium, in the form of morphin sul- phate, is the most efifective, and one-eighth to one-quarter of a grain may be administered hypodermically. The patient should be kept as quiet as possible until reaction is complete. When the shock is due to great loss of blood, as from tooth extraction, a saline solution, consisting of sterilized water looo parts, ammonium carbonate i part, and common salt 6 parts, may be slowly injected, the nearer to the place of injury the better. The hypodermic syringe should always be kept in order, and be thoroughly sterilized before being used. The proper remedies may be obtained in tablet form, ready prepared for making solutions. The operator, before using the hypodermic solution, should see that no air is in the barrel, whence it may be driven into the circulation. This may be determined by holding the point of the syringe up after filling, and expelling the air by means of the piston. Of course, every operation is inhibited during the existence of shock. It matters not what form it may take, whether that of increasing lethargy or growing excitement, the 234 ORAL PATHOLOGY AND PRACTICE. attention must at once be given to securing recovery. If indica- tions of hysteria are observable, that may be one of the symptoms of excitable shock, and the patient should be given an anodyne and placed in a recumbent position in a quiet place, the operation, if it be dental, not to be resumed until another day. No one suffering from any form of shock, the result of an oral operation, should be allowed for a moment to remain in the operat- ing chair, as the recumbent position is the first essential. This does not seem to be properly appreciated by dentists. The extrac- tion of teeth, especially when an anesthetic is administered, can be much better accomplished when the patient is lying down. A couch, specially adapted to the purpose, should be provided by those who give anesthetics for the extraction of teeth. The danger from administration is very materially lessened, while convenience in operating is proportionately increased. The couch should be about the height of a common table, and only wide enough easily to hold the patient. Standing on either side for upper teeth, and at the head in extracting lower ones, the operator has much better command of the situation and is less liable to fracture tooth or alveolus, while the chances of dropping a fragment into the trachea, or of choking the patient with blood, are very materially lessened. Recovery from anesthesia, and from the shock conse- quent upon the operation, are much more prompt and satisfactory. No general surgeon would for a moment even consider the ques- tion of operating in any case with the patient sitting up. Dentists should change their methods, and — at least in operations involving the administration of anesthetics and the extraction of a number of teeth — adopt a position that is surgically more appropriate. INDEX. Acid fermentation, lo. Alcoholic fermentation, 9. Algre, the, 6. Alternate periods of growth, 58. Alveolar abscess, blind, 93. definition, 92. external treatment, loi. incipient, 93. infection not necessarily at foraminal opening, 94. secondary pockets and other complica- tions, 96. symptoms, 97. Alveolus, caries of, differs from that of bone, 154. Arsenous ulceration, 47. Articulations, classification of, 225. Articulo-cartilage, 225. Anemia, 21. Aneurisms, 214. Animal and vegetable kingdoms, 4. Ankylosis, 216. Antiseptics, 14. Miller's table of, 16. Antiseptic mouth-washes, 79. Antrum a resonant chamber, 125. alveolar abscess discharging into, 127. catarrhal conditions, 126. cysts of, 139. dilatation of walls, 129. drainage of, 131. foreign substance in, 128. inlundibulum opening into, 135. necrosis of walls, 134. opening of, 131. may not close, 134. roots of teeth seldom penetrate, 127. septa dividing, 133. symptoms of degeneration in, 129. tents and plugs in, 132. Aphthous stomatitis, 48. Bacilli, the, 3. Bacteria, classification of, 4. self-limiting, 10. Bad feeding, 60. Bandaging, 37. Birth-rate, 56. Bistoury in gum-lancing, 69. B'.ack, G. \'., experiments of, 77. Bleaching teeth, chlorin in, 177. Bone, caries of, 151. Garretson's experiments, 153. symptoms of, 152. treatment of, 153. living portions may take on inflamma- tory conditions, 149. nourishment of, 148. osteitis the initial point in degenerations of, 149. the result of an irritant, 150. structure of, 148. I'reaking down of tissue,. 32. Building up of tissue, 30. Cachectic conditions, 27. Cancers, malignant tumors, 144. Cancrum oris, 44. Care concerning infection, 18. Caries limited by cleanliness, 78. prophylactics for, 78. of bone, symptoms of, 152. treatment of, 153. Cause of stomatitis, 45. Cementum a modification of bone, 75. Chlorin in bleaching teeth, 117. Cocain formulje, 170. Cohnheim's observations, 27. Crowding of the dental profession, 39. Cryptogams, 6. Cyst, definition of, 137. Cysts, aspiration of, 13S. cause no functional disturbance, 137. classification of, 138. dentigerous, 140. dermoidal, 140. Dkath, mean age at, 55. Death-rate, 56. Deaths, percentage of, 55. Delayed union, 222. Dental caries, ancient and modern, 70. caused by infection, 73. Miller's theory, 71. Dentinal papilla-, pressure on, 68. Dentin a modification of bone, 75. caries of, analogous to necrosis, 165. hypersensitive, anesthetics in obtuiiding, 165. 236 INDEX. Dentin, hypersensitive, cataphoric medication in obtunding-, 168. coagulation of fibrillae in obtunding, 168. gentleness a factor in obtunding, 170. inefficiency of medicinal agents in obtund- ing, 167. influence of heat and cold upon, 167. irritation of fibrillae in obtunding, 166. prophylactic medication as sedative, 169. not normally sensitive, 80. sensitive when irritated, 81. caries a cause of, 164. denudations a cause of, 164. due to irritation, 163. empirical remedies for obtunding, 161. vitiated oral secretions a cause of, 164. zone of infected, -jz. Dentistry, "painless," 161. its true mission, 161. Dentition and the death-rate, 54. retarded, 68. Deodorants, 16. Detergents, 17. Diagram of death-rate, 62. of mortality from digestive diseases, 63. Diarrheas, formulae, (>(>. Diet among the poor, 61. Direct nervous action, 22. Discoloration not usual with living pulps, 176. Diseases of dentition confined to a few, months, 61. Disinfectants, 16. Dislocations, 225. classification of, 226. diagnosis of, 226. how treated, 227. of inferior maxilla, 227. Electricity in paralysis, 121. Electrozone, 16. Enamel a modification of bone, ■;(). congenital marks and the enamel organ, 180. influence of exanthematous disease on, 180. pitted and furrowed, 179. Environments. 2. Epulis, character of, 147. from pericementum, 147. Evacuation of pus, 38. Experiments in inoculation, 13. Extraction in necrosis, 158. recumbent position in, 234. Facial paralysis, traumatic and idiopathic, 119. Fermentation, 7. Ferments, organic and inorganic, 7. Fibrillae, inhibiting their ability to convey impulses, 166. Fibro-cartilage, 225. Filling sterilized roots, 102. First intention, 30. Fissation, 8. Follicular stomatitis, 42. Food, gradation to age, 59. Foramina, drilling open the, 101. Foraminal apex not necessarily the point of infection, 94. opening not a single direct aperture, 88. Foreign substances in antrum, 128. Fractures, classification of, 218. deformity of, 218. delayed union in, 222. diagnosis of, 220. general treatment of, 223. how produced, 218. non-union of, 222. of the maxillae, 223. of the nasal bones, 222. reduction of, 221. treatment of compound, 221. Frontal sinus, opening of, 135. Function, normal and disturbed, i. Functional harmony, 122. Fungi, aerogenic, 7. cnromogenic, 7. distinguishing characteristics, 6. multiplication of, 9. office of, 3. pure cultures of, 11. pyogenic, 7. resistance to, 12. saprogenic, 11. saprophytic, 11. Garretson, experiments of, on bone, 153. Gemmation, 8. Germicides, 15. Glossitis, S3. Granulation, or second intention, 31. Green stain, 103. Growth of fungi, 8. Gum irritants, 40. ■lancing, 68. Gums, appearance of, in health, 65. Gutta-percha caps over teeth, 91. Haversian canals, analogues of, in teeth, 88. Heat as a sterilizer, '14. Hemorrhage, arterial, venous, and capil- lary, 216. Hemorrhagic diathesis, 218. Homologous and heterologous tumors, 142. Hydrogen peroxid, 16. Hypercementosis the analogue of exostosis, 174. true cementum, 175. INDEX. ^V Hyperemia, 21. Hypersensitive dentin due to inflamma- tions, 82. Hypodermic medication, 233. Implantation, no revivification of tissues in, 184. now an accepted practice, 183. physiology of, 185. Incubation in primary syphilis, 188. in secondary syphilis, 190. in tertiary syphilis, 191. Induration, 29, 103. Infection, 18. care concerning, 18. Infective inflammation, 20. Inflammation, 21. general remedies for, 36. of pulp, 80. predisposing and exciting causes of, 26. stages of, 24. symptoms of, 25. Inorganic matter, 5. Insalivation, i. Interference, external, 2. Ischemia, 21. Lactic acid treatment, 41. Laxatives, food and mineral, 87. Leafy cryptogams, 6. Leucocytes in the blood, 27. Lichens, 6. Ligaments, 226. Lupus, tuberculous nature of, 145. Luxations of lower jaw, 227. Malnutrition, 2. Massage in facial paralysis, 122. of the gums, 41. Media for organisms, 8. Metchnikoff's theory, 13. Microbes, 3. Micro-organisms, 3. Miller's theory of caries, 71. Mortality, average infant, 56. Mouth-washes, antiseptic, 79. Necrosis, acid treatment of, 159. analogous to gangrene, 155. as a sequela, 156. definition of, 34. diagnostic signs of, 157. drainage in, 159. extraction in, 158. general treatment of, 160. impacted teeth in, 156. indicative of debility, 155. operations for, 160. ' result of dental operations, 156. Nerve resection does not necessarily de- vitalize teeth, 89. Neuralgias, character of, 116. gouty diathesis in, 118. usually in afi'erent nerves, 115. Noma, cancrum oris, 44. Non-union, 222. Nutritive changes in teeth, 124. Odontoblasts within the pulp, 171. Odontoma, 139. Oral pathology, 2. tissues, appearance of, in diseased con- ditions, 207. Organic matter, 4. Osteitis always present in pericemental in- flammation, 150. diagnosis of, 150. result of wedging, 151. Paralysis, reflex, 120. I'athogenic fungi, 11. Pathology, definition of, 2. Pericemental infection, 97. sterilization, 99. Pericementitis, calcium sulphide in, 91. hot water in, 91. Pericementum active in serumal forma- tions, 106. a placental organ, 88. compound function of, 89. new growth of, 185. Phanerogams, 6. Pharyngitis, cause of, 49. in cleft palate, 50. Pharynx, the, 49. Physical diagnosis, 196. auscultation, 197. murmurs, 203. percussion, 197. Physiology, i. Plantation of teeth, antiseptic, 182. Plastic exudate, 28. Plethora, 21. Poultices, ZT- Pregnancy, sympathetic complications of, 123. Proud flesh, 211. Pulp, blood vessels of, modified, 81. chamber opening, precautions in, 92. extravasation, 83. infection, sources of, 93. inflammation like other inflammations, 80. symptoms of, 85. treatment of, 86. irritation, symptoms of, 84. normally insensitive, 81. sensitiveness due to irritation, 82. stones analogous to osteo-dcntin, 172. Pulpitis, comparative symptoms of, 90. Pulse, difTerent kinds of, 199. in disease, 199. 238 INDEX. Pulse in health, 198. rate at different ages, igS. where and how taken, 198. Pure cultures, 11. Pus, composition of, 17. different kinds of, 33. evacuation, 95. essential, 38. gatherings, abortive measures in, 98. Putrefactive fungi, 10. media, 13. Pyorrhea, chemical agents in treatment of, 112. general treatment of, 114. in animals, 107. three forms recognized, no. without deposits, 114. Pyorrheal pockets, deflection of the teeth caused by, in. not always connected with oral cavity, 11 1. Pyrozone, 16. Ranula, 139. " Raw ham" appearance, 189. Reflex nervous action, 23. Replantation, when called for, 181. Resection of maxillary nerves, 119. Resolution, 30. Respiration, artificial, 204. Sylvester's method, 204. in health and disease, 201. kinds of, 201. sounds heard in, 202. various rales, 203. Salivary calculus, 104. Secondary dentin and pulp devitalization, 173- as a protection, 172. common, 173. in animals, 172. not readily diagnosed, 174. formations due to special stimulus, 171. Segmentation, 8. Sensation in dentin due to irritation, 82. Sensitive apex of roots, 102. Septic and aseptic conditions, 14. conditions, general symptoms of, 98. Sequestrum, definition of, 35. Serumal calculus, 105. Shock, age and sex in, 208. anesthesia in preventing, 229. consequent on wounds, 208. definition of, 228. prohibits operations, 234. prophylaxis of, 230. susceptibility to, 229. treatment of, 232. Splints, 223. Spore -formation, 8. Sprains, 228. Sterilization by absorption, loi. Stomatitis, cause of, 46. Successful operations, a test for, 163. Suppuration, 32. when to be encouraged, 99. Sympathetic dental disturbances, 123. Syphilis a constitutional, infectious dis- ease, 186. by inoculation, 186. care in diagnosing, 187. chancre rarely suppurates, 189. induration of, 188. chancres about the mouth, 194. chancroids, 192. condylomata, 192. glandular affections, 191. glossitis in, 195. gummata, 192. hereditary, 193. Hutchinsonian teeth, 193. infectious discharges, 191. mucous patches, 190. periods of incubation, 189. primary sore, or chancre, 187. readily yields to treatment, 186. secondary eruptions in the mouth, 194. symptoms, 189. "smoker's patches," 195. syphilides, 191. syphilitic children, 193. tertiary stage, 192. ulcerative lesions of the mouth, 194. Teeth are vital organs, 74. are modifications of bone, 73. composition of, 74. stained pink, blue, or green, 176. when "set on edge," 165. Thallogens, 6. Thrush, symptoms of, 43. Tissues, all, are organic, yT. "Toad's back" appearance, 195. Tongue as an index, 52. ulcers of, 54. Tongue, color of, in disease, 206. dry and moist, 206. "fur" coating of, 205. in diagnosis, 205. indications of danger by appearance of, 207. natural appearance of, 205. Tonics, vegetable and mineral, 160. Tonsillitis, 51. Tooth abrasions, many forms of, 178. acid condition in, 178. prophylaxis of, 179. vitiated secretions in, 179. pulp normally insensitive, 162. INDEX. 239 Torula, or yeast plant, 7. Transplantation, precautions in, 183. Trichloracetic acid, 41. Tumors, benign or malignant, 142. carcinomatous, 144. classification of, 142. comparison of, 146. diagnosis of, 143. epitheliomatous, 144. general treatment of, 143. homologous or heterologous, 142. sarcomatous, 144. structure of, 141. Ulcerative stomatitis, 43- Ulcers of the tongue, 54. Unhygienic conditions, 2. Uric acid diathesis, 108. Vaso-motor nerves, 23. Von Recklinghausen's theory, 29. Warts and corns, 141. White deposit, 103. Wounds, classification of, 209. closing of, 214. definition of, 208. drainage of, 215. exuberant granulation of, 211. first, second, and third intention in heal- ing of, 210. hemorrhage in, '208, 213. how controlled, 213. how distinguished, 208. loss of function after, 208. manner of healing, 210. septic conditions of, 212. shock after, 208. Zone of infected dentin, 72. Zymogenic fungi, 7. Zymotic diseases, 12. um 'U^^ 1 to ^ '^^C* qH_^. "ttS Aft S •?\ ^-^Yd rf» "^ •^'11-9 »Cv^ Oral patholoqv .iiifi i.Mriirp 2002370166 RK301 Barrett Oral pathology and practice. B27 cop.l