DESCRIPTION OF PLATE I. 
P. N. Anterior Palatine Nerve. 
P. A. Greater Palatine Artery. 
P. V. Palatine Vein. 
P. Periosteum. 
P. R. Palatine Rugae. 
P. G. Palatine Glands. 
T. of T. V. P. Tendon of Tensor Veli Palatini. 
M. B. M. Buccinnator. 
I. F. of P. M. Interlacing Fibers of the Palatine Muscles. 
P. M. R. Pterygomandibular Raphe. 
M. C. P. M. Cephalopharyngeus. 
M. P. P. M. Pharyngopalatinus. 
M. G. P. M. Glossopalatinus. 
P. T. Palatine Tonsils. 
M. G. Molar Glands. 
D. S. A. F. P. P. Deep Surface of the Anterior Fasciculus of the Pharyngopalatinus 
L. V. P. Levator Veli Palatini. 
P. F. P. P. Posterior Fasciculus of the Pharyngopalatinus. 
S. P. Salpingopharyngeus. 
A. F. P. P. Anterior Fasciculus of the Pharyngopalatinus. 
M. S. of T. Median Sulcus of the Tongue. 
C. P. Gircumvallate Papillae. 
Fgf. P. Fungiform Papillae. 
Fol. P. Foliate Papillae. 
F. P. Filiform Papillae. 
T. T. Tip of Tongue. 
U. Uvula. 
I. F. Isthmus of Fauces. 
P. P. A. Pharyngopalatine Arch (Posterior Pillar of the Fauces). 
G. P. A. Glossopalatine Arch (Anterior Pillar of the Fauces). PLATE I THE SURGERY 
OF 
ORAL DISEASES AN D 
MALFORMATIONS 
THEIR DIAGNOSIS AND TREATMENT 
BY 
GEORGE VAN INGEN BROWN,DJ)KJLD.,CAL,E.A.C.S. 
MAJOR, MEDICAL OFFICERS' RESERVE CORPS, U. S. ARMY. 
ORAL SURGEON TO ST. MARY'S HOSPITAL AND TO THE CHILDREN'S FREE HOSPITAL AND 
COLUMBIA HOSPITAL, MILWAUKEE; FELLOW OF THE AMERICAN MEDICAL ASSOCIATION; 
MEMBER OF THE NATIONAL DENTAL ASSOCIATION; CHAIRMAN OF THE SECTION ON 
ORAL SURGERY OF THE FOURTH INTERNATIONAL DENTAL CONGRESS, ETC. 
SECOND EDITION 
WITH 521 ENGRAVINGS AND 20 PLATES, AND A SELECTED LIST OF 
EXAMINATION QUESTIONS 
LEA & FEBIGER 
PHILADELPHIA AND NEW YORK 
1917 Copyright 
LEA & FEBIGER 
1917 TO 
EMILY LYNCH BROWN 
MY MOTHER 
AND 
ELIZABETH KATHLEEN SELBY BROWN 
MY WIFE VI 
PREFACE 
chapters on Diseases of the Mucous Membrane of the Mouth 
and Syphilis; to Dr. Francis J. Wilson, of Paris, formerly of the 
American Ambulance Hospital, Neuilly, France, Dr. George B. 
Hayes and Dr. William S. Davenport, of the American Ambulance 
Hospital, Neuilly (Paris), France, Dr. Edward C. Kirk, editor of 
the Dental Cosmos, Dr. Joseph Hilus Eastman, Indianapolis, Ind., 
formerly chief surgeon, Reserve Hospital No. 8, Vienna, Austria, 
Dr. George E. Meyer, of Chicago, Ill., Major R.A.M.C., formerly 
Oral Surgeon of the Twenty-third General Hospital, British Expedi- 
tionary Force, France, and Captain S. D. Boak, D.S.C., Columbus 
Barracks, Columbus, Ohio, for original contributions and assist- 
ance in the preparation of the chapter on the Treatment of 
Wounds under War Conditions; to Dr. Sheppard W. Foster, of 
Atlanta, Ga., for much clinical illustrative material; to Dr. Albert 
J. Ochsner, of Chicago, and Drs. Edward S. Judd and Gordon 
New, of the Mayo Clinic, Rochester, Minn.; Dr. Fred H. Albee, 
of New York, Dr. Vida A. Latham and Dr. Eugene S. Talbot, of 
Chicago, for valuable illustrations and descriptions of interesting 
cases. 
A special word of thanks is also due to Dr. George A. Harlow, 
of Milwaukee, whose advice and efficient cooperation in conducting 
army examinations went far toward making possible the completion 
of this work under present conditions, and to Dr. Selby Van Ingen 
Brown for additional assistance of this character. 
G. V. I. B. 
Milwaukee, 1917. PREFACE TO THE FIRST EDITION. 
In the preparation of this work the author has endeavored to 
meet certain demands the urgency of which has been borne in 
upon his mind after more than thirty years' experience in the 
treatment of oral diseases and malformations. During the last 
ten years of this period his practice has been limited to these affec- 
tions. Through frequent consultations and cooperation in the 
treatment of patients who have been referred, he has been closely 
in touch with dentists, general surgeons, internists, and those 
whose practices have been limited to rhinology, ophthalmology, 
otology, pediatry, dermatology, and other divisions of medical 
practice. This volume is therefore designed to be a book of reference 
touching all these medical interests in their oral relation. 
As a teacher of oral surgery he has also become convinced that 
for many reasons there is great need of a text-book adapted to 
both didactic and recitational instruction on this subject, suffi- 
ciently concise and well systematized to permit of accommoda- 
tion of the course to the stringent time limitations of a college 
curriculum and yet impressing the salient points to the best possible 
advantage, and so arranged as to facilitate the work of students 
in preparing themselves for examination. While meeting these 
requirements, it is believed that this work is sufficiently compre- 
hensive and practical to make it a useful guide in trying clinical 
situations after graduation. 
The chapters on Hare-lip and Cleft-palate represent the chief 
part of the author's life-work. His conception of the presentation 
of these subjects is based upon extended observation of the con- 
fusing conditions which surround those who are called upon to 
treat such cases in the course of general practice. There is much 
diversity of opinion among writers as to the best methods of pro- 
cedure, and the ill results of a wrong step in treatment are great 
and long continued. The clinical aspect has been kept constantly VIII 
PREFACE TO THE FIRST EDITION 
in view in order to provide a dependable source of information. 
Many original drawings have been carefully prepared to show 
each operative step in the correction of these deformities. Much 
space has been given to the explanation of operative methods and 
the underlying factors which influence results. The pictures of 
large numbers of patients are shown in order to emphasize the 
thoroughly practical clinical value of operations and corrective 
measures that are recommended. These are in the form of engrav- 
ings made from photographs. They are therefore true examples 
of the results of treatment which is in harmony with the develop- 
mental principles that govern facial symmetry, speech function, 
and nasal form. Upon these influences also depend freedom from 
nasal disease and other more widely distributed affections, both 
general and local. All illustrations except those credited to other 
writers are representations of the author's cases. 
It is well known that grave consequences might often be avoided 
by the early detection and correction of quite simple mouth diseases. 
Too commonly these cases have been allowed to advance to a state 
of hopelessness, or radical surgical operations have been inad- 
visably performed with unnecessary personal disfigurement or 
danger as the result. Many extrabuccal affections might also be 
checked in their incipiency if dentists who have opportunity to 
observe them during early stages fully recognized their significance. 
The discussion of a field of practice with hitherto ill-defined 
limitations, situated like the hub of a great physiological and 
pathological wheel, around which center and f-rom which radiate 
almost limitless possibilities for the reception and extension of 
disease, has required much thought in the determination of its 
boundaries. In this effort the difficulty of conveying a true idea 
of the etiological and pathological importance of the oral region 
in relation to other parts and to the organism as a whole, without 
going too far afield in the discussion, has been realized. 
Great labor has been expended in an effort to present the subject 
with sufficient broadness to cover all affections directly and indirectly 
related, and yet to confine descriptive matter to facts that are 
essential to the fulfilment of the purpose of the work. 
Widening of the nares by separation of the maxillse for the 
correction of nasal defects and the control of pathological influ- 
ences that may affect the nose and associated parts through the PREFACE TO THE FIRST EDITION 
IX 
mouth is fully illustrated and described, because such work is 
properly within the scope of the functions of the oral surgeon. 
The operative treatment of diseases of the nose and throat 
has been omitted, because this lies outside of the province of oral 
surgery. Although partial or complete stenosis of the nares, 
deflected nasal septa, diseases of the nasal accessory sinuses, 
adenoids and enlarged tonsils, and pathological results attendant 
upon these conditions are commonly associated with diseases 
and malformations of the mouth, their improvement often being 
attendant upon the correction of oral defects, it is nevertheless 
true that rhinologists are better fitted for the local operations 
they require, and whenever possible should be the only ones to 
attempt them. 
In like manner it will be obvious to all thoughtful readers that 
operations such as the removal of the Gasserian ganglion can only 
be safely performed by surgeons of acknowledged skill and long 
experience in brain surgery, and extensive resections of the jaws, 
grave operations upon the tongue, dissections of cervical glands, as 
well as many less extensive operations upon the eyes, ears, nose, and 
other parts that may be and often are associated with the mouth in 
disease, can best be performed by those whose practice has especially 
fitted them for the diagnosis and surgical operative treatment of 
pathological conditions within the region of their greatest experinece. 
Description of the technic of all such operations, with sufficient 
detail to prepare those unfamiliar with them for their proper per- 
formance, would be impossible in a work of this character, and the 
attempt would be unwarranted. On the other hand, because the 
symptoms of diseases requiring such operative treatment are so 
frequently manifested in the mouth, familiarity with their nature 
and the indications by which they may be recognized is vitally 
important for all who treat oral diseases. Again, in order to secure 
the best results it is necessary not only that such cases be carefully 
diagnosticated, but also that the one who refers them should have 
at least an intelligent idea of the most appropriate methods of 
treatment. It has therefore been the author's purpose to include 
all important pathological conditions that affect or are influenced 
by the buccal cavity and its immediately surrounding parts; to 
deal thoroughly with the etiology and symptoms of these affections, 
and to describe the necessary operative procedures clearly and X 
PREFACE TO THE FIRST EDITION 
concisely with sufficient detail to give a thorough understanding 
of the most approved methods of treatment, the risk involved, and 
the probable results. 
Mindful of the great advancement of dentistry, particularly 
in oral hygiene and prophylaxis, oral bacteriology and pathology, 
the treatment of buccal diseases and the study of their underlying 
developmental principles; cognizant also of the great opportunity 
for the application of knowledge of general diagnosis, pathology, 
and surgical treatment in this field, such as might only be expected 
of those whose experience has been upon the broad lines of more 
general medical practice; with keen realization of the imperative 
necessity for exact and specific methods of diagnosis when other 
parts are involved in oral disease, the author has long hoped to 
provide a work for consultation which might lead to a more direct 
clinical application of all these opportunities. 
The author is greatly indebted for valuable advice, scientific 
information, personal letters, and other assistance to Dr. Edward 
C. Kirk, of Philadelphia; Dr. Eugene S. Talbot, of Chicago; Dr. 
O. H. Foerster, Dr. Nelson M. Black and Henry I). Goodwin, 
of Milwaukee; Dr. Lee W. Dean, of Iowa City; Dr. Vida A. 
Latham, of Chicago; Dr. M. H. Cryer, of Philadelphia; Dr. 
Albert J. Ochsner, of Chicago; Dr. Charles H. Frazier, of Phila- 
delphia; Dr. George W. Crile, of Cleveland; Parke, Davis & Co. 
and Dr. N. S. Ferry, of Detroit; Dr. Shepard W. Foster, of Atlanta, 
Ga.; The Journal of the American Medical Association, The S. S. 
White Dental Manufacturing Company, and many other friends 
and confreres in this and other countries for helpful cooperation 
and contributions to literature which have been freely quoted. CONTENTS. 
CHAPTER I. 
Anesthesia-Hemorrhage-Shock 17 
CHAPTER II. 
Pathological Dentition 63 
CHAPTER III. 
Infectious Diseases 88 
CHAPTER IV. 
Diseases of the Mucous Membrane of the Mouth 168 
CHAPTER V. 
Diseases of the Nervous System Affecting the Buccal Region . 215 
CHAPTER VI. 
Diseases of Bone 359 
CHAPTER VII. 
Diseases of the Glands . 458 
CHAPTER VIII. 
Tumors 486 
CHAPTER IX. 
Diseases of the Maxillary Sinus 558 XII 
CONTENTS. 
CHAPTER X. 
Diseases, Tumors, and Malformations of the Tongue .... 599 
CHAPTER XI. 
Nasal Deformities and Diseases in Relation to the Manillas . 616 
CHAPTER XII. 
Malformations, Diseases, and Injuries of the Lips 646 
CHAPTER XIII. 
Harelip, Cleft Palate, and Defects of Speech 650 
CHAPTER XIV. 
The Treatment of Wounds under War Conditions 750 
Selected List of Examination Papers 770 
Index 781 SURGERY OF ORAL DISEASES AND 
MALFORMATIONS. 
CHAPTER I. 
ANESTHESIA-HEMORRHAGE-SHOCK. 
ANESTHESIA. 
The administration of anesthetics for oral operations presents 
all the dangers incident to general anesthesia for operations in 
other regions, as well as additional factors which render safe con- 
tinuous insensibility to pain more than ordinarily difficult to secure. 
As these are of primal clinical importance in oral surgical opera- 
tions, it seems best to limit the consideration of the general subject 
of anesthesia to its essentially practical aspects, without attempt- 
ing to include details which may be found in monographs and 
text-books such as De Ford's work on Anesthetics.1 
The term anesthesia literally denotes loss of sensation of touch, 
but its usual application is accepted as meaning the state of pro- 
found unconsciousness induced by anesthetics. 
Insensibility to pain may be produced with or without simul- 
taneous loss of common sensation, but as usually applied in surgery 
analgesia means loss of - ability to feel pain without complete 
unconsciousness. 
Anesthesia may be local or general. The pnncipuZ anesthetic 
agents are: 
Solutions injected into the tissues to produce local anesthesia. 
Freezing. 
Nitrous oxide gas. 
Nitrous oxide gas and oxygen. 
Nitrous oxide gas, oxygen, ether sequence. 
Somnoform. 
Ethyl chloride. 
Chloroform. 
1 Lectures on Anesthetics in Dentistry. 18 
ANESTHESIA-HEMORRHAGE-SHOCK 
A. C. E. (alcohol, chloroform, and ether) mixture. 
Ether. 
Scopolamin, morphin, ether. 
Rectal anesthesia. 
Spinal anesthesia. 
Intravenous anesthesia by ether and chloroform. 
Local Anesthetics.-Local anesthetics, consisting of various 
combinations of cocain, eucain, and other drugs, have been quite 
generally used in minor operations for many years, particularly 
by dentists in the extraction of teeth. Sloughing and necrosis, 
which sometimes involve the bone structures extensively, have 
been frequent results of this practice. In at least one case within 
the author's knowledge paralysis and serious cerebral symptoms 
followed the use of cocain and adrenalin injected with a high- 
pressure syringe for the extraction of an impacted third molar. 
Failure to observe proper surgical cleanliness, which may cause 
bacterial or other matter to be forced from the oral cavity into the 
circulation, and drugs which may act as emboli, have caused much 
of this trouble. With careful technic and discriminate use of drugs, 
local anesthesia has an important place in oral as well as of her opera- 
tions. It is valuable not only when entirely depended upon to 
abolish painful sensation, but also as an adjunct to general anes- 
thesia for nerve blocking to prevent shock and to reduce the amount 
of the general anesthetic required. 
Cocain.-Cocain, an alkaloid extracted from coca leaves, is 
widely and successfully used by application to mucous membrane 
surfaces, particularly for operations on the eyes and nose. It also 
forms the basis of many of the extensively advertised proprietary 
local anesthetics. 
The difficulty of obtaining a supply of novocain under war con- 
ditions has recently caused more or less experimentation in the 
clinical application of cocain by injection, and better results are 
reported with the more improved modern technic than was formerly 
obtained by old methods. Various combinations of cocain with 
adrenalin have given good results without appreciable toxic effect. 
Nevertheless its high degree of toxicity cannot be denied. Almost 
unlimited clinical evidence points to the danger of individual 
susceptibility which sometimes renders almost infinitesimal doses 
very dangerous. Even the combination of cocain with adrenalin 
or suprarenin does not always give entire freedom from toxic effects. 
The possibility of the beginning of the much-to-be-dreaded cocain 
habit is also a serious objection to its use. ANESTHESIA 
19 
Eucain.-Eucain is much safer than cocain, and possesses nearly 
as well-marked anesthetic properties. 
Stovain and Novocain (0.5 per cent, solution).-Mainoli1 strongly 
urges a wider use of this mode of anesthesia in major as well as 
minor operations. He has had no local difficulties, e. g., skin slough- 
ing, but he seldom uses a stronger solution than 1 per cent, given 
in a 10 c.c. syringe. It is well to remember, if the syringe is ster- 
ilized in an alkaline solution, that stovain becomes chemically 
altered and is physiologically inert. Lately he has discarded 
adrenalin, as he claims it gives no real advantage. Novocain, he 
holds, lessens the smarting which stovain sometimes causes. 
Apothesin.-Apothesin is a synthetic anesthetic now being 
brought forward as a substitute for novocain. It is claimed to be 
fully as potent as, and also less toxic than the various similar sub- 
stances, such as stovain, cocain, novocain, and eucain. Allen2 
states it is readily soluble in alcohol and very soluble in water. 
He reports in detail upon a large number of injections made upon 
himself for experimental purposes and also has had successful 
clinical experience. It is supplied in 1 |-grain tablets, which dissolved 
in 60 minims of water makes a 1 per cent, solution. It is claimed 
to be suitable for use in any surgical procedure which requires the 
use of a local anesthetic. The solution generally employed is 5 
per cent, to 3 per cent. Reports from 900 to 1000 operations by 
many operators, and for a large variety of operations, seem to indi- 
cate its safety and efficiency, both of which time will be required 
to fully determine. 
Quinine-urea Hydrochloride.-The advantages claimed for quinine- 
urea hydrochloride as a local anesthetic are: (1) Any operation 
ordinarily done under cocain can be done with quinine-urea. (2) 
The duration of anesthesia with 0.5 to 1 per cent, solutions is 
longer than when cocain is used. (3) Solutions of this strength 
(1 per cent.) cause some induration. (4) Union may be a little 
delayed by a fibrinous exudate when the stronger solutions (1 per 
cent, or over) are used. (5) In operations about the anus and in 
tonsillectomies it is the anesthetic of choice, as it has a hemostatic 
effect and the pain of dressings is avoided. 
Its advantages over cocain are: (1) Its absolute safety. (2) 
The duration of anesthesia. (3) Its hemostatic effect. 
H. F. Graham tried this combination in 17 cases. A 1 per cent. 
1 British Med. Jout., November 19, 1910, quoted from Riforma Medica. 
2 New Orleans Med. and Surg. Jour., March, 1917. 20 
ANESTHESIA-HEMORRHAGE-SHOCK 
solution was generally used (made from the 2-grain tablets of 
P., D. & Co.), and the solution boiled before use. As a result of 
his experience, he believes it is a perfectly safe local anesthetic, 
causing only slight local irritation. It does not cause tissue destruc- 
tion, and if it interferes with healing at all, does so only to a slight 
degree. 
Partial Scopolamin Anesthesia for Aged.-A method of anesthesia 
for the aged, advocated by J. H. Gleason,1 is as follows: Some six 
years ago he conceived the idea of combining partial scopolamin 
anesthesia with local anesthesia, using 0.1 per cent, of cocain. 
The scopolamin was added to control the nervousness and excite- 
ment usually complicating operations under local measures. This 
technic proved so successful that about a year later, opportunity 
having presented itself, he began to use partial scopolamin anes- 
thesia combined with local sterile water infiltration in the aged. 
Infiltration Anesthesia.-Schleich's formula for infiltration anes- 
thesia : 
Cocain hydrochlorate 0.2 
Morphin hydrochlorate 0.025 
Sodium chloride 0.2 
Water to make 100.0 
Sterilize and then add two drops of 5 per cent, solution of car- 
bolic acid. 
Infiltration and Conductive Anesthesia (Nerve-blocking).-Novo- 
cain is a synthetic preparation entirely different in its chemical 
nature from cocain. Its record of thousands of injections in persons 
of all ages, under many different conditions, with almost no serious 
results at present entitles it to first rank among the agents for 
inducing both infiltration and conductive anesthesia. 
According to Le Borcq, "If the toxicity of cocain be represented 
as 1, then 
"The toxicity of alypin will represent 1.25. 
"The toxicity of nirvanin will represent 0.814. 
"The toxicity of stovain will represent 0.625. 
"The toxicity of tropacocain will represent 0.500. 
"The toxicity of novocain will represent 0.490. 
"The toxicity of beta-eucain lactate will represent 0.414." 
Braun recommends the use of solutions for this purpose varying 
from 0.25 per cent, to 2 per cent, novocain, but from 1 per cent, 
to 1.6 per cent, solution is recommended by Fischer, Seidel, Blum 
and Thoma, and approximately these percentages are generally 
used for dental and oral operations. 
1 New York Med. Jour., June 30, 1910. ANESTHESIA 
21 
Fischer advocates a novocain solution of the following 
composition: 
Novocain lor 1.5 or 2.0 
Sodium chloride 0.5 
Calcium chloride 0.04 
Potassium chloride 0.02 
Sterile aqua destillata 100.0 
Synthetic suprarenin (1 to 100) 0.002 
Fig. 1.-Fischer injection syringe. 22 
ANESTHESIA-HEMORRHAGE-SHOCK 
The equipment for this purpose consists of a syringe, as shown 
in Fig. 1 with both long and short needles, and trochar needles, as 
shown in Figs. 2 and 3; a glass jar for preserving the syringes in 
the sterile alcohol solution; a small porcelain dissolving cup, and a 
stock flask for the Ringer solution (Fig. 4); platinum and iridium 
needles are desirable because of the danger of breaking which steel 
Fig. 2.-Syringe for trocar. 
points offer. Distilled water is preferable to undistilled boiled 
water because of its greater purity. A convenient apparatus for 
the distillation of water makes a desirable addition to this armamen- 
tarium. The best way to make a syringe sterile is to boil it. 
Technic of Infiltration Anesthesia.-The technic of Thoma, of 
Harvard, includes scrupulous cleansing preparation of the mucous 
membrane surface, touching the point of entrance with the solution ANESTHESIA 
23 
of iodin and aconite. Then with the syringe held like a writing 
pen the needle is pushed-opening directed toward the bone- 
down to the periosteum, and thence upward, just a little higher 
than the apex of the root. The injection must be made slowly 
and evenly, and, if correct, very little force is needed. In this 
manner, deposit of 1 to 1.5 c.c. of a 1.6 per cent, solution just over 
Fig. 3.-Trocar needles with telescoping attachments. (Fischer.) 
the apex of the root, between mucous membrane and bone. The 
tissue should not turn white and the velum is hardly noticed, 
because the deposit of the solution is higher than the mucous fold 
of the cheek. At the palatal side, insert the needle nearer the 
gingival margin, push it down parallel with the root and inject 
0.25 c.c. of the solution. The anesthesia lakes place in from five 24 
ANESTHESIA-HEMORRHAGE-SHOCK 
to eight minutes. Massage of the part will help quicken the process. 
The anesthesia lasts for one hour, and any dental or surgical opera- 
tion can be performed on this tooth. 
Braun states that descriptions of the method of anesthetizing 
the inferior alveolar and lingual nerves at the lingula were given 
by Halsted and Raymond (1885). Efforts were then made by 
Fig. 4.-Hermetically sealed glass jar for preserving syringes, dissolving cup, 
and pliers in alcohol-glycerin solution. (Fischer.) 
dentists to block the inferior alveolar nerve at the lingula (Thiesing, 
Krichelsdorf, Dill and Huebner) by means of cocain-suprarenin 
solution, and this method has now become one of the common 
procedures of the dentist. The technic of the operation, according 
to Braun's method is as follows: 
In order to anesthetize both nerve trunks, proceed in this manner: 
With the patient in a sitting posture and the mouth wide open, the ANESTHESIA 
25 
operator introduces the index finger of the left hand and locates the 
anterior border of the coronoid process, and the "trigonum retro- 
Fig. 5.-Illustraton of the direction of the syringe in injection on the labial side 
for roots of the anterior teeth. 
molare" (retromolar triangle). The needle is directed from the oppo- 
site canine tooth toward the retromolar triangle and held parallel 
Fig. 6.-Illustration of the direction of the syringe for injection of the lingual aspects 
of the roots of the anterior teeth. 
to the biting surface of the lower teeth. The needle is inserted at 
the above-mentioned point 1 cm. above and laterally to the biting 26 
ANESTHESIA-HEMORRHAGE-SHOCK 
surface of the last molar tooth into the "trigonum retromolare." 
Immediately under the thin mucous membrane the bone should 
Fig. 7.--Illustration showing the direction of the syringe for injection on the 
palatal side for bicuspid and molar roots. 
be felt. If this is not the case, the point of the needle is too far 
mesially, a mistake frequently made by beginners. The needle 
is now directed gradually toward the median line until the internal 
Fig. 8.-Injection at the infra-orbital foramen. 
oblique line is felt. The needle finally passes along the inner surface 
of the lower jaw into the deeper parts. It must now be further ANESTHESIA 
27 
inserted to a depth of 2 to 2.5 cm., keeping it always in contact 
with the bone. On the whole path described by the needle point, 
Fig. 9.-Injection at the mental foramen for anesthesia of the anterior teeth 
beginning immediately under the mucous membrane, where the 
lingual nerve lies, 5 c.c. of a 1 to 2 per cent, novocain-suprarenin 
Fig. 10.-Direction of syringe for injection at the mandibular foramen. 
solution should be injected. The methods of injection are illus 
trated in Figs. 5 to 10. 28 
ANESTHESIA-HEMORRHAGE-SHOCK 
fischer's tables for injecting local anesthesia. 
TECHNIC OF INJECTION EMPLOYED. 
(b) 
(a) In cases complicated by periostitis. 
Teeth. 
I. Upper. 
Simple cases. parulis, abscesses, etc. 
1. Central 
Needle inserted at mid- Needle inserted at middle of 
incisors. 
die of root of lateral, and roots of canine of same, and central 
directed to root apex of of opposite side, whose root apices 
central. are infiltrated with solution palat- 
ally, injections at lateral of same, 
and central of opposite side. Or 
conductive anesthesia at infra- 
orbital foramen, and mucous anes- 
thesia at central of opposite side, 
palatally. 
2. Lateral 
Needle inserted at mid- Needle inserted back of root 
incisors. 
die of root of canine and apex of canine, where solution is 
directed to root apex of deposited; same procedure at root 
lateral. Palatally, injec- apex of central. Palatally, injec- 
tion at lateral. tion at lateral, or at central and 
canine. 
3. Canines. 
Needle inserted at root Conductive anesthesia at infra- 
apex of canine, where solu- orbital foramen. Palatally, injec- 
tion is deposited. Palat- tion at canine, or first bicuspid 
ally, injection at canine. and lateral. 
4. First 
Needle inserted at mid- Injection at maxillary tuberos- 
bicuspids. 
dle of root of canine, and ity. 
directed to root apex of 
first bicuspid. Or injection 
at maxillary tuberosity. 
5. Second 
Needle inserted at mid- Injection at maxillary tuber- 
bicuspids. 
6. First 
molars. 
die of root of first bicuspid osity. 
and directed to root of sec- 
ond bicuspid. Or injection 
at maxillary tuberosity. 
7. Second 
molars. 
8. Third, 
molars 
II. Lower. 
Injection at maxillary 
tuberosity. 
9. Central 
Needle inserted at root Needle inserted in reflection of 
incisors. 
of lateral and directed to mucous membrane below canine 
root apex of central. Lin- and directed to mental fossa, wdiere 
gually, injection at central. solution is deposited. 
10. Lateral. 
Needle inserted at mid- Needle inserted in reflection of 
incisors. 
die of root of canine, and mucous membrane below canine, 
directed to lateral. Lin- and directed to mental fossa, where 
gually injection at lateral. solution is deposited. 
11. Canines. 
Needle inserted in reflec- Needle inserted in reflection of 
tion of mucous membrane mucous membrane below canine, 
below canine, and directed and directed to mental fossa, where 
to mental fossa, where solu- solution is deposited. Mandibular 
tion is deposited. Lin- anesthesia. 
gually injection at canine 
• first bicuspid, or mandibu- 
lar anesthesia. 
12. First and Mandibular anesthesia, 
second 
bicuspids 
and first 
and second 
molars. ANESTHESIA 
29 
Stern recommends an injection of the sphenomaxillary, for which 
purpose he uses a modification of the Fischer syringe with bayonet 
attachment and needle (see Figs. 11 and 12) and claims thereby 
a more complete anesthetization, which includes with greater 
certainty the pulps of the bicuspid teeth. 
Fig. 11.-Stern's modification 
of the Fischer syringe with 
bayonet attachment for spheno- 
palatine injection. 
Fig. 12.-Illustration of Stern's method of 
sphenopalatine injection. 
Danger.-The actual danger, with careful technic, is practically 
nil, but cases have been reported in which unduly prolonged, 
apparently hypnotic slumber, evidences of slight toxic action, and 
distress due to injection of the agent into the muscles instead of 
close to the bone, and occasionally local disturbances due to hemor- 
rhages have been observed. 
The forcing of infection from septic foci at the apices of, or 
otherwise in connection with the roots of the teeth is always a serious 
menace when such conditions exist. Stern1 calls attention to this 
danger, and Fischer has also given the matter much consideration 
as shown by the foregoing partial representation of his chart, 
indicating the difference in the technic of injection employed in 
simple and diseased cases. Doubtless many results attributed to 
the anesthetic agent have really been due to injudicious extension 
through faulty technic. 
General Anesthetics.-For general anesthesia the oral surgical 
operator is practically limited to nitrous oxide and oxygen, som- 
1 Dental Cosmos, January, 1916. 30 
ANESTHESIA-HEMORRHAGE-SHOCK 
noform, ether, and the nitrous-oxide-oxygen-ether, or the scopol- 
amin, or hyocin-morphin-ether sequence, as nitrous oxide without 
oxygen is not capable of sufficiently extended use, and the safe 
employment of ethyl chloride is too limited. 
Rectal anesthesia is objectionable because of the likelihood of 
irritation and intestinal disturbance following its long continuance. 
Spinal anesthesia is not applicable. 
Intravenous anesthesia by ether and chloroform has been recom- 
mended by L. Burkhardt,1 who uses a 5 per cent, solution of ether 
in sterile salt solution. This method is too little known and pre- 
sents too many dangerous possibilities to warrant immediate 
recognition. 
Chloroform.-Notwithstanding the fact that chloroform has long 
been held to be the most satisfactory anesthetic for mouth opera- 
tions, the author, after having used it for a number of years, unhesi- 
tatingly states that, except in the extremely rare cases where other 
anesthetics are contra-indicated, it should never be used even with 
infants and children. By careful administration, satisfactory 
results may be obtained by the use of ether, with less immediate 
and postoperative danger than follows chloroform. One patient, a 
young woman, aged about twenty-two years, was lost five days 
after operation, after sufficient recovery to have enabled her to 
return home if desirable, as a result of acetonuria and fatty degenera- 
tion of the liver, evidenced by almost continuous vomiting, which 
ended in black vomit, delirium, coma, and death, and other similar 
cases have since been reported by Bevan, Guthrie, Favill, and others. 
These have convinced the author that there is no warrantable 
excuse for the continued general use of an agent attended by the 
immediate mortality due to chloroform, and the comparatively 
high though seldom recorded postoperative death-rate that is 
doubtless even greater than is commonly believed. 
Some exception must be made when chloroform is used with 
an apparatus attached to an oxygen cylinder, so that pure oxygen 
may be forced in with the anesthetic. In this way the quantity 
of chloroform required to produce insensibility to pain is greatly 
reduced and the direct effect of the oxygen undoubtedly combats 
the dangerous elements of the drug. Unless there are contra- 
indications of unusual character, the author, however, prefers the 
use of ether, as described on page 34. 
Nitrous Oxide Gas and Oxygen.-Nitrous oxide gas undoubtedly 
is the safest of all general anesthetics. Although extensively used 
1 Munchen. med. Wchnschr., November 16, 1909. ANESTHESIA 
31 
for a long time, it is only recently that a full appreciation of its 
usefulness has developed, because, notwithstanding its simplicity, 
this agent requires great skill in administration to obtain the best 
result. Its mortality record during the years of its general use is 
much better than that of any other general anesthetic, and some 
of the deaths attributed to nitrous oxide anesthesia are undoubtedly 
due to other causes. Any operator can administer gas to the point 
of complete insensibility with the usual appearance of temporary 
asphyxiation and in short minor operations by rapid work accom- 
plish fairly good results.. But its safe administration in combination 
with oxygen, continued for an hour or longer, with the patient in a 
state of complete muscular relaxation or of analgesia, more or less 
conscious of what is being done but without painful sensation, 
requires skill, which must be supplemented by natural talent and 
adaptability upon the part of the administrator, and even then this 
skill can only be acquired by long experience, in sufficient degree 
to insure successful accomplishment. Such a result, however, is 
well worth painstaking effort to secure, because freedom from 
nausea and other unpleasant symptoms at the time of operation, 
and quick recovery, are, in many cases and under a large variety 
of pathological conditions, of priceless value. 
That the prolonged administration of nitrous oxide gas is not 
unattended by danger is shown by the following table of deaths:1 
Case 1.-Teter: "Shock and Primary Cardiac Failure," Jour. 
Am. Med. Assn., August 7, 1909, p. 448. 
Case 2.-Crile: "Myocarditis Six Hours after Operation," 
Southern Med. Jour., January, 1910, p. 29. 
Case 3.-Lydston: "Anesthetic," Med. Record, November 12, 
1910, p. 866. * 
Case 4.-Allen: "Uremia," Boston Med. and Surg. Jour., 
October 19, 1911, p. 589. 
Case 5.-Allen: "No Details," Jour. Am. Med. Assn., February 
10, 1912, p. 396. 
Case 6.-Allen: "No Details" (ibid.). 
Case 7.-Gatch: "Hyperthyroidism," Jour. Am. Med. Assn., 
November 11, 1911, p. 1593. 
Case 8.-Gatch: "Pericardial Effusion" (ibid.). 
Case 9.-Gatch: "Lymphatic Diathesis" (ibid.). 
Case 10.-Olow: "Diseased Heart and Arteries," Beitrdge 
kiln. Chir., December, 1911. 
1 Miller, Alfred H.: Dental Cosmos, June, 1915. 32 
ANESTHESIA-HEMORRHAGE-SHOCK 
Case 11.-Boys: "Anesthetic," Surg., Gynec. and Obst., April, 
1912, p. 388. 
Case 12.-Miller: "Suffocation from Inspired Vomitus," Jour. 
Am. Med. Assn., November 23, 1912, p. 1847. 
Case 13.-Flagg: "Anesthetic," New York Jour. Med., 
November, 1912. 
Case 14.-Teter: "Impure Gas," Jour. Am. Med. Assn., 
November 23, 1912, p. 1849. 
Case 15.-Teter: "Impure Gas" (ibid.). 
Case 16.-Salzer: "Anesthetic," Jour. Am. Med. Assn., 
November 23, 1912, p. 1872. 
Case 17.-Collins: "Impure Gas," Jour. Am. Med. Assn., 
November 23, 1912, p. 1862. 
Case 18.-Buchanan: "Anesthetic," Jour. Am. Med. Assn., 
November 23, 1912, p. 1860. 
"A. H. Miller1 has collected references to 18 deaths. Teter 
knows of 26 fatalities. Rovsing was able to get track of 13 deaths, 
several of which had been suppressed. Gwathmey knows of 20 to 
40 unreported deaths." 
Practically all anesthetists state most positively that death occurs 
only from asphyxia, and if the anesthetist watches the color and 
pushes the oxygen, death cannot occur. In none of the cases 
detailed was death the result in any way whatever of asphyxia, 
but in all occurred without warning. 
In Columbus, O., there have been 12 or 13 deaths when given for 
1200 to 1300 major operations. 
Nitrous Oxide-oxygen-ether Sequence.-The administration of 
nitrous oxide gas, preliminary to ether anesthesia, is at present 
quite generally employed in hospitals throughout the United 
States. Many ingenious devices, such as the inhalers of Teter, of 
Cleveland; Dr. Willis M. Gatch, of Baltimore; A. E. Clark, of 
Chicago; the S. S. White Co., of Philadelphia, and others have 
been designed to regulate the respective quantities of nitrous 
oxide, oxygen, and air employed, and the addition of chloroform 
or ether in such manner as to produce safe and gradual transition 
to the agent (whether chloroform or ether) that is to be depended 
upon for continued general anesthesia during the operation. Thus 
one of the principal objections to the use of nitrous oxide as a first 
step to ether is avoided, viz., that during the preliminary stage, 
patients quite frequently recovered sufficiently to overcome the 
intended benefit of the quick induction through the nitrous oxide 
1 Baldwin: Practical Medicine Series, ii, 25, and Medical Record, July 29, 1916. ANESTHESIA 
33 
of the anesthetic state. The apparatus which also permits reinha- 
lation it is claimed gives much benefit. 
Somnoform.-Somnoform is safer than ethyl chloride or ethyl bro- 
mide, which with methyl chloride are its component parts. Of all 
the general anesthetics, it is undoubtedly the easiest to administer 
and most rapid in action. According to De Ford, " the time required 
being from fifteen to thirty seconds, with a period of available 
anesthesia from sixty to three hundred seconds." (The death-rate 
of ethyl chloride is estimated to be 1 in about 5000 administrations.) 
Its chief recommendation for safety, however, lies in this, that 
it has been generally and carelessly administered, yet with almost 
perfect success, in clinical exhibitions and otherwise, by absolutely 
untrained people, to individuals who have had no sort of prepara- 
tion or preliminary physical examination. Had it not been a more 
than ordinarily safe agent, the death-rate would long ago have 
become a serious matter. For very brief operations its value is 
undoubted. The limited knowledge of its effect in continued use or 
repeated administration, however, seems to limit it to operations 
that can be quickly performed or to administration as a prelimi- 
nary to ether anesthesia. For children under an age when nitrous 
oxide can be readily and satisfactorily given, and when the terror 
incited by ether administration is a serious danger in unduly 
exciting brain cells which may involve the vital centers, its use is 
undoubtedly advisable. Except in these cases the combination of 
nitrous oxide and oxygen, which can with reasonable safety be 
continued for an almost indefinite period, seems to be much more 
satisfactory. 
The Desirable Conditions for Anesthesia for Mouth Operations. 
--With the mouth wide open and the operative field occupied 
by the hands of the operator, comparatively little opportunity is 
given to prevent the inhalation of air. Thus it is advisable to 
give the agent in concentrated form through such airways as are 
available and wfith the apparatus out of the way of the operator. 
For this purpose a rubber tube or tubes may be passed through 
one or both of the nares back into the pharynx, or the agent may 
be given by the mouth through a tube, hollow mouth gag, or other 
similar device. In this way at least some anesthetic may be con- 
tinuously administered while the operation is in progress. Blowing 
chloroform or even ether in this manner, as with the Yunker and 
similar apparatus, so that condensation may force the anesthetic 
into the pharynx and thus lead to its being swallowed or inhaled 
in crude form, may greatly increase its irritating properties and 34 
ANESTHESIA-HEMORRHAGE-SHOCK 
even endanger the life of the patient. To avoid this, the author 
recommends the use of heated anesthetics, given by the Gwathmey 
(Figs. 13 and 14) or some similar apparatus. By this method ether 
Fig. 13.-Gwathmey's vapor inhaler: a, a, bottles arranged for chloroform or ether, 
and hot-water bottle through which these agents are blown before passing into the 
administration tube. The proportions of air and anesthetic agent are regulated by 
turning the key at the top of the apparatus; b, hollow inhaler, with holes at the side 
to allow the vapor to pass under the mask covered with gauze; c, tube through which 
the vaporized anesthetic agent is blown into the mouth or nose. These are attached 
to the apparatus by rubber tubing and air is blown in by the use of rubber bulbs or 
foot bellows. 
Fig. 14.-Rubber face mask placed over the inhaler to prevent the escape of the 
vapor during preliminary administration. 
which has become vaporized by heat is blown through the tube 
in such manner that there will be a definite proportion of air with it. 
The increased efficiency of heated, vaporized ether makes a suffi- ANESTHESIA 
35 
ciently steady anesthesia possible with a much smaller proportion 
of ether. Thus the danger is reduced and the likelihood of post- 
operative vomiting minimized. The latter almost invariably means 
infection in mouth operations and in cleft-palate cases, particularly 
after staphylorrhaphy, for the strain thus affecting the freshly 
united soft-palate tissue predisposes to failure, and must be avoided 
if possible. Too profound anesthesia, with all reflexes abolished, 
should be guarded against when profuse hemorrhage is likely, even 
though it may only be momentary, as blood is apt to be inspired 
in spite of. every precaution, except when the pharynx is packed, 
and this is inadmissible for many operations. With care and skilful 
administration, the patient can be kept completely insensible to 
pain and sufficiently quiet for the steady progress of the operation, 
and yet not so deeply under the anesthetic as to abolish reflex 
action entirely, which, even though limited, is a very important 
safeguard. The ideal condition for anesthesia in this region is 
administration lasting the shortest possible time consistent with the 
rapid, thorough performance of the procedure. This implies skilful 
operation, with safe, continued, steadily maintained insensibility 
to pain, without loss of muscular and nervous activity sufficient to 
cause inspiration of blood, and prevent prompt recovery, with 
freedom from postoperative nausea and other ill effects. 
A hypodermic injection of | gr. of morphin and yyt Sr- °f atropin, 
one-half hour before operation, reduces the time taken for induction 
of anesthesia, and therefore lessens the amount of the anesthetic 
required, thus diminishing the danger of the early stages of anes- 
thesia and, in a considerable measure, also the tendency to shock. 
The atropin diminishes secretion and thus lends important aid to 
both anesthetic and operative conditions in the buccal and pharyn- 
geal cavities. One-eighth to one-quarter grain of morphin injected 
after the operation serves to bring about a more quiet, restful 
recovery, with valuable abatement of the unpleasant symptoms 
following prolonged anesthesia. 
The essence of orange administered with the ether at the beginning 
of the anesthesia is sometimes beneficial when the patients particu- 
larly dread the smell of ether. 
Scopolamin-morphin or hyoscin-morphin administered hypo- 
dermically to bring about sleep, though insufficient for the per- 
formance of a major operation without the administration of an 
additional anesthetic, reduces the required amount of ether or 
other similar agent to the minimum. It has been frequently recom- 
mended by many writers, and is useful where more than ordinary 36 
ANESTHESIA-HEMORRHAGE-SHOCK 
apprehension of danger from ether exists. Its injudicious use 
has in some instances caused death through retardation of the 
action of the heart beyond the point of control; and until such 
time as experience shall have defined the limitations of this com- 
bination of drugs, prudence would indicate that its employment 
be regarded as merely substituting one form of danger for another. 
H. C. Wood1 reports 1988 cases and 23 deaths, 9 of which he believes 
should justifiably be attributed to the anesthetic, leaving the 
record of 1 death in 221 anesthesias. He states: "In view of 
the fact that this combination for the production of anesthesia 
is scientifically irrational, and has yielded a mortality of 4 per 
1000, and in 69 per cent, of the cases the anesthesia has been 
unsatisfactory, ... it must be either a very bold or very 
careless surgeon who will persist in its use." 
Collins, who has had an experience of 1120 cases in which scopol- 
amin-morphin was given preliminary to general anesthesia, gives 
the following description of its use. 
"Tablets are obtained containing a combination of scopolamin 
Tyo gr., and morphin | gr., and the solution is made just before 
it is administered hypodermically, which is done one and one-half 
hours before operation. Relatives or friends are not allowed to 
see the patient after the hypodermic has been given." 
The patient is not to be talked to and aroused. All necessary 
manipulations and handling of the patient are completed before 
the hypodermic is administered. The room is darkened and every- 
thing kept quiet, and he falls into a tranquil slumber. About 
twenty minutes before operation a layer of damp cotton is placed 
over the eyes and the patient is taken to the operating room and 
placed on the table. The preliminary cleansing of the skin is gently 
done while the general anesthetic is being administered. The prep- 
aration and anesthetization are usually completed about the same 
time, and the operation proceeds. 
"The preliminary injection is given to all patients from eight 
years up. If an elderly patient is strong enough to undergo an 
operation, he is strong enough to have the beneficial effects of 
the combination, and it has not been withheld on account of age. 
Children are more apt to be nervous and apprehensive than adults; 
therefore the preliminary is given to all children of eight years and 
older. 
" About thirty minutes after the hypodermic the patient becomes 
1 Jour. Am. Med. Assn., December, 1906. ANESTHESIA 
37 
drowsy, and all apprehension and fear regarding the operation are 
gone. The transition from a partial sleep to complete anesthesia 
is not sudden, as from complete wakefulness, and is easily accom- 
plished. After the operation he usually sleeps from three to five 
hours, and may partially awake and go to sleep again several 
times before becoming completely awake. The sleep saves him 
from the smarting pain of the recently incised tissues. There is 
much less postoperative vomiting, most patients having practi- 
cally none. The secretion of mucus is markedly checked and in 
most cases is completely stopped. This prevents aspiration."1 
Endotracheal Anesthesia.-Endotracheal as administered with the 
Janeway apparatus gives perfect relaxation with less anesthesia 
than with inhalation, and its convenience for operations when sur- 
geon and anesthetist occupy the same field is also emphasized. 
The method is apparently passing the trial stage, but until it is 
more generally adopted, there seems no good reason why it should 
supplant other well-established and satisfactory methods of anes- 
thetic administration except in selected cases.2 
Oil-ether Colonic Anesthesia.-J. T. Gwathmey3 claims the fol- 
lowing advantages for this methods of anesthesia. 
(1) The apprenhension and fear caused by a mask is avoided; 
(2) no expensive apparatus required; (3) after-effects reduced to a 
minimum; (4) a more complete relaxation than with any other 
method; (5) limits of safety are widely extended compared with 
other methods; and (6) a more even plane of anesthesia is auto- 
matically maintained than possible by any inhalation method- 
unless administered by a skilled anesthetist using a perfected 
apparatus. 
The bowels should be cleared by castor oil and by irrigation. 
One hour before operation a mixture of 2 to 4 drams of ether in 
which is dissolved 5 to 10 grains of chloretone and 2 to 4 drams 
of olive oil, is injected into the rectum, or a suppository containing 
5 to 10 grains of the chloretone is inserted. Half an hour before 
the operation a hypodermic injection is given of | to | grain of 
morphin sulphate and T(j7j- grain of atropin sulphate. About 
fifteen minutes before the operation the patient should be laid on 
the left side in a modified Sims position and a mixture of 25 parts 
olive oil and 75 parts ether passed into the rectum gradually, 
1 Jour. Amer. Med. Assn., March 26, 1910. 
2 Vedin, A.: New York Med. Jour., July 29, 1916. Ochsner: Practical Medi- 
cine, Series 11, 1917. 
3 Lancet, December 20, 1913. 38 
ANESTHESIA-HEMORRHAGE-SHOCK 
through the small tube to which the funnel and clamp have been 
fitted. One minute should be allowed for the introduction of each 
ounce of the mixture. For children a mixture containing 50 to 65 
per cent, of ether is sufficiently strong. One ounce of the mixture is 
required for each 20 pounds weight. 
Good care should be taken to keep respiratory conditions free. 
At the conclusion of the operation the clamp on the rectal tube 
is released, and the end lowered so the residual mixture is syphoned 
off. The Lockwood tube is inserted about 6 inches alongside the 
rectal tube. About a gallon of cold soapy water is then introduced 
through the funnel,, being syphoned off by the Lockwood tube. 
Toward the end of this process the colon is massaged gently from 
right to left, thus expelling any liquid which may be left. The 
Lock wood tube is then removed; from 1 to 2 pints of cold water 
(tap water) is introduced through the rectal tube and the tube 
withdrawn. 
W. M. Johnson,1 with an experience of 50 cases with no untoward 
effects, recommends the following prescription: 
Paraldehyde 5ij-iij 
Olive oil gij 
* Ether giij-v 
He gives castor oil at 2 p.m. the day preceding, and the same night 
(after oil has acted) colon irrigation. In the morning one or two 
colon irrigations are given until the water returns clear. Two 
hours before operation 5 to 15 grains of chloretone per os. 
A. D. Bevan2 reports results of his study of anesthesia which 
would cover fully the entire surgical field to determine which would 
be the safest, most efficient, most satisfactory, to both patient and 
surgeon, simplest and least complicated. He desired also to find 
anesthetics which could be adopted and employed by medical men 
generally. From this stand-point the following have been analyzed: 
Chloroform by open drop method; ether by open drop method; 
nitrous oxide gas; scopolamin and morphin; spinal anesthesia; block- 
ing; infiltration; intravenous, general and local; intrarectal; intra- 
tracheal; intrapharyngeal; mixtures; sequences; anoci-association. 
In each instance these agents and methods have been analyzed 
from the stand-point of: 
Safety; comfort; efficiency; control; simplicity and general 
adaptability; after-effects on blood and tissues and viscera; com- 
1 Practical Medicine, Series 11, 1917. Ochsner (editor): from Vermont Medical 
Monthly, Aug., 1916. 
2 Jour. Am. Med. Assn., October 23, 1915. ANESTHESIA 
39 
plications, vomiting, etc., paresis of bladder and bowels; effects 
on immunity to pus organisms, pneumococcus, etc. 
The final results of his analysis are as follows: 
1. Drop ether should be today chosen as the standard general 
anesthetic when a prolonged anesthesia is desired with relaxation 
and unconsciousness. 
2. Gas should be chosen in short anesthesias in which uncon- 
sciousness is desired, and in special cases, e. g., kidney insufficiency. 
3. Intrapharyngeal ether should be chosen in mouth and jaw 
cases when it is desirable to remove the anesthetist and the apparatus 
out of the operative field. 
4. Local infiltration anesthesia should be chosen when the sur- 
geon has the full cooperation of the patient and when the field 
can be completely infiltrated and anesthetized by a safe amount 
of novocain and epinephrin. 
These simple and safe methods can be made to cover all surgical 
cases. This places anesthesia on a very unpretentious, simple 
basis, but here as in most fields of surgery we finally learn that 
simplicity is near to truth. 
After performing operations upon dogs that had been given 
preliminary injections of chloretone at the Parke, Davis & Co. 
laboratories, and observing the growing tendency to recognize the 
value of morphin, scopolamin, and morphin, and similar prepara- 
tory drugs, the author believes that future advances will un- 
doubtedly be in the direction of greater use of these and similar 
preparations. 
In this connection Dr. George V. Crile, of Cleveland, gives the 
following description of anoci-association, a word he has coined: 
"The difference between anesthesia and anoci-association is 
that, although inhalation anesthesia confers the beneficent loss 
of consciousness and freedom from pain, it does not prevent the 
nerve impulses from reaching and influencing the brain, and hence 
does not prevent surgical shock nor the train of later nervous 
impairments so well described by Mumford. Anoci-association is 
accomplished by a combination of special management of patients 
(applied psychology), morphin, inhalation anesthesia, and local 
anesthesia. 
"In operations under inhalation anesthesia the nerve impulses 
from the trauma reach every part of the brain-the cerebrum that 
is apparently anesthetized as well as the medulla that is known to 
remain awake-the proof being the physiological exhaustion of and 
the pathological change in the nerve cells. 40 
ANESTHESIA-HEMORRHAGE-SHOCK 
"But if the nerve paths connecting the field of operation and the 
brain be blocked, then there is no discharge of nervous energy 
from the trauma, and consequently no exhaustion, however severe 
or prolonged the operation." 
Many authorities do not hold with Crile in these conclusions. 
Nevertheless, there can be no question as to the result of their 
application when applied to modify the ill effects of anesthetic 
administration. 
HEMORRHAGE. 
Hemorrhage denotes the escape from the bloodvessels of all 
the constitutents of the blood. The recognized forms are: Arterial, 
venous, capillary, mixed, hemorrhage per diapedism, i. e., dia- 
pedesis and extravasation through intact vessels; and hemorrhage 
per rhexin, i. e., by actual rupture of the vessel. 
Etiology.-Hemorrhage may be due to trauma or diseases of 
the bloodvessels, or it may result from neuropathic condition or 
the hemorrhagic diathesis (hemophilia). 
Classification.-The principal forms of hemorrhage are as follows: 
Epistaxis, nosebleed; hemoptysis, hemorrhage of the lungs; hema- 
temesis, hemorrhage from the stomach; gastrorrhagia, hemorrhage 
from the stomach due to lesion; enterorrhagia, hemorrhage from the 
bowels; metrorrhagia, uterine hemorrhage at other than menstrual 
periods; menorrhagia, immoderate hemorrhage at the menses; 
ecchymosis, hemorrhage infiltration beneath the skin or mucous 
membrane; hemorrhagic infarcts, infiltralion of blood involving 
localized portions of a tissue or organ; and hematoma, blood tumor. 
From a surgical point of view, hemorrhages are chiefly divided 
into (1) primary, immediately following division of the vessels; 
(2) reactionary, when the clot first formed is dislodged by force of 
circulation in recovery, imperfect ligatures, or other causes during 
the first few hours after operation or injury; (3) secondary hemor- 
rhage, from sloughing of the vessels or too early absorption of 
ligatures several days after operation. 
Symptoms.-The symptoms of hemorrhage are local and general. 
Local Symptoms.-In the case of the larger arteries the local 
symptoms are recognized by bright red blood appearing in jets; in 
the case of veins the blood flows steadily and is dark, and in the 
case of capillaries it oozes. In ordinary wounds there is a com- 
bination of the three. 
General Symptoms.-These are exceedingly important, because 
the flow of blood may be internal or at least concealed from external HEMORRHAGE 
41 
observation. They are recognized by rapid pulse, which becomes 
shallow and irregular, and finally so slow and faint as to be almost 
imperceptible. The face is pale and the skin moist and clammy, 
with cold perspiration. With continued profuse flow of blood 
unchecked, respiration becomes short and noticeably difficult. 
Roaring in the ears, light flashes before the eyes, fainting, and 
finally syncope ensues, which sometimes brings such a weakened 
action of the heart that hemorrhage ceases sufficiently Io admit 
of recovery. When this does not occur, dyspnea, cessation of the 
action of the heart, and death may result. 
Treatment.-The various methods commonly used in arresting 
hemorrhage are as follows: Ligation, tying of the ligature; forci- 
pressure, grasping the vessel with a forceps; torsion, by twisting 
the vessel with forceps; acupressure, the passing of a needle under 
the vessel, bringing the ends above the tissues upon each side, and 
ligating in the form of a figure 8; tourniquet, passing a cord or 
bandage of sufficient strength around the parts and twisting until 
compression checks the flow of blood; Esmarch bandage, a rubber 
bandage wrapped about the part to make compression for tem- 
porary purposes, as for amputation of an extremity; styptics, 
drugs used to promote contraction of the vessels or coagulation 
of the blood; constitutional treatment, frequently required to bring 
the blood into normal condition, when as a result of disease or 
predisposition its coagulative properties are insufficient and the 
tendency to hemorrhage unusual; direct transfusion of blood, resorted 
to for the double purpose of overcoming the result of excessive 
hemorrhage and introducing into the circulation blood which will 
be more nearly normal for correction of the hemorrhagic tendency; 
by intravenous infusion; proctoclysis, rectal administration and 
hypodermoclysis (directly into the tissues), normal salt and other 
solutions are also introduced into the system to overcome both 
the effect of and tendency to hemorrhage; heat, cold, position, and 
pressure are useful adjuncts in arresting the flow of blood to an 
affected part. 
Certain details of surgical technic belong more properly to 
text-books covering elementary surgical principles, but both 
immediate and secondary hemorrhages may be important features 
in many mouth and jaw operations. This is especially true in 
cases of hemophilia, when large, raw, periosteal surfaces are exposed, 
and direct control of minute vessels from which serious oozing 
may take place is exceedingly difficult or perhaps impossible, and 
for this reason it seems advisable to describe briefly, yet with 
necessary detail, the various methods of meeting these emergencies. 42 
ANESTHESIA-HEMORRHAGE-SHOCK 
Preparatory Measures.-Careful examination of the blood, 
especially the hemoglobin, is always a safe procedure preliminary 
to every grave surgical operation, and is imperative whenever 
indications point to unfavorable blood conditions. Sometimes 
these cannot be satisfactorily overcome, and the necessity of 
immediate operation is so urgent as to preclude corrective attempts. 
When permissible, tonics, good hygiene, and nourishing food 
may be greatly beneficial. Tendency to hemorrhage may also be 
reduced by the administration of calcium lactate, or adrenalin or 
suprarenal extract, for several days before operation. All these 
have been employed with more or less satisfactory results. The 
possibility of hemophilia should be recognized by a careful study of 
family history and records; and questions should be asked to 
determine whether other members of the family have been bleeders. 
Swelling of the joints is almost constantly present in these indi- 
viduals, and this indication, if sought for, may at least serve to 
place the operator on his guard. 
The coagulation time of the blood of the patient should be taken 
before operation. In this way much danger may be avoided. The 
author has found the Boggs coagulometer very satisfactory for this 
purpose. Its use should be a routine measure in all cases wherever 
possible. 
Treatment of Grave Hemorrhage.-It is assumed that the operator 
has made careful incisions, as elsewhere described, of such form 
as to favor the firm retention of gauze packing if required, and that 
he has carefully ligated all vessels of sufficient size to be conse- 
quential factors. Under these circumstances hemorrhage which 
cannot be controlled by ligature, direct application, or packing 
necessitates the employment of other more general measures. 
The position of the patient by raising the body or the head of the 
bed may be helpful. Clamping or ligation of the external carotid, 
the facial and lingual arteries will be described later (Chapter 
VI). Cold applications in the form of ice packs, cloths wrung in 
ice-water and placed about the head, face, and neck, and heat 
applied to the extremities, are sometimes helpful expedients. 
Compression with rubber bands around the arms close to the shoulders 
and the thighs near the hips will be described later (Chapter VI). For 
internal medication, ergot administered internally, ergotin hypoder- 
mically, powdered ferropyrin in 20 per cent, solution, and other 
similar remedies have been quite generally used and recommended. 
In the author's experience, however, they are not sufficiently 
effective to meet the requirements of surgical mouth wounds in HEMORRHAGE 
43 
serious cases. Calcium lactate, 5 to 20 grains every three or four 
hours by mouth, supplemented by thirty drops per rectum once 
or twice daily, seems to increase the coagulability of the blood 
appreciably. In the author's cases, when hemorrhage has been so 
controlled by packing that only a slight oozing of blood can take 
place, thus allowing a period of several days to get control of the 
blood conditions without serious injury to the patient, treatment 
of this kind has proved to be exceedingly beneficial. 
Adrenalin (1 to 1000) given internally in 10- to 30-minim doses 
every two or three hours also has a beneficial effect, and when 
hemorrhage is more profuse, prompt action may be secured by the 
hypodermic injection of 10 to 20 minims. Pituitary extract is now 
highly recommended as having a prompt, more powerful, and 
longer continued effect than the adrenalin. Gelatin, 2 per cent, to 
3 per cent, in normal saline solution, given by hypodermoclysis, is 
among the valuable remedies; but since attention has been called 
to the frequency with which tetanus has followed this use, 
extreme care in the sterilization of the gelatin solution should be 
taken. 
Coagulose (Hemostatic Ferment).-Coagulose, a blood serum ob- 
tained by precipitating horse serum by means of a suitable mixture 
of acetone and ether, is fully as effective as fresh serum. It is sup- 
plied in 15 c.c. glass bulbs which contain 0.65 gram of the desiccated 
powder, equivalent to 10 c.c. of blood serum, and can be used to 
advantage for local application to staunch persistent oozing of blood, 
or by injection, to increase coagulability. The author has found it 
very useful in a number of cases of serious hemorrhage. The great 
advantages are that this preparation does not deteriorate with 
ordinary care for a period of one year, and that it is always ready 
for immediate use. 
Thromboplastin.-Thromboplastin is tissue juice made from 
brain and thromboplastin solution. It is claimed that it gives, 
upon local application, just the necessary properties to promote 
coagulation. Thromboplastin hypodermic is used hypodermically 
for the same purpose. The author's experience with these remedies 
is confined to a few cases, and is by no means conclusive. Theoreti- 
cally, however, they promise much usefulness. 
Direct Transfusion of the Blood.-The introduction of blood 
directly from the artery of a healthy person into the vein of one 
affected by an uncontrollable hemorrhage, or suffering from the 
effect of excessive loss of blood, is the best measure for extreme 
cases. 44 
ANESTHESIA-HEMORRHAGE-SHOCK 
The technic of the operation as performed by Crile and described 
in concise form by Brewer is as follows: 
"The recipient and donor are placed on two tables and their 
arms prepared in the usual manner. Under cocain anesthesia the 
radial artery of the donor is exposed for about two inches and 
ligated at its distal extremity. A temporary clamp is next placed 
on its proximal end and the artery divided near the ligature. The 
redundant layer of the adventitia is drawn outward and cut off, 
and the vessel threaded through the lumen in the cannula (Fig. 15). 
The lumen of the vessel is then grasped by thin equidistant mos- 
quito forceps and drawn backward over the distal end of the cannula, 
forming an inverted cuff with intima downward. This is held in 
place by a ligature of fine silk placed over the second groove. The 
vein of the donor is prepared in the same manner, its lumen exposed 
by three small clamps, and drawn over the 
inverted arterial cuff on the cannula. The two 
are secured in place by a second ligature placed 
over the first groove, which securely holds the 
vessels in contact. The temporary clamps are 
next removed and the blood allowed to flow 
into the vein of the recipient. The flow at first 
is often slow, owing to the contraction of the 
artery from exposure. The application of wet 
compresses at a temperature of 108° to 112° F. will generally bring 
about relaxation of the arterial walls, and a vigorous flow of 
blood follows, which causes marked pulsation in the vein. 
"The above technic, while not particularly difficult to one who 
has had an opportunity of rehearsing the operation either upon 
an animal or the cadaver, is often attended by certain embarrass- 
ments, especially in young children." 
Brewer simplifies the operation by the use of glass tubes shown 
in Fig. 16, which are sterilized, dipped in melted paraffin, and 
allowed to cool. The paraffin which adheres to the inner surface 
he has proved by experimentation upon dogs will eventually 
prevent coagulation of the blood. He describes his operation 
as follows: 
"The technic of this operation is simple, and consists in exposing 
the radial artery, dividing it, drawing the proximal end over one 
extremity of the glass tube and securing it by a silk ligature, then 
introducing the opposite end of the tube into the proximal end of a 
divided vein and securing it in the same manner. As soon as the 
Fig. 15. - Crile's 
transfusion cannula. 
X 2. (Brewer.) HEMORRHAGE 
45 
temporary clamps are removed from the vessels, blood is readily 
transfused from one individual to the other."1 
Dr. Robin Ottenberg, of New York,2 describes his method of 
direct blood transfusion as follows: "It consists in the use of a 
small silver ring whose surface has two grooves. The ring is held 
by a self-retaining spring forceps, which greatly facilitates the 
procedure. The cut end of one of the divided vessels to be anas- 
Fig. 16.-Brewer's glass cannulte for direct transfusion, showing paraffin coating on 
inner surface. 
tomosed is pushed through the ring and turned back over it like a 
cuff (Figs. 17, 18 and 19). This cuffing is very easily done if the 
open lip of the vessel is caught at three points in its periphery by 
three tension sutures of fine silk. 
"This cuff is then tied in place by a piece of fine silk in the pos- 
terior groove, and the other vessel is pulled over it. Then at once 
the two vessels are fastened together, intima to intima, by two 
1 Brewer: Text-book of Surgery, pp. 151 and 152. 
2 Annals of Surgery, April, 1908, pp. 486 to 488. 46 
ANESTHESIA-HEMORRHAGE-SHOCK 
fine pieces of silver wire, which fit into the tw'o grooves. (The 
instruments used are shown in Figs. 20, 21 and 22.) 
Fig. 17.-Ring and self-retaining forceps in place, and vessel prepared for turning 
back to form cuff. 
Fig. 18.-Cuff tied ready to have vessel pulled over it 
Fig. 19.-Vessel drawn over cuff and tied ready for transfusion of the blood. HEMORRHAGE 
47 
Indirect Transfusion of Blood.-Percy1 recommends the following 
method: "The tube consists of a glass cylinder 4 cm. in diameter, 
Fig. 20 
Fig. 21 
Fig. 22 
Figs. 20, 21 and 22.-Ottenberg's instruments for blood transfusion 
with a cannula leading from one end, the other end being drawn 
out into a tube about 1 cm. in diameter to which a Y connection 
is made. To one arm of the Y, a rubber tube is attached for suction 
Fig. 23.-Instrument used in indirect method of transfusing blood. Percy's 
modification of the Brown tube. 
to aid in filling the tube, and to the other arm a rubber bulb is con- 
nected to aid in injecting the blood. 
1 Surg., Gynec. and Obst.,. September, 1915. 48 
ANESTHESIA-HEMORRHAGE-SHOCK 
"The cannula part of the tube is so constructed that it can be 
inserted directly into the vein of the donor and then the recipient. 
(See Fig. 23.) 
"The dangers of transfusion are two; i. e., immediate and delayed. 
The immediate dangers are embolism either from air or clotted 
blood, or acute dilatation of the heart consequent to such rapid 
inflow of blood that the recipient's heart is overwhelmed. The 
delayed danger is that from hemolysis, which danger cannot always 
be eliminated by the most careful tests prior to the operation. 
To guard against hemolysis preliminary tests should be made 
except when emergency conditions are prohibitive. All syringes, 
glassware and other instruments used in the tests are dry sterilized. 
Twenty c.c. of blood are drawn from a vein of the donor, and a like 
amount from a vein of the recipient. Each is subjected to the 
following treatment: Five c.c. may be placed in a test-tube con- 
taining glass beads, and the tube shaken for five minutes. This 
defibrinates the blood with resultant corpuscles. The remaining 
15 c.c. of blood are placed in a test-tube on a slant and kept at room 
temperature until clotting has taken place. Then it is placed in 
an incubator at 37° C. to facilitate precipitation of the serum. 
The defibrinated blood is washed and centrifuging in physiological 
salt solution of the washed corpuscles, a 5 per cent, suspension 
is made by taking 0.5 c.c. of corpuscles and 8.5 c.c. of saline. Of 
this 5 per cent, emulsion of red corpuscles 0.5 c.c. is used, the cells 
of the donor are treated with a serum of the recipient and the 
cells of the recipient are treated with the serum of the donor. 
Control of the saline corpuscles of both are made. 
"If the blood cells remain as a layer in the bottom of the test- 
tubes and there is a clear, nearly colorless fluid above, or if the tube, 
when shaken, be quite cloudy and not transparent, there has been 
no hemolysis. If there are no red cells present as a layer, or if the 
shaken tube is clear, there has been hemolysis of the red cells. The 
two control tubes should show no hemolysis. If they do, there has 
been an error in technic. 
"Preparation of Tube.-The tube should be cleansed by washing 
with water, alcohol, and then with ether, and, after it is perfectly 
dry, two ounces of melted grocer's paraffin is poured into the tube 
through the upper end. It is then wrapped in a towel and placed 
in a steam autoclave for fifteen minutes under fifteen pounds of 
pressure, after which, with sterile rubber gloves over the hands, 
the tube is rolled around while cooling so that every part of the 
inside is covered with melted paraffin and any excess allowed to HEMORRHAGE 
49 
run out of the large end (D). Care should be taken not to allow 
the cannula to become plugged with paraffin. If it does, the tip 
is warmed over a flame and the paraffin allowed to run back into 
the tube. Sterilizing the rubber tubing, glass Y, and mouth-piece 
is done by placing them in a towel and autoclaving in the same way 
and at the same time as the transfusion tube, or boiling them for 
twenty minutes. The atomizer bulb is thoroughly washed with 
alcohol to sterilize it. When ready to use, the connections are all 
made and two ounces of sterile liquid paraffin aspirated into the 
tube through the cannula by means of suction at the mouth-piece. 
"Technic of Transfusing the Blood-The arms of both the donor 
and the recipient are prepared as for surgical operation. An 
ordinary blood-pressure apparatus placed about the arm and 
pumped up to 60 to 80 mm. of mercury, depending upon the rapidity 
with which the blood flows, makes an excellent constrictor. By 
this means the venous circulation is impeded, but not the arterial. 
"Under local anesthesia, using 0.5 per cent, novocain solution 
intradermally, an incision is made over the cephalic vein just above 
the elbow on both the donor and the recipient, and a ligature placed 
about the vein in its proximal portion in the donor and in its distal 
portion in the recipient. Small Carrel clamps are placed on that 
portion of the vein away from the ligature in each patient and a 
longitudinal incision 3 mm. long made through all coats of each 
vein midway between clamp and ligature. Small retention clamps 
are placed on the two edges of the incision in each vein in order to 
hold them open. The cannula is placed, pointing distally into the 
vein of the donor, and the Carrel clamp released from the vein. 
By means of suction at the mouth-piece, venous blood is drawn into 
the tube up to the required amount. The blood is well protected 
from the sides of the glass by the paraffin coat and from the air by 
the liquid paraffin which floats over and completely covers the blood. 
As soon as the tube is filled, which in our experience averages about 
three and one-half minutes to withdraw 600 c.c. of blood, the 
aspirating tube is clamped, the cannula removed from the vein and 
the small clamp reapplied to the donor's vein. 
"The cannula is now quickly placed in the lumen of the vein of 
the recipient and the Carrel clamp released. The blood will now 
flow into the vein of the recipient toward the heart, the velocity 
of which flow may be controlled by careful pumping of the rubber 
atomizer bulb. As soon as it is evident that the blood is flowing 
properly, an assistant may release the constrictor from the donor 
and ligate the vein distally to the opening from which the blood has 50 
ANESTHESIA-HEMORRHAGE-SHOCK 
been taken. Not more than five minutes should be utilized in 
obtaining the blood, nor more than five minutes in injecting it. 
The length of time required to fill the tube with blood varies with 
different donors. It is well to have two tubes ready, so that if it is 
found that the first tube fills slowly, taking more than five minutes 
to get the required amount, the process may be repeated with the 
second tube, aspirating only the remainder of the required amount 
of blood." 500 to 850 c.c. of blood may be given at one time. 
Paraffin seems to be the best anticoagulative agent for purposes 
of transfusion. 
Herudin (leech extract), the citrate of sodium, and the meta- 
phosphate of sodium have sometimes been satisfactorily employed 
for this purpose. 
Fig. 24.-Funnel and tube for intravenous injection. (Brewer.) 
Intravenous Infusion of Normal Salt Solution.-This has a prompt 
effect upon the circulation. When a large quantity of blood has 
been lost it quickly supplies the circulating medium for the vessels 
and for heart action, gives immediate general stimulation, and is 
of material assistance in helping to combat toxic elements. While 
not so completely efficient in grave conditions of shock, collapse, 
and uncontrollable hemorrhage as the direct transfusion of blood, 
its simplicity and the readiness with which it can be performed 
without preparations which may involve delay make it a useful 
therapeutic measure that is more powerful than other methods of 
saline administration. The apparatus used is very simple (Fig. 24), 
and may be even more so in emergency, as an ordinary funnel 
attached to rubber tubing and an eyeglass dropper can be utilized. 
A superficial vein is exposed. Usually the median cephalic or 
basilic vein is chosen. Compression for a few moments causes the 
vein to become prominent and facilitates the operation. A short HEMORRHAGE 
51 
incision is made, the vein cleared and ligated above the point of 
the ligature, the cannula is introduced through a small incision 
which is made for the purpose, and fixed in position by a second 
ligature. Great care should be exercised to make sure that both 
tube and cannula are filled with solution before introduction^to 
prevent air being forced into the vein. 
The temperature of the sterile salt solution should be from 110° 
to 118° F. It should be slowly introduced unless there be pressing 
need of haste, and a quantity which may vary from 1 to 4 or 5 
pints allowed to flow into the veins, this being measured by the 
nature and exigencies of the case and the effect upon the patient. 
Normal salt solution may be prepared by adding 130 grains of pure 
sodium chloride to one quart of sterile water. 
Roswell Park's Balanced Physiological Solution is as follows: 
Sodium chloride, 0.09; potassium chloride, 0.03; calcium chloride, 
0.02; sterile water, 100. 
Hypodermoclysis.-Hypodermoclysis is the subcutaneous injec- 
tion of saline or other solutions in large quantity. For this purpose 
an irrigator connected with a rubber tube having a long aspirating 
needle attached is used. Both the apparatus and the solution must 
be carefully sterilized. The aspirating needle is thrust through 
the skin into some fleshy part of the body, such as the abdomen, 
thorax, thigh, buttock, etc. 
The skin is first cleansed with alcohol. One or two pints of 
normal salt solution are allowed to infiltrate the tissues. The dis- 
tention of the parts immediately surrounding the needle point is 
reduced by gentle massage, which facilitates absorption. This 
treatment is usually sufficiently marked and prompt for ordinary 
cases, and has the advantage that any capable nurse may employ 
it instantly upon indication for its use. Thus, the frequently grave 
delay of waiting for a surgeon capable of performing the more 
serious operative procedures incident to the methods of blood 
transfusion or saline intravenous infusion is avoided. 
Proctoclysis.-The slow, drop-by-drop introduction of normal salt 
solution into the rectum or colon, a period of thirty minutes or 
one hour or more being required for a pint or quart, is a valuable 
remedy in reduced systemic states from long-continued fevers, 
intestinal diseases, and kindred conditions. It is also used in 
postoperative treatment to replace fluid lost from the circulation 
through hemorrhage, to supply active general stimulation, to relieve 
thirst following anesthesia, and to give a generally soothing effect. 
The addition of small quantities of coffee or whisky adds materially 52 
ANESTHESIA-HEMORRHAGE-SHOCK 
to the beneficial result. The introduction of saline solutions during 
the continuance of grave hemorrhage is objected to because it is 
claimed that the flow of blood is increased thereby, but when 
the hemorrhage has been checked it sometimes gives marked 
assistance in recovery. 
Hemophilia Treated by Transfusion.-The following cases have 
been selected for description because of their features of special 
interest: 
Case I.-Francis C. Allen has described the case of a boy, aged 
twelve years, who entered the hospital with a history of having 
bled from the mouth for four days previously. The bleeding had 
been profuse. 
On admission, the patient was comatose, very pale, the skin was 
flabby and waxy, and a thin stream of blood was oozing from the 
mouth. 
He was treated for two days with various drugs and with saline 
solution subcutaneously. The oozing continued, and the boy 
became weak and more deeply unconscious. The hemoglobin on 
the day of admission would not register on the hemoglobinometer, 
which does not register below 10, but the resident physician esti- 
mated it as 5. 
The second day after admission, with an uncle of the child as 
the donor, a small amount of blood was transfused, but how much 
it was impossible to state. During the operation the boy's mental 
condition changed, and he became bright enough to complain of 
pain and to call the doctor hard names. 
Two days after operation the hemoglobin had risen from 5 to 14, 
and the red cells from 1,060,000 to 1,240,000. The bleeding stopped 
after the transfusion, but recurred slightly at intervals for the next 
five or six weeks. The hemoglobin continued to increase. 
On June 4, one month after admission, the hemoglobin registered 
68, and the red cells 3,930,000. The boy was discharged in good 
condition, the only thing observable being that the teeth were 
carious and very irregular. It was almost impossible to ascertain 
the source of the bleeding; at times it seemed to come out of the 
teeth themselves, two of which were mere shells; at other times 
it seemed to come from the edges of the gums. 
The boy has been back to the hospital three or four times since. 
During the last winter he was admitted with hemoglobin register- 
ing 15. Blood was not transfused on this occasion, but he was 
treated medically. The hemoglobin gradually rose. Two or three 
weeks ago he was in fair condition, although he has one swollen HEMORRHAGE 
53 
knee-joint, and there was a slight oozing from the gums on the least 
provocation. 
Case II.-Report of case of Dr. Cobb, Medical Officer in Com- 
mand, United States Public Health and Marine Service, Milwaukee. 
C. B., aged twenty-two years, born in United Slates, admitted 
to St. Mary's Hospital, Milwaukee, September 6, 1909. Dis- 
charged December 10, 1909, recovered. 
Family History.-There is a distinct family history of bleeders. 
Grandfather on mother's side is living and is a bleeder. All of 
six sons of his mother's sisters are bleeders. One brother of this 
patient bled to death, and his other brother is a bleeder. Today, 
September 10, blood count, red corpuscles, 2,250,000; white cor- 
puscles, 13,125; hemoglobin, 35 per cent. 
When admitted had foul tongue, temperature 101°, and muddy, 
yellowish skin, typical of infection. Tumor in iliac fossa which 
gradually increased in size until September 4. 
Operation.-An incision about four inches long was made down 
through the abdominal muscles to the tumor. It had the appearance 
of a hematoma. A ttocar was inserted and pure blood returned. 
The next day a blood count was made, which showed 15,000 
whites, 2,400,000 reds, and hemoglobin, 50 per cent. On September 
6, hemoglobin, 40 per cent.; September 9, red blood count, 1,800,000; 
whites, 15,900; hemoglobin, 28 per cent. 
The tumor increased rapidly in size after the operation and 
oozed slightly from the day of operation. By September 10 the 
tumor was noticeably bulging through the wound. During the night 
of September 13 the blood began to spout in a fine stream. To 
control the bleeding a median incision was made in the abdomen 
large enough to admit the hand. Through this an assistant con- 
trolled the common iliac artery. Then the tumor was hastily laid 
open and the great mass of black, clotted blood turned out. With 
gauze ready to pack, the iliac artery was released. There was no 
gush of blood, as was expected. There was no damage to any large 
bloodvessel, but there was rapid oozing from the walls which filled 
the tumor sac. The sac was firmly packed, the median wound closed, 
and the patient returned to bed. 
When the first packing was removed the wound was filled with 
ferropyrin. This was continued until September 24. The patient 
was given calcium lactate in maximum dosage up to September 20. 
On the latter date we began the subcutaneous injection of 100 c.c. 
of a 2 per cent, gelatin solution. This was given every day. Still the 
patient bled every day some time between one and five. October 1, 54 
ANESTHESIA-HEMORRHAGE--SHOCK 
gave 3000 units of antidiphtheritic serum. No change. Dr. G. V. I. 
Brown suggested the Crile transfusion. Dr. John L. Yates, of 
Milwaukee, performed the operation of blood transfusion by the 
Crile method October 4. The effects were immediate. The red 
count was 5,000,000 on the morning of October 5. The hemoglobin 
was 75 per cent. The patient did not bleed again. In five days 
the red count was 5,400,000 and hemoglobin 92 per cent. The 
wound cavity, which extended to the kidney above and filled 
the iliac fossa, had showed no tendency to heal as long as there 
was bleeding, but it began to fill in rapidly after the transfusion. 
Patient bled thirty-two days. Discharged December 10, 1909. 
The following is a personal report of a case of subcutaneous injec- 
tion in small quantities of human blood in spontaneous hemorrhage 
of the newborn, by Dr. A. W. Myers, of Milwaukee. 
At noon on June 20, when the child was thirty-two hours old, 
a large stool was expelled composed entirely of tarry blood clots. 
This was repeated at 2, 3, 4, 5, 6, and 8 p.m. At 4, 6, and 8 p.m. 
the expulsion of the bloody stools was accompanied by vomiting of 
considerable quantities of clotted blood. 
During the night the child slept quietly until 4 a.m., when there 
was a bloody stool with vomiting of blood. This was repeated at 
7 a.m., and at 10 and 11.30 a.m. there were bloody stools without 
vomiting. 
When seen at noon of June 21 the child's condition seemed 
almost hopeless; the weight had fallen to 4 pounds 8 ounces, the 
mucous membranes were very pale, the skin was colorless. The 
cord was normal, no bleeding occurred at this point, and there 
were no hemorrhages into the skin or the visible mucous membranes. 
Three c.c. of blood were drawn from a vein of the mother's arm 
and quickly injected into the subcutaneous tissues of the baby's 
buttock before there was time for the blood to coagulate in the 
syringe. This was done at 12 m. 
At 2.30 p.m. a stool was passed containing rather old-looking 
clots and a small amount of fresh blood. 
At 4.30 p.m. a second injection of maternal blood was given into 
the other buttock. There was absolutely no more bleeding. 
The child was put to the breast and nursed well after the first 
few times. There was no more vomiting, and the following stools 
presented the typical meconium character, gradually changing to 
the milk-stool appearance in a few days. 
The blood injected was quickly absorbed, and a few hours .after- 
ward the site of injection could be recognized only by the needle 
puncture in the skin. SHOCK 
55 
The subsequent history of the child was uneventful. On June 
23 the weight was 4 pounds 10 ounces, on July 2, 5 pounds, and on 
July 16, 6 pounds. 
Schloss and Commisky1 report 7 cases of spontaneous hemor- 
rhage in the newborn treated in this manner, of which 6 recovered 
and 1 died. The fatal case was in an infant in a moribund con- 
dition from multiple hemorrhages for eight days. 
The ease with which this method of treatment can be carried 
out under any surroundings, and the brilliant results reported by 
Schloss and Commisky, will do much to commend it to all who 
have frequently encountered this alarming condition. 
Welch has reported 12 cases with hemorrhage in the newborn 
successfully treated by the subcutaneous injection of human blood 
serum. 
Upon two occasions the author has had 2 to 5 c.c. of blood taken 
from his own arm and injected into the buttock when newly born 
infants' blood failed to coagulate after hare-lip operation. 
There was more or less induration surrounding the point of 
injection in each case, but the hemorrhage ceased. 
If time should prove that human blood may be spontaneously 
injected in infants without harmful results, and with prompt 
benefit, such as the cases thus far reported have received, it would 
be a great step forward in the treatment of many other affections 
as well as spontaneous hemorrhage in the newborn. The direct 
transfusion of blood by even the simplest method is difficult and a 
more or less slow process because of the smallness of the infant's 
vessels, and even the preparation of serum requires more time than 
is necessary for the subcutaneous injection of blood as described. 
The time limit alone may decide the question of life or death in a 
critical situation. 
Experience with many patients in which low blood coagulation 
has been a serious factor has impressed upon the author's mind the 
necessity for familiarity with every means of controlling hemor- 
rhage. Many times this has meant the saving of life. The several 
methods of blood transfusion and other treatments are therefore 
presented in this light. 
SHOCK. 
Shock is defined as a depression of the vital powers caused by 
painful injuries or strong mental emotion. According to Crile, 
"the central nervous system is in shock whenever it has been sub- 
1 Am. Jour. Dis. of Children, April, 1911. 56 
ANESTHESIA-HEMORRHAGE-SHOCK 
jected to a sufficient afferent stimulation to produce pathological 
alteration of function." 
Shock usually follows immediately upon the reception of an 
injury, but may appear some time after. The author believes that 
the effect of deferred shock in long-continued operations in dental 
chairs is much greater and more frequent than it appears to be, and 
that because the symptoms are not immediate their real cause is 
not recognized. 
Etiology.-Psychic Causes.-The physical manifestations of purely 
mental impressions as exemplified in shock are modified by many 
conditions related to bodily health, temperament, and other control- 
ling factors; thus, sudden fright, the effect of bad news, the stirring 
of some memory center through the senses, might be slight or 
serious, or even cause syncope and death, according to the tempera- 
ment or condition of general health of the individual, or of some 
vital organ. 
Operative Causes.-The shock from surgical, operative, or other 
injuries likewise is in a general way proportionate to the character 
and extent of the injury, subject to modifying conditions, so that 
sometimes a very slight traumatism or surgical operation will 
produce symptoms of severe shock, while serious injuries may 
pass with but slight disturbance. 
Grave accidental injuries accompanied by fright, such as rail- 
road or similar accidents, almost invariably cause severe shock. 
Surgical shock is aggravated by the influence of predisposing 
potent factors, lowered vitality, extremes of age (infancy and old age), 
malnutrition, exhaustion (as from chronic disease, overexertion, 
mental or bodily suffering, etc.), diseases of the blood, kidneys, and 
heart, tuberculosis, syphilis, chronic or acute nervous states, and 
pregnancy. 
Direct Factors.-It has long been known that certain classes of 
injuries are attended with marked shock, such as injuries of the 
viscera, testicle, and much lacerated wounds of the trunk and 
extremities. 
Crile and Lauer, from notes on 5800 major operations, enumerate 
the factors in shock as follows: 
" (a) Psychic excitation, such as fear, foreboding, etc. This 
has seemed to be a more powerful factor than is usually considered. 
" (b) Hemorrhage, also a self-evident factor, and often very 
difficult to estimate closely. 
" (c) Cold. The depressing effect of lowering the body heat, 
as in exposure to cold on battlefields, undue exposure in the operat- SHOCK 
57 
ing room, and many physiological experiments, is well established. 
In practice, Crile sometimes places the patient on a hot-water bed, 
adapted to the operating table. 
" (d) Acute and chronic infections. In these there is a marked 
physical disturbance of many parts of the body, and certainly not 
the least is circulatory mechanism."1 
The primary and essential factor in shock is an effect upon the 
vasomotor centers, evidenced by lowered blood-pressure. The 
resulting loss of vascular tone in the arteries with correspondingly 
diminished activity of the heart causes an unequal distribution 
of the blood. 
As a result the abdominal veins become distended, the right side 
of the heart engorged, and because the blood becomes lodged 
in the paralyzed and the dilated venous system there is compara- 
tively little blood circulation. This in turn acts upon the central 
nervous system and results in impairment or cessation of its func- 
tions. Crile's experiments on dogs, corroborated by study of 
human cases, has shown the effect of blood-pressure on respiration. 
In 90 out of 103 experiments he found that respiratory failure 
was the actual cause of death, and that, contrary to the generally 
accepted opinion, the heart was the one factor most to be depended 
upon; that heart weakness was due to the reduced amount of fluid 
in its cavities more than to any direct effect of the shock, thus 
giving a practical basis for treatment, which has been fully cor- 
roborated by the results of blood transfusion in both animals and 
man. 
Some experimental studies on shock and, hemorrhage are reported 
by F. C. Mann2 from the Mayo Clinic. 
In a normal dog 66 per cent, of the blood can be obtained from 
the femoral and 10 per cent, from the heart, leaving 24 per cent, 
in the tissues. 
In an animal in which the C. cord is sectioned, producing medul- 
lary vasomotor paralysis, 54 per cent, of the blood can be obtained 
from the femoral and 12 per cent, from the heart, leaving 34 per cent, 
in the tissues. 
In an animal in which blood-pressure is depressed practically 
to zero by an overdose of ether, 46 per cent, of the blood can be 
obtained from the femoral and 13 per cent, from the heart, leaving 
41 per cent, in the tissues. 
In an animal in which the viscera have been exposed until the 
1 Practical Medicine, Series 11, 1906, p. 82 (after Jour. Am. Med. Assn., June 17, 
1905). 2 Surg., Gynec. and Obst., October, 1915. 58 
A NESTHESIA-HEMORRHAGE-SHOCK 
clinical signs of shock are present but in which the vasomotor 
reflexes are as active or even more so than normal, only 28 per cent, 
of the blood can be obtained from the femoral. 
He concludes that the clinical signs of shock which appear after 
section of the abdomen and exposure of the viscera are due to a loss 
of circulatory fluid. This loss is not dependent upon any primary 
impairment of the medullary center and takes place at a point 
beyond the control of the vasomotor mechanism. The causes for 
this loss are apparently the same as those which determine the accu- 
mulation of fluid in any other irritated area and produce the signs 
of inflammation. The nervous system probably plays no greater 
part in the former case than in the latter. The condition is made 
grave when the viscera are exposed because of the great vascularity 
of the tissues involved. 
Pike and Coombs'1 conclusions from their experimentations are 
that: 1. When the cells of the brain and medulla oblongata are de- 
prived of blood for a period of from ten to twenty minutes, a change 
in the staining reactions of the cells is demonstrable if the brain and 
upper portion of the spinal cord are removed some minutes after 
the circulation to the head has been restored.2 
2. There is a greater susceptibility of these previously damaged 
cells to strychnin. Paralysis and failure of function from adminis- 
tration of strychnin during the resuscitation period occur more 
readily in the anterior (cephalic) portion of the central nervous 
system, which has been deprived of blood for a time, than in the 
posterior portion through which the circulation has been maintained 
continuously.3 
3. Such damaged nerve cells will recover when a proper supply 
of oxygenated blood is provided. Respiration, blood-pressure and 
pulse-rate soon become normal.4 
In some cases collapse or complete prostration doubtless occurs 
rapidly from grave injury which appears to be the result of inhibi- 
tory reflex directly affecting the vagus. The foregoing more or less 
conflicting conclusions from experimental research with reference 
to hemorrhage and shock will undoubtedly be cleared up in the near 
future, as its relation to the vegetative nervous system and vago- 
tonic conditions, and the influences which bear upon the balance 
of control between the sympathetic and vagus systems become 
1 The Relation of Low Blood-pressure to a Fatal Termination in Traumatic Shock 
Jour. Am. Med. Assn., June 23, 1917. 
2 Gomez and Pike: Jour. Exper. Med., 1909, p. 11. 
3 Stewart and others: Journal. Exper. Med., 1906, pp. 176 and 248. 
4 Pike: Am. Jour. Physiol., 1912, xxx, 436-450. SHOCK 
59 
better understood in the light of researches now well under way by 
many investigators. From a surgical operative point of view, 
however, the net result is much the same, for all conclusions point 
in the direction of better operative technic. 
Symptoms.-All symptoms of shock have a certain resemblance, 
but for clinical convenience these are, so far as possible, arranged 
in graduated order from the milder to the graver conditions, as 
follows: 
There is a feeling of weakness, giddiness, and slight nausea. 
The appearance of the face is pale, with beads of cold perspiration 
upon the skin surface. The extremities are cold, the pulse becomes 
weak and irregular, and syncope may occur, followed by partial 
or complete loss of consciousness. 
Severe shock is indicated when the restoration to consciousness 
is slow and there is a tendency to recurrence after the patient has 
been temporarily aroused, when the pupils are markedly dilated 
and slow in response to light reaction, and when the surface of the 
body is cold and clammy with perspiration and there is no response 
to warmth or rubbing, and when there is a marked subnormal 
temperature, and the pulse unusually weak, rapid, irregular, and 
compressible. 
The profound unconsciousness of coma or delirium, subnormal 
temperature of 97° F. or less, with unusual restlessness or great 
feebleness, relaxation of the sphincters, sighing, feeble, irregular, 
unusually slow or exceedingly rapid and shallow respiration, with 
eyes rolled upward and failure to respond to stimulus of any kind, 
are indications for grave prognosis. 
Treatment.-Prophylactic.-In cases of accident or emergency 
there is often little opportunity for more than an attempt to over- 
come the direct evidences of shock. When it is possible to be more 
deliberate, the mental attitude of the subject should be kept in 
mind, and brooding over the operation or a gloomy outlook should 
be avoided so far as possible by surrounding the patient with persons 
who are cheerful, hopeful, and competent. 
Especially with infants, too long a period of starvation must be 
avoided. Nourishment in moderate quantity should be given 
from one and one-half to three hours before operation, according 
to the age of the infant. Starving babies bear shock badly. In 
older persons, except those in feeble health, precaution in this 
respect is not so necessary. The hypodermic injection of morphin, 
gr. | to |, with atropin, gr. 120 to 100, thirty minutes before opera- 
tion, or similar injections of scopolamin, gr. T^, morphin, gr. |, 60 
ANESTHESIA-HEMORRHAGE-SHOCK 
will relieve the nervousness and make it possible to secure complete 
anesthesia with less anesthetic, besides reducing the danger of 
inspiration of mucus through control of the activity of glandular 
secretion. 
The operating room should be warm. It is the author's custom 
to have infants and young children lie upon a warm water bottle 
upon an operating table or upon his special table arranged with a 
hot-water tank to maintain continuous warm temperature. This 
table was designed, made and contributed by Dr. R. M. Hall, of 
the Milwaukee Children's Free Hospital, whose kindness has given 
much benefit to many children. With older persons the table may or 
may not be warmed. But the body should not be unnecessarily 
exposed to chilling during the operation. Every drop of blood 
that can be saved reduces shock to just that extent; every fractional 
part by which the amount of anesthetic given can be reduced not 
only reduces the immediate danger of shock, but leaves just that 
much less of the depressing toxic effect for the system to overcome 
afterward; every moment by which the time of operation can be 
reduced without undue haste, which might cause neglect of impor- 
tant operative procedures, and every traumatic effect in the handling 
of tissue, violence in sponging, or contact with important nerves 
that may be avoided, is just that much accomplished toward reliev- 
ing shock of its grave features. The previous administration of 
stimulating drugs, such as strychnin or even whisky, the author 
believes to be disadvantageous, because if a time should come when 
stimulation of this character is actually required its effect cannot 
be relied upon. 
After-treatment.-The patient should be covered with warm 
blankets and protected against chilling of the body when he is 
taken from the operating room to the bed, which should previously 
have been warmed with hot-water bottles. He is then wrapped 
in warmed woollen blankets and the bodily temperature is main- 
tained with water bottles, with, of course, protection to prevent 
burning the body during unconsciousness. Normal salt solution, a 
pint by the rectum, containing whisky or coffee, serves to restore 
circulatory conditions and to supply lost fluid in the circulation. 
It is soothing, tends to reduce the thirst for water, and favors 
normal reaction in every way. Quiet, restful surroundings and 
encouraging assurance that all is well with the first signs of returning 
consciousness often serve to reduce excitement and favor rest and 
recovery. 
A 5 per cent, solution of glucose may be substituted for other SHOCK 
61 
stimulants in proctoclysis. Burnham1 advises its continuous use 
when necessary and states that 300 to 500 calories a day may be 
introduced in this way. 
Of all the many drugs that have from time to time been recom- 
mended, the hypodermic injection of strychnin appears to H. P. 
Cole2 to find favor among the greatest number of surgeons (46 
per cent.), but those in opposition to its use hold that under some 
circumstances strychnin rather aggravates than improves the con- 
dition in shock.3 
Bandaging.-A firm bandage about the abdomen or bandaging 
the extremities, or Crile's pneumatic suit, may be employed to 
equalize the circulation and temporarily assist the heart. Except 
when contra-indicated, the patient should be kept with the head 
low during recovery and the face turned upon one side to prevent 
inspiration of the blood or mucus. Additional advantage in a 
weakened state may be gained by raising the foot of the bed so 
that the body inclines with the head slightly downward. 
Care should be taken that normal salt solution given by the 
rectum is maintained at a sufficiently high temperature. Murphy 
has proved that ordinarily a loss of several degrees occurs by the 
time the salt reaches the colon. Some one of the many forms of 
keeping the solution hot must be used, otherwise the effect may be 
to decrease rather than increase bodily temperature. The salt 
solution is best administered by the drop method, slowly, taking, 
if necessary, an hour for the administration of a pint of saline 
(p. 51). 
When the effect of salt solution by the rectum is insufficient, it 
may be given by hypodermoclysis directly into the tissues (p. 51). 
A syringe point is made for the purpose after the form of a hypo- 
dermic needle, only somewhat larger. It is attached to the rubber 
tube connected with the vessel containing the salt solution, and is 
forced into the tissues in a fleshy part of the body. The absorption 
of the fluid is assisted by gentle manipulation of the tissue around 
the point. In cases where still more rapid reaction is required 
the intravenous injection of saline solution (p. 50) is indicated. 
Mummery recommends the intravenous infusion.of a solution of 
adrenalin in normal salt solution, 1 to 20,000, at the rate of about 
3 to 5 c.c. per minute, to be continued until blood-pressure remains 
at a safe level. Crile urges, and has demonstrated beyond question, 
the value of direct blood transfusion according to his method (p. 43). 
1 Am. Jour. Med. Sc., September, 1915. 
2 Southern Med. Jour., June, 1909. 
3 J. P. L. Mummery: Lancet, April, 1903. 62 
ANESTHESIA-HEMORRHAGE-SHOCK 
Henderson1 claims to have demonstrated that lack of carbon 
dioxide in the blood causes a lack of venous tone, and this lack of 
venous tone diminishes the amount of blood that reaches the auricles 
and, therefore, ventricles of the heart during diastole. He also 
states that even when the anesthetic appears to be sufficient, the 
sensitive nerves still note injuries and pain, and shock may be 
caused unless the anesthesia is profound. This means clinically 
that anesthesia should always be sufficient before operation and 
during operation. He claims that a lowered arterial tension improves 
rapidly when physiological saline impregnated with carbon dioxide 
is administered intravenously. 
Henderson terms this condition of diminished carbon dioxide 
content of the blood acapnia (from the Greek kapnos, meaning 
smoke), literally a "smokelessness." 
"1. Severe pain should never be allowed; it should be prevented 
by enough of the narcotic which seems indicated in the individual 
cases. 
"2. Anesthesia should be complete both before beginning opera- 
tion and during it. 
"3. If shock occurs after operation or after other injuries, trans- 
fusion into the veins of physiological saline saturated with carbon 
dioxide should be done. Also, at any time during shock, air or 
oxygen, with moderate amounts of carbon dioxide, should be 
inhaled. 
"4. Whenever there is likelihood of pain following the recovery 
of the patients from anesthesia, morph in should be injected to 
prevent it. 
"5. However valuable strychnin injections may be as a stim- 
ulant to the nerve centers and as a stimulant to general metabolism 
to perhaps promote normal cellular activity, and perhaps, there- 
fore, the production of a normal amount of carbon dioxide, exces- 
sive amount of strychnin as a cardiac and respiratory stimulant 
in shock should not be used. Large doses of strychnin, or strych- 
nin repeated too frequently, seem to interfere with normal diastole 
of the heart and prevent the normal filling of the heart cavities 
and therefore the normal output of the heart into the arteries. 
Henderson seems to have shown that such cardiac stimulants 
cannot increase the output from the heart cavities. 
"6. Digitalis would rarely be indicated, if ever, in acute shock. 
The greatest advantage of digitalis is in cardiac dilatation, and 
its best activity is in cardiac hypertrophy with dilatation." 
1 Jour. Am. Med. Assn., August 7, 1909, p. 461. CHAPTER II. 
PATHOLOGICAL DENTITION. 
Defective embryonic development. 
Perverted development. 
Malnutrition. 
Syphilis. 
Rachitis. 
Neurotic tendency. 
Other diseased conditions. 
Predisposing 
Causes . 
Arrested maxillary development. 
Undue thickening and resistance of over- 
lying tissue, causing pressure from 
crowns of teeth to react through the 
open ends of roots upon the dental 
papilla, thus giving direct irritation. 
Malposition. 
Exciting 
In considering pathological conditions coincident with irrita- 
tion manifested during the period of tooth eruption in infants, 
it should be remembered that the germs of the first teeth begin 
to develop as early as the fifth week of embryonic life, that these 
are quickly followed by those of the permanent set, and that at 
birth the tooth follicles for both sets are present in the jaws in 
course of development.. 
During the period of tooth development of infants a high mor- 
tality, the prevalence of intestinal disturbances, skin eruptions, 
and spasmodic and other nervous affections are noted. The same 
tendencies appear at later periods, notably about the fifth, sixth, 
or seventh year, as the first permanent molars appear, and again 
when the second and third molars are endeavoring to erupt. 
Kiernan, Talbot, Kirk, Upson, and others have called attention 
to the fact that these periods of stress frequently mark the time 
of the first manifestations of chorea, epilepsy, and other neurotic 
tendencies (p. 349). 
The process of tooth eruption is related to these affections by 
direct irritation through pressure caused by resistance of the 
inflamed or thickened tissue, covering the tooth crown, forcing 
the sharp borders of the incompletely developed roots against the 
pulp tissue with its as yet unprotected nerves and bloodvessels. 
Indirectly this irritation tends to reduce the bodily resistance to 64 
PATHOLOGICAL DENTITION 
bacteria, disturbs digestive functions, and accentuates inherent 
tendencies to neurotic states (Fig. 25), now recognized as vagotonia. 
All too frequently, patients have been referred to the author 
with a history of having been under treatment for third molars 
that were expected to erupt, but instead, cancer was found on the 
site of the inflamed tissue over and around the malposed teeth 
which had been allowed to progress beyond the reasonable hope 
of cure because of delay. 
Fig. 25.-Erupting tooth. 
Symptoms.-The symptoms are local and general. 
Local Symptoms.-Local symptoms are readily recognized in 
infant cases by the evident desire of the child to bite upon any 
substance it can put into its mouth, by the excessive flow of saliva 
incident to the unusual irritation, and by the appearance of the 
mucous membrane surface of the mouth in the region of the erupt- 
ing tooth crowns, where it may be slightly swollen, red, and inflamed 
in appearance, or more often white, when the gum tissue has 
become tightly stretched across the incisal or occlusal tooth surfaces 
and toughened until unusually resistant. SYMPTOMS 
65 
Occasionally the mouth becomes so tender that the infant can 
with difficulty be made to take the nipple or bottle, and the charac- 
teristic stomatitis affects the membrane surface. 
With' adults, the local manifestation may be noted in the appear- 
ance of the cusps or crowns of teeth through the gum upon the 
surface of the alveolar ridges, or the gum may be swollen and tender 
from being bitten upon by the antagonizing tooth in the opposite 
jaw. Spasmodic contraction of the muscles of mastication may 
result from direct nerve irritation, or the inflammation may extend 
until surrounding muscles and glands are involved, and cause 
temporary ankylosis, the degree of which may be slight, or suffi- 
cient to cause complete fixation of the mandible. 
The swelling may be confined to the tissues in the region of the 
angle of the jaw, or include the parotid and submaxillary structures 
also. Pain may be continuous and severe, or be noticed only upon 
attempt to open the mouth. The tissues of the floor of the mouth 
and tongue may become infected and cause symptoms identical 
with Ludwig's angina, and thus endanger life through difficulty 
in respiration and swallowing. 
General Symptoms.-In infant cases it is sometimes practically 
impossible to differentiate between some of the many expressions 
of disease that may be coincident with tooth eruption and other 
pathological affections to which such infants are prone. 
Spasms, infantile paralysis, disturbance of the digestive tract, 
diseases of the skin and mucous membrane, trophic changes, 
meningitis, and affections of the spinal cord leading to muscular 
atrophy, etc., may be the result of predisposition engendered by 
direct nerve irritation, infection, or weakened resistance incident 
to tooth eruption; on the other hand, these may be due to other 
etiological agencies, therefore diagnosis is necessarily made by 
exclusion. 
In adult cases malposed or supernumerary teeth are frequent 
causes of reflex pain (Fig. 26, and p. 350) and of other disturbances 
of similar origin, such as facial spasm, chorea, epilepsy, and kindred 
spasmodic affections, paralysis, sensory alterations, neuralgia, or 
trophic changes, which may be manifested in many different 
forms. 
Such teeth may become encysted and thus occupy the central 
position in cysts that are sometimes of enormous size. Many 
serious pathological states may result from irritation and in- 
fection of the tissues surrounding teeth that are in course of 
eruption, especially if impacted or in malposition, Long-continued 66 
PATHOLOGICAL DENTITION 
nasal and antral diseases have been proved to be due to malposed 
teeth in these situations. Blindness, deafness, tinnitus aurium, 
and other affections indicating interference with some cranial nerve 
have been more or less frequently reported from the same cause. 
Local infection may occur, especially in the case of malposed third 
molars, that are unable to erupt and have a more or less complete 
covering of gum tissue remaining upon their crown surfaces. The 
accumulation of bacteria-laden secretions and debris is thus favored 
by the pocket which is formed between the gum and tooth surface. 
Aided by abrasion, swelling and other inflammatory symptoms 
result, which, once inaugurated from the center thus established, 
Fig. 26.--Skull with an unerupted cuspid tooth placed in the same situation as 
that in which it was found in the mouth of a man who suffered for many years with 
tic douloureux. 
may readily enter the lymphatic pathways of the neck and lead 
to septicemia, pyemia, and other disorders of the blood and lym- 
phatic systems. The final result may be grave or slight, according 
to the resistance of the individual and other factors upon which 
the prognosis of all such affections must depend. Figs. 26 to 42 are 
examples of such cases. 
Diagnosis.-Infant Cases.-Erupting teeth in infant mouths are 
usually easily recognized by prominences upon the alveolar ridges 
and the appearance of the gum tissue over and around the erupt- 
ing tooth crowns, which become dark and slightly swollen, or 
white if reduced to a toughened, resistant membrane. DIAGNOSIS 
67 
Adult Cases.-With adults the diagnostic guides are: (1) Absence 
of a tooth without history of extraction or loss from other known 
Fig. 27.--Impacted teeth in adult 
case. Deciduous teeth crowned through 
error on the part of dentist. Chronic 
disease in this region finally led to diag- 
nosis with the x-rays. 
Fig. 28.--Impacted cuspid in adult 
case, with an interesting history of 
neuralgic pain. 
Fig. 29 
Figs. 29 and 30 show two impacted lower third molars in the jaw of a girl, aged 
fifteen years, who suffered great pain and other distressing nervous symptoms. 
Fig. 30 
Fig. 31.-Two unerupted cuspids situated in the palate of a girl, aged 
twenty-two years. 
cause, the possibility of other supernumerary teeth always being 
borne in mind in this connection. (2) Unusual fulness in the por- 68 
PATHOLOGICAL HEN TITION 
Fig. 32.-Radiogram of the mouth of a young woman, aged twenty years, show- 
ing an impacted third molar. In this case severe neuralgic pain in the head was 
relieved by removal of the impacted teeth. 
Fig. 33.-Unerupted left cuspid near the orbit in the case of a man, aged 
twenty-six years. Maxillary sinus on left side involved. DIAGNOSIS 
69 
lion of the jaw in which the suspected unerupted tooth may lie. 
(3) Exploration with a smooth, sharp-pointed, stiff probe passed 
through the gum tissue and into the bone structure, which, in the 
Fig. 34.-Teeth in course of eruption. This illustrates the difficulties encountered 
when teeth are crowded in the jaws. 
Fig. 35.-A view of an impacted lower third molar. (.Cryer.J 70 
PATHOLOGICAL DENTITION 
process of absorption incident to tooth eruption or during the 
effort of an impacted tooth to erupt, usually becomes more or 
Fig. 36.-An uncommon impacted lower third molar. (Cryer.) 
Fig. 37.-Showing an inverted lower third molar erupting into the' submaxillary 
fossa. (Ottofy.) 
less porous, and thus permits of the passage of the probe until it 
touches the hard, smooth, easily recognized surface of the tooth 
crown. £4) The x-rays. TREATMENT 
71 
In the third molar region differentiation must be made to exclude 
mumps, submaxillary or parotid inflammation from other cause, 
syphilis, ptyalism, tumors, true ankylosis, and other infectious 
diseases. The presence of the tooth is the determining factor, 
Fig. 38.-Showing tooth malposed in ramus of the mandible. (Cryer.) 
and the x-rays the final method of decision when other diagnostic 
efforts fail. 
Treatment.-Treatment of Infants.-Give direct relief by cutting 
through the overlying tissue down to the erupting tooth crown. 
An attendant should hold the baby firmly, and by lowering its 
head induce it to cry.' This immediately causes the mouth to be 
Fig. 39.-Impacted third molar below the second molar. (Cryer.) 
opened, so that there is little difficulty in gaining access to the 
alveolar ridges. With a sharp-pointed bistoury or a surgical knife, 
protected by being wrapped with gauze, tape, or other material, 
the point alone being exposed, make an incision longer than the 72 
PATHOLOGICAL DENTITION 
Fig. 40.-An impacted upper third molar. A similar condition found on the oppo- 
site side of the skull. (Cryer.) 
Fig. 41 -Radiogram showing impacted canine. (Cryer.) TREATMENT 
73 
tooth is wide, if it be one of the anterior teeth; cut down upon 
the incisal surface, and follow it entirely across. 
Bicuspids and molars require crucial incisions long enough in 
each direction to include the cusps of the erupting teeth as shown 
in Fig. 43. 
Occasionally it is necessary to remove the entire portion of gum 
which covers the occlusal surfaces of the erupting teeth. 
Fig. 42.-Radiogram of mandible, showing rudimentary fourth molar. (Cryer.) 
Fig. 43.- Lines of incision in lancing: a, over the molars; &, b, over the canines 
and incisors before eruption; c, c, c, over the molars and canines after partial eruption. 
(J. W. White.) Complete removal of the overlying gum tissue by an incision 
extending completely around the crown of the tooth is often required. 
Treatment of Adults.-Preservation of the Teeth.-When malposed 
or impacted teeth are diagnosticated with the aid of the x-rays 
or otherwise, it should be remembered that they need not neces- 
sarily be condemned, because, unless they are supernumerary teeth, 
each one has its rightful place in the complement of the perfect 
individual. Usually such teeth are crowded out of place and their 74 
PATHOLOGICAL DENTITION 
eruption is prevented by insufficient or at least imperfect develop- 
ment of the jaws and dental arches. The proper remedy, there- 
fore, except when some unusual circumstances contra-indicate 
such treatment, is to expand the dental arches and regulate the 
teeth in such manner as to give opportunity for the impacted 
tooth or teeth to erupt. When this is done, even with persons 
of quite advanced years, and the eruption of the teeth stimulated 
by methods well known to orthodontists, such teeth, unless very 
abnormally situated, can usually be brought into proper position 
quite satisfactorily. 
Frequently upper third molars appear to erupt with their crown 
surfaces turned toward the cheek and apparently outside of the line 
of the upper dental arch. As a matter of fact, it is the arch that 
should be expanded out to the line of the third molars, thus giving 
them room to erupt in correct position. This at the same time 
restores to some extent the size of the nares, which under proper 
examination are often found contracted and otherwise deformed. 
Extraction of the teeth, while giving apparent relief, usually 
increases instead of decreasing the ill effects. 
In like manner, lower third molars may be impacted, with the 
usual tipping forward of the crown with its occlusal surface turned 
toward the distal side of the second molar. Unless too firmly 
locked or too solidly embedded in the angle of the jaw to make such 
treatment practicable, they may sometimes be wedged away from 
the second molar sufficiently to free the mesial line angle from 
being locked under the contoured distal surface of the adjoining 
tooth, thus enabling it to come forward and upward into natural 
position. 
The author does not urge extreme treatment in these cases, 
but he has abundant clinical reasons for believing that this aspect 
should always be considered before resorting to extraction. 
In adults a thick, resistant, bony covering sometimes lies between 
the tooth crown and the surface, which for some reason has resisted 
absorption. In these cases it is always beneficial and sometimes 
necessary to remove this bone structure with a surgical or dental 
engine burr, so that eruption of the tooth may be facilitated, and 
that, if necessary, proper attachments be made to the crown for 
orthodontic purposes. 
Treatment in cases of supernumerary, and also of geminated 
(twin) teeth must be determined by consideration of the cosmetic 
results as well as the effect upon underlying pathological and devel- 
opmental conditions which may be influenced by extraction or REMOVAL OF IMPACTED TEETH 
75 
retention. The time of correction is often an important factor in 
these respects. 
Palliative Treatment.-Patients suffering from acute inflamma- 
tory conditions, due to erupting teeth, particularly third molars, 
frequently come for treatment in a state of great distress from 
pain, inability to open the mouth, and associated symptoms of 
local disturbance, together with rise in temperature and other 
general indications of the toxic influence of the infection. Although 
it may be apparent that the offending tooth must be extracted, 
the decision as to the time of extraction is a matter of much impor- 
tance. A number of deaths have been reported from immediate 
operation upon cases during the acute inflammatory stage, and 
the presence of microorganisms in the blood appears to have 
demonstrated that the opening of bloodvessels incident to opera- 
tion for removal of the impacted teeth has allowed the direct 
entrance of septic matter into the circulation and converted septic 
intoxication into true septicemia. The wiser plan wrould therefore 
be to await the subsidence of the acute symptoms in every case 
before undertaking operation. This, however, is not always practic- 
able, because the danger involved from continued progress of the 
inflammation and infection may absolutely force drastic measures, 
even though they be adopted with full knowledge of the danger. 
In most cases, however, notwithstanding the usual urging of the 
patient for relief, the fixed jaw can be gradually opened by the use 
of a mouth gag with or without the aid of an anesthetic, and retained 
in at least a partially open position by the use of rubber corks, as 
indicated under treatment of ankylosis (Fig. 199, p. 420). With 
the mouth thus opened, it is possible to reach the seat of the inflam- 
mation, to draw off the pus from over and around the impacted 
tooth crown, to disinfect the mouth, and to make local applications, 
both intrabuccal and extrabuccal, for the relief of the inflammation. 
After this, extraction of the tooth may be accomplished with greater 
safetv. 
REMOVAL OF IMPACTED TEETH. 
When unfavorable conditions which contra-indicate the imme- 
diate removal of impacted teeth have been overcome, or in the 
unusual cases which require operation without waiting for their 
subsidence, and when orthodontic methods for effecting correct 
eruption are precluded or inadmissible, the removal of such teeth 
is required. 
The first principle in the removal of impacted third molars and 76 
PATHOLOGICAL DENTITION 
other impacted teeth is that surrounding bone which may seriously 
interfere with extraction should be removed before unusually 
forcible attempts are made with dental forceps. Unwise use of 
these instruments is apt to result in failure to extract the tooth, 
causing much unnecessary pain and discomfort or even serious 
injury to the patient. The crown of the tooth may be crushed 
or broken off, thereby increasing the difficulties of extraction; 
pieces of bone may be splintered in such manner as to cause necrosis, 
or the jaw bone may be fractured, as has been known to occur, 
especially when the so-called Physick forceps have been used. 
The Danger of Such Operations.-On account of the anatomical 
situations of impacted third molars and other teeth, and the pecu- 
liar conditions under 'which their removal must be effected, the 
following definite dangers, in addition to those common to other 
surgical operative risks, must be anticipated: 
1. The inspiration of blood. When the patient is deeply under 
a general anesthetic and lying in the prone position, blood may 
easily be drawn into the trachea in such quantities as to fill the 
bronchi and to flood the lungs sufficiently to cause instant death. 
Fatalities during mouth operations have not uncommonly occurred 
from this cause. 
2. The inspiration of even small quantities of blood with bacteria- 
laden saliva may lead to inspiration pneumonia, and this may 
indirectly cause a fatal termination. 
3. The immediate loss of blood, if unchecked, may be a serious 
menace to the vitality of the patient, or secondary hemorrhage 
may be difficult to control and be serious in its results. There is 
always also the danger of encountering a hemophiliac even when 
neither the pathognomonic swelling of the joints or the family 
history may be sufficiently indicative to serve as a warning. The 
dangers and difficulties attendant upon the management of a bleeder 
with wounds of this character in the mouth need hardly be 
elaborated. 
4. The danger of general infection, which has been already 
referred to. 
5. The danger of fracturing the jaw or causing temporary or 
permanent ankylosis or injuries to the nerves, that may leave 
serious postoperative effects. 
6. Accidental failure to secure the tooth when forced out into 
the mouth, through which it may be swallowed or become lodged 
in the trachea or bronchi, causing suffocation and death. A number 
of such cases have been reported. REMOVAL OF IMPACTED TEETH 
77 
List of Serious Accidents of Extraction.-The following list of 
serious accidents of extraction, compiled by Dr. Julius Endelman, 
of Philadelphia, from the Dental Cosmos, up to and including 1904, 
and reported at the Fourth International Dental Congress, at 
St. Louis, gives an indication of the possibilities of these dangers. 
While by no means complete and not including accidents since 
that date, it is nevertheless sufficient to call attention to the fre- 
quency and the nature and character of the most common of such 
accidents, as well as to the danger which attends them. 
Hemoval of the floor of the antrum, 2; contraction of the muscles 
of the forearm and flexors of the fingers and adduction of thumbs, 
1; tooth impacted in bronchus, death, 1; swallowing of tooth, 1; 
swallowing of a tooth, recovery, 1; fracture of maxillae, 2; shock 
following extraction, death, 1; taking cold after extraction, infection, 
1; migration of stump, 1; removal of tuberosity, 1; tooth in bronchus, 
recovery, 4; choked by tooth, death, 1; pneumonia caused by a tooth 
in bronchus, 1; paralysis after extraction, 4; dislocation of mandible, 
1; suffocation by swallowing of a tooth during extraction, 1; third 
molar driven into jaw during extraction, 1; fracture of palatine 
bone, 1; purulent infection after extraction, 1; purulent infection 
following fracture of jaw during extraction, 1; broken piece of forceps 
left in jaw after extraction, infection, 1; death after extraction, infec- 
tion, 3; tooth slipped from forceps into trachea, 1; forcing tooth 
into antrum, 1; hemorrhage, death, 1. 
"Out of the total of 35 cases, 8 terminated fatally; 3 of the 
fatal cases were the result of infection directly traceable to foul 
instruments. 
"There have probably been many similar accidents not reported, 
but cases of serious infection following extraction and death from this 
cause in a considerable number have undoubtedly not been reported." 
Anesthetics.-In many of the less serious cases the injection 
of a local anesthetic seems to be sufficient. The author, however, 
fears local anesthesia chiefly because of the danger of carrying 
infection into the tissues and because the large quantity of the 
anesthetic required for the removal of deeply embedded teeth has 
often caused local necrosis and serious general effects. A marked 
instance of this occurred in an individual for whom an impacted 
third molar was removed under local anesthesia induced by the 
use of cocain and adrenalin injected by a high power syringe. 
Some hours after the operation loss of consciousness and paralysis 
ensued, with complete destruction of the usefulness of the life of 
the patient, presumably through an embolus forced into the brain 78 
PATHOLOGICAL DENTITION 
Conductive anesthesia by blocking the nerve supply with novo- 
cain as described on page 20 and illustrated in the section on 
Anesthesia gives satisfactory results. 
In this way not only is freedom from pain assured, but the 
adrenalin, or suprarennin effect, is shown in marked lessening of 
the hemorrhage. 
This facilitates both rapidity and accuracy in the performance of 
the operation. 
When a general anesthetic is used, whether nitrous oxide gas, 
nitrous oxide gas and oxygen, somnoform, or ether, the operator 
should make certain that the anesthesia will continue sufficiently 
long to permit a complete operation without undue haste, and 
without the disadvantages attending such operations under imper^ 
feet anesthesia. Neglect of this has caused many accidents which 
might have been avoided had anesthetic conditions been more 
favorable. 
Asepsis.-Surgical cleanliness should be rigidly enforced and 
every effort made to avoid infection. Whenever possible, the 
teeth should be thoroughly cleaned. The mucous membrane 
surfaces of the tongue, cheeks, lips, and the surfaces of the tooth 
crowns should be thoroughly cleansed with alcohol and the imme- 
diate field of operation painted with iodine. Neglect or carelessness 
in these respects may cause great suffering to the patient or even 
death. 
Position of the Patient.-As a safeguard against the inspiration 
of blood, the patient, if lying in a prone position, should have the 
shoulders raised sufficiently to tip the head backward. When the 
face is turned to one side the blood and mucus will then tend 
to flow into the side and posterior portion of the pharynx. In 
this situation quick sponging is made possible and the likelihood 
of passage into the trachea is decreased. In this position also a 
tube may be passed through the nose down to a point opposite 
the tracheal opening through which the anesthetic may be admin- 
istered and the pharynx packed with gauze. This procedure, while 
objectionable in some respects, is effective in preventing the escape 
of blood and mucus or the tooth in this direction. 
Control of the Field of Operation.-The entire field of operation 
may be brought into view and the operation greatly facilitated by 
drawing back the corner of the mouth and cheek with a retractor 
and holding the tongue out of the wray by a roll of gauze grasped 
in a forceps. The latter also serves to prevent the blood from 
flowing into the pharynx (Fig. 45). REMOVAL OF IMPACTED TEETH 
79 
Exposure of the Embedded Tooth Crown.-The tooth crown 
with its embedded root should be exposed (Figs. 44 to 49) suffi- 
Fig. 44.-Impacted lower third molar, with overlying bone removed to facilitate 
extraction. 
Fig. 45.-This shows the method of controlling the field of operation in extraction 
of impacted lower teeth. Gauze held between tongue and jaw, retractors and mouth 
gag in place, and the surface of the impacted lower third molar exposed ready for 
extraction. 
ciently to allow it to be firmly grasped by the forceps or raised 
with an elevator. When this method is followed, it usually renders 80 
PATHOLOGICAL DENTITION 
the use of the so-called Physick forceps unnecessary, and thus tends 
to avoid the danger of unnecessary fracture of the alveolar process 
or iaw. 
Fig. 46.-Another form of impacted lower third molar, exposed and ready for removal 
This is best accomplished by the removal of the overlying and 
surrounding bone structure with surgical or dental engine burs. 
When a dental engine is used, the burs made for bone cutting or 
those used for finishing vulcanite plates or root canal reamers are 
Fig. 47.-Method of exposing an impacted upper third molar for extraction. 
best adapted for this purpose, because the flanges are more open and 
will cut fresh bone better than those intended for cutting dentin 
or enamel, which quickly clog and become useless. WOUNDS OF THE MOUTH 
81 
Fig. 48.-Method of exposing an impacted upper cuspid on the palate surface. 
Fig. 49.-Method of exposing a malposed and impacted upper cuspid from the labial 
side of the jaw. 
WOUNDS OF THE MOUTH. 
General Consideration of Wounds.-Definition.-A wound is a 
solution of the continuity of the tissues of the body caused by some 
external agent. Solutions of the tissues of the body resulting from 
disease are not classed as wounds. In surgery it is generally under- 
stood that skin or mucous membrane must be involved. In medical 82 
PATHOLOGICAL DENTITION 
jurisprudence any lesion of the body resulting from external violence 
is so classed, thus giving much wider range in application than when 
the term is used in surgery. 
Varieties.-Wounds are classified as follows: Incised, cut with 
a sharp instrument; punctured, cut with a pointed instrument; 
lacerated, torn; contused, bruised; gunshot, made by a projectile; 
poisoned, caused by toxic substances introduced into the tissues 
of the body, as from the bite of a venomous snake, insect, rabid 
dog, or from dissecting wounds. 
These may be considered under one general division: Aseptic, 
free from infection by microorganisms; septic, infected by the 
microorganisms of fermentation or putrefaction. 
They may be again subdivided for the purpose of description 
into superficial, affecting the skin or mucous membrane only; 
deep, involving the underlying tissues; simple, without complica- 
tion; complicated, when there is any complication in addition to 
the wound, as from a foreign body or substance, serious infection, 
unusual hemorrhage, or injury to large nerves, bone, vessels, or 
other important structures; surgical wound, when made in the 
performance of a surgical operation; flesh wound#, involving only 
soft tissues; subcutaneous, beneath the skin; and open or closed. 
Repair of Wounds.-Healing by Immediate Union.-When the 
lips of a clean incised wound are brought together at once and kept 
in close approximation, rapid healing occurs. In this case a micro- 
scopic examination shows slight exudation from the surface of the 
wound and proliferated connective-tissue cells. The epithelial 
continuity is restored by proliferation of the epithelial cells. This 
is called healing by immediate union. 
Healing by First Intention.-When apposition of the wound sur- 
face is less accurate, the amount of exudation is greater. Twenty- 
four hours after injury the parts are red and swollen, but soon 
become glazed in appearance. The process is much the same as in 
immediate union, except that the amount of exudation is greater 
and the healing process is slower. This is called healing by first 
intention. 
Healing by Second Intention, or Healing by Granulation.-Reten- 
tion by or of foreign bodies or continued exposure causes small 
red elevations, called granulations, to appear upon the surface of 
the wound within two or three days after injury. These granu- 
lations are newly formed capillaries covered by round cells, and 
later on giant cells occasionally appear. If the wound is infected 
and pus appears, the proliferated round cells gradually elongate WOUNDS OF THE MOUTH 
83 
to form new fibrous tissue, which ultimately contracts to form 
cicatrices or scars. Epithelial continuity is brought about by 
multiplication of epithelial cells at the surface of the wound. 
Healing by Third Intention, or Adhesions by Granulation Surface.- 
Some authors use this term to signify the process which takes 
place when large surfaces are required to be filled in by granula- 
tions, in order to complete the healing process, as the cavities 
of large abscesses, and large exposed surfaces which sometimes 
require months to fill in. As there is no essential difference from 
the healing by second intention, except in degree, it seems hardly 
necessary to consider it as a special form of healing process. 
Treatment of Wounds of the Mouth.-The steps in treatment 
of wounds in this, as in other regions, are as follows: 
1. Prevention or correction of septic conditions. 
2. Control of hemorrhage. 
The order of importance of these two procedures is necessarily 
interchangeable, because with accident or injury to large vessels 
the first consideration would obviously be arrest of hemorrhage 
regardless of sepsis. In the absence of dangerous flow of blood, 
septic considerations would naturally be first. 
3. Coaptation of the Wound Surfaces to Promote Healing.- 
Wounds of the mouth involving maxillary bone structures do 
not often permit exact approximation of the overlying soft tissues. 
Incisions or injuries affecting the cheeks and lips require the greatest 
possible care. Not only must the deeper tissues and the mucous 
membrane, as well as skin surfaces, be brought into direct contact 
to facilitate union, but reunion of divided muscles necessitates 
skilful adjustment to secure correct muscular action after the healing 
process has been completed, and to give freedom from the contrac- 
tion of scar tissue, which causes deformity when the parts are at 
rest, and in even greater degree during muscular action. 
4. Dressings if required. 
5. Prevention of Undue Physiological Action.-The prevention of 
tension and provision for physiological rest are matters of great 
importance and often of considerable difficulty. Sutures and dress- 
ings intended to overcome this strain upon the wound surfaces must 
be of such character as to hold securely until a period of time has 
elapsed sufficient to enable the muscular fibers to become securely 
united. 
6. Drainage is sometimes required, but rubber or glass tubes 
and other methods employed to prevent the collection of fluid in 
deep wounds of other parts of the body are, as a rule, imprac- 84 
PATHOLOGICAL DENTITION 
ticable to use in the mouth. The capillary drainage of gauze 
packing is the correct procedure. 
Dressing.-Dressings in the buccal cavity, as dressings in other 
parts, should give protection against external pathogenic bacteria, 
permit the healing process, and prevent the collection of pus or 
other fluids which tend to delay the process of repair. In addition, 
they should have antiseptic properties to combat the pyogenic and 
other microorganisms constantly present in the oral secretions. 
The danger of swallowing germicidal agents, however, necessitates 
a weaker strength than would otherwise be advisable. The almost 
unavoidable further weakening by solution with the salivary secre- 
tions renders it exceedingly difficult to find an agent capable of 
maintaining its own integrity under these conditions for a sufficient 
length of time. 
The author's rule is to leave shallow cavities and open surfaces 
in the mouth uncovered and to depend upon frequent cleansing 
with mild antiseptic solutions for the prevention of serious infec- 
tion and to promote granulation. In deep inaccessible or unfavor- 
ably situated cavities in bone, which of necessity cannot drain 
themselves properly, packing with sterile gauze wrung out in 
acetozone, or some antiseptic solution, such as compound tincture 
of benzoin, or 1 to 10,000 bichloride of mercury, and sealed with a 
solution of gutta-percha and chloroform, or collodion, is required. 
The gauze should not be allowed to remain more than twenty-four 
hours, because of the bacteria-laden secretions which are necessarily 
absorbed. Wounds upon the buccal surfaces of the lips and cheeks 
which permit of coaptation can be well protected by careful suturing 
of the mucous membrane with fine gut sutures. 
In the treatment of all wounds the first consideration should be 
directed to the cause. Poisoned wounds of all varieties necessarily 
require, in addition to local treatment, an effort to prevent the 
introduction of the poison into the general circulation, and in this 
way to limit its effect. Beyond this there must still be general 
treatment to enable the system to overcome and throw off the 
effect of the poison. The bite of a dog, for example, should, if 
possible, be cauterized immediately. If rabies is suspected, the 
Pasteur treatment should be given in addition. Ordinarily the 
only danger from bites of animals is infection from the mouth 
secretions, which are sometimes highly toxic, especially if carrion 
has recently been eaten. The bites of poisonous serpents are 
more apt to occur at the extremities, and may sometimes be con- 
trolled by ligatures tied above, to close the portals of the general WOUNDS OF THE MOUTH 
85 
circulation. Free blood-letting in wounds of this character and 
the removal of a considerable portion of tissue in the immediate 
vicinity of the wound, with suction to draw out the poison, are 
sometimes advantageous methods of protection against the general 
poisonous effect. Hypodermic injections of strychnin and anti- 
toxin prepared in the usual manner from the poison of these serpents 
are believed to be efficacious. General symptoms are intense 
localized irritation, followed by marked swelling, usually accom- 
panied, if progress be unchecked, with marked symptoms of 
nausea, vomiting, rapid or feeble pulse, mental disturbance, 
and death. 
Tn the one case of a rattlesnake bite that has come under the 
author's observation, the arm of the hand that was bitten swelled 
to several times its natural size and became quite black. There 
was marked spasmodic muscular twitching over the whole body, 
almost to the point of convulsions, and delirium which lasted 
several hours, after which there was slow recovery. 
Wounds received in making dissections lead to septicemia, 
which will be considered under that heading. In gunshot wounds 
and accidental injuries received from fireworks there is marked 
tendency to tetanus. Unless the bullet be favorably situated for 
removal, or in contact with some vital part w'hich makes its imme- 
diate extraction imperative, it is not well to probe too much in an 
effort to locate it. Good care should be used in thoroughly cleansing 
a wound made by a projectile, whether it be a bullet or some 
other substance driven into the tissues of the body by an explosive 
force, because there is always the danger of infection from the 
skin surfaces, or from particles of clothing, fractured pieces of bone, 
or teeth driven into the wound. Aside from this consideration the 
care is practically like that of any other traumatic lesion. 
All experiences in the treatment of wounds of many kinds since 
the beginning of the war in 1914, and particularly the vast number 
of mouth, jaw, and face injuries from projectiles of every descrip- 
tion complicated as these have been by infections, tetanus, gas 
bacilli, and other complications which have been favored by the 
situations and conditions of warfare render it necessary to give 
more detailed consideration to the treatment of wounds of the mouth 
in Chapter XIV, devoted to this subject. 
Treatment of Hemorrhage from Wounds of the Mouth.-There are 
some special considerations pertaining to the treatment of hemor- 
rhage following operations upon the tissues of the mouth and jaws, 
which, notwithstanding the fact that they are necessarily frequently 86 
PATHOLOGICAL DENTITION 
referred to in the description of surgical operative procedures, 
require distinct recognition in this connection. 
1. Preceding operations of serious character, the coagulation 
time of the blood should be taken. 
2. As a matter of postoperative precaution during the period 
of unconsciousness following the administration of a general anes- 
thetic, the patient's head should be kept turned upon one side, 
so that the blood, if any, will flow out of the mouth, where it will 
be observed and not be likely to be inspired. 
3. When wounds of the mouth give evidence of excessive flow 
of blood from a vessel, or of capillary oozing with tendency to 
persist, whether the operation that has been performed be the 
extraction of a tooth or other minor procedure, or a major opera- 
tion involving division of tissue over a large area, the bleeding 
should, if possible, be checked immediately at the time of opera- 
tion. Too often dentists or physicians and surgeons are inclined 
to underestimate the serious possibilities of the flow of blood from 
these slight wounds. Patients are allowed to leave the operating 
room or even go home with blood still flowing in more or less con- 
siderable quantity, the operator carelessly trusting to the cessation 
of hemorrhage in natural course, as he has usually known it to occur. 
Sometimes such hemorrhages are allowed to become matters of 
vital menace before hemostatic measures are instituted. It is some- 
times difficult to pick up and ligate small vessels in unfavorable 
situations in the mouth, but it is an exceedingly simple procedure 
to carry a good suture in a small curved needle around the point 
of hemorrhage and to tie it with sufficient pressure to check the 
flow of blood. The small portion of tissue, other than the vessel 
itself, which may be included in the ligature is not important. 
Dentists, particularly, would save themselves and their patients 
trouble by the habitual use of this simple procedure. All incisions 
in the mouth in surgical operations should be made so far as prac- 
ticable of such form and in such situations that blood may be checked 
either by ligation or packing of the wound. This can nearly always 
be accomplished, and the principal dangers of postoperative hemor- 
rhage thus avoided. Ligation or compression of the external carotid 
is an important emergency procedure to prevent uncontrollable or 
dangerous loss of blood in certain grave operations, and compres- 
sion of the vessels of the extremities by rubber bands at the shoulders 
and hips is one of the measures sometimes adopted to reduce the 
activity of blood flow in mouth and head operations. 
The author has but little faith in the use of local astringent appli- WO UN DS OF THE MOUTH 
87 
cations, and believes it is safe to assume that hemorrhage is under 
control only when it is positively checked by ligature, packing, or 
natural coagulation and vascular contraction. The local applica- 
tion of adrenalin directly or as a spray is useful in slight capillary 
hemorrhage. 
When a tooth has been extracted, it is usually practicable to pack 
the socket with gauze, but sometimes the gushing of blood, even 
under these circumstances, is so great as to force the packing out. 
In these cases a packing much larger than is necessary to fill the 
tooth socket must be used, and the surplus packing arranged above 
the alveolar ridge in such manner that the jaws can be bound 
together and sufficient pressure exerted to overcome that of the 
blood. Cases have been reported of dangerous hemorrhage where 
several teeth have been simultaneously extracted, particularly 
when the outlines of the tooth sockets have been destroyed by the 
removal of portions of the surrounding alveolar processes incident 
to the extraction of badly decayed roots; and in these cases it is 
often impossible to locate a particular vessel as being the cause of 
the flow of blood, and packing, except in a general way, is also 
impracticable. 
Under these circumstances a simple method sometimes resorted 
to by dentists where strictly surgical methods have failed is to fill 
an impression cup with plaster of Paris, placing this in the mouth 
as if to take an impression, but allowing it to remain in situ and 
binding the jaws firmly against it. When it becomes evident 
that a patient's blood does not have the normal property of coagu- 
lation, whether this be due to hemophilia or to some temporary 
pathological state affecting the blood, treatment must be instituted 
to arrest the hemorrhage. (For further description see page 42.) CHAPTER III. 
INFECTIOUS DISEASES. 
A better understanding of toxicogenic and pathogenic micro- 
organisms and the chemical substances which they elaborate, as 
well as the laws governing the action of body tissues and organs 
when subject to morbid conditions, has led to the belief that many 
terms in their strict sense are misleading or incompatible with 
our present knowledge of bacteriology and pathology. It has also 
shown the need of avoiding expressions which imply distinction 
between forms of disease that are rarely applicable to actual 
clinical conditions. The wide differences of opinion expressed 
by eminent writers on pathology, surgery, physical diagnosis, and 
clinical medicine, with regard to the application and meaning of 
the terms sapremia, septicemia, toxemia, septic intoxication, 
pyemia, etc., warrants a few simple definitions even at the risk of 
appearing to be too elementary, in order that the author's concep- 
tion of correct classification may be clearly understood. 
Definitions and Nomenclature.-Septic intoxication is the ab- 
sorption of toxic products with resulting general symptoms of 
disease without entrance of the infecting microbe into the blood 
current (Keen). 
Infection is a condition produced by the entrance and growth 
within the body of pyogenic microorganisms (Pearce, Osler). 
Poisons.-This term, when given broad application, signifies any 
substance injected or developed within the body which causes 
disease (Smith, Keen). 
Distinction is made between true toxin, a special ferment charac- 
teristic of certain bacteria, and protein poison, the intracellular 
toxin that is caused by bacterial destruction when the sensitized 
body cells, by the special ferment thus formed, break down the 
bacterial cells. Protein poison is produced by destruction of 
bacterial proteins. 
Toxemia.-A condition of the blood in which it contains poi- 
sonous products,. either those produced by the body cells and not 
properly eliminated or those due to the growth of microorganisms 
(Gould). DEFINITIONS AND NOMENCLATURE 
89 
Sapremia (Putrid Intoxication).-According to derivation and 
older application, sapremia was intended to describe a result of 
the bacteria of putrefaction. Among recent writers, both Johnston 
and Brewer accept its meaning in that light. Johnston says, "It 
is a condition caused by the absorption into the system of the 
saprophytic bacteria," but admits that poison solely due to the 
saprophytes or bacteria of putrefaction without toxemia from pus 
microorganisms does not often occur even with gangrenous condi- 
tions. Stengel expresses the more general sense in which sapremia 
has become understood when he says it is a condition that results 
from the absorption into the general circulation of toxic products 
from local suppurative foci. 
Septicemia is the descriptive term applied when the infecting 
bacterium itself enters the blood current without giving rise to 
any secondary collection of pus. Anders defines septicemia as 
"A disease due to the introduction into the system of the products 
of putrefaction (sapremia) or to microbic invasion of the blood 
and tissues (true septicemia), with or without the presence of a 
local seat of infection." Pyemia signifies that microorganisms have 
been carried through the circulatory channels and that infective 
emboli have formed new foci of inflammation with resulting 
metastatic abscess. "Septicemia plus metastatic abscesses." 
Pearce1 calls attention to the confused state of the nomenclature 
of these affections, and suggests the use of the word "toxemia," 
the meaning of which he would circumscribe as follows: "Under the 
term may be included- all intoxications due to the absorption of 
bacterial poisons. For convenience of description two subdivisions 
may be made: (1) The toxemias associated with affections demand- 
ing surgical intervention-the so-called 'sapremia;' and (2) those 
of the acute infectious diseases, such as diphtheria, typhoid fever, 
and pneumonia." 
Smith specifically urges the abolishment of the term sapremia 
and other indefinite or inaccurate expressions, and also brings 
forward the word toxemia as a suitable substitute; but he desires 
to limit it even more strictly than Pearce, and claims that it should 
only be intended to "apply to the diseases in which one or more 
poisons are present in the blood which are not of parasitic produc- 
tion, while septicemia should be applied to diseases which present 
poisons in the blood that are of parasitic origin, the parasite itself 
being in the blood."2 
1 Osler: Modern Medicine, vol. ii, p. 647. 
2 Alfred Smith, in Keen's Surgery, vol. i. 90 
INFECTIOUS DISEASES 
Bacteriemia (the presence of schizomycetes in the blood) has 
come to be quite generally used in the effort to avoid technical 
confusion. 
Notwithstanding these differences of opinion among authorities, 
when judged from a surgical point of view the essential distinction 
resolves itself into the simple question as to whether the cause of 
the symptoms of disease is non-septic or septic in character. It 
appears to the author, after a careful review of the opinions of 
the writers whose definitions have been given, and many others 
that could not be included, that toxemia, according to the definition 
given by Pearce, is in some degree a better and less confusing term 
than sapremia, which has been so variously applied. According to 
this, our division of the subject would then be toxemia, septicemia, 
and pyemia. That these conditions may be coincident or may 
follow each other without the possibility of a distinct line of demar- 
cation in many cases is undoubtedly true. It is also a notable fact 
that efforts to clarify the meaning of these terms in general use by 
coining new words or attempting to outline absolute limitations 
for their use tends to make the matter of proper classification 
more instead of less difficult. 
PYREXIA (FEVER). 
Hyperthermia, or elevation of bodily temperature above normal, 
is one of the expressions of many pathological conditions. 
Direct exposure to heat has been known to cause hyperthermia 
in animals and in small degree in man, but the heat-regulating 
adjustment is usually so-effective that the change from this cause 
alone is slight in individuals in good health. Excessive heat may 
lead to nervous or other disarrangement of bodily conditions, 
whereby toxic substances may be produced. It is in this way that 
the heat centers of the brain become affected in sunstroke. 
It is important to remember, in the treatment of fever, that 
causes other than bacteria and their products may incite increase 
of bodily temperature, and again that fever is sometimes beneficial 
in favoring bacterial conditions and then becomes one of the 
natural efforts to overcome the disease. 
Drugs which reduce the temperature by reducing the heart's 
action are therefore to be avoided, and therapeutic efforts should 
always be directed to the relief of the cause rather than this 
symptom. 
Hysteria and nervous diseases of such character as to affect PYREXIA 
91 
these centers directly have also been known to cause fever. But, 
as a general rule, fever is caused by toxic substances. These may 
be from bacteria, or products of the growth of microorganisms, 
albuminous bodies of this nature, or those developed quite outside 
of bacterial action.1 
The irritability of the heat-regulating center (presumably in the 
basal ganglia because a proper heat regulation cannot be main- 
tained unless certain parts of the midbrain are intact) is particu- 
larly susceptible to chemical action and infectious processes. 
Friedberger found that small specific proteid caused fever in ani- 
mals sensitized by that proteid, while collapse with subnormal tem- 
perature and even death resulted from the injection of larger 
amounts. He holds that anaphylatoxin is the uniform cause of 
infectious fevers by stimulation of the heat-regulating center. 
Aseptic Fever.-Aseptic wound fever, ferment fever (von Berg- 
mann), resorption fever (Billroth), after fever, traumatic fever. 
Etiology.-This form of fever is now believed to be chiefly if not 
altogether due to the absorption of nucleins and albumoses, sub- 
stances occurring in extravasated blood. This has been proved 
by the introduction of these substances into the circulation of 
animals. It was formerly looked upon as a result of absorption 
of the fibrin ferment formed in extravasated blood. That other 
factors also enter into the causation of fever following surgical 
operations under aseptic conditions is shown by the well-known 
fact that rise in temperature may be but slight after severe opera- 
tions and higher when the operation is in no respect severe. The 
loss of large quantities of blood, the length of time of operation, 
imperfect hemostasis, bruising and strangulation of tissue, an 
undue amount of general anesthetic, operation in the region of 
important nerves, and other factors which govern the degree 
of shock are all important elements in the increase of temperature 
after surgical operative procedures. Fright alone may so act upon 
the heat centers as to cause fever. Just where the line of demarca- 
tion should be drawn in a dogmatic way, distinguishing a single 
element as responsible for aseptic wound fever, is uncertain. 
Septic Fever.-A fever caused by one or more of the forms of 
acute general sepsis, such as toxemia, septicemia, pyemia, and 
allied conditions. 
Etiology.-The bacteria generally gain entrance through wounds 
or the mucous membrane of the alimentary, respiratory, or genito- 
1 Beilfield: The Basis of Symptoms, p. 404. 92 
INFECTIOUS DISEASES 
urinary tracts, or the infection may occur in the course of pneu- 
monia, erysipelas, puerperal fever, typhoid fever, and other similar 
diseases. 
Occasionally it is impossible to determine the point of entrance 
of the microorganisms, and such an infection is described as 
cryptogenet ic. 
Since the bacteria of septicemia are identical with those of 
pyemia, it is difficult to understand why they form foci of inflam- 
mation in some cases and not in others. 
The organisms most frequently responsible for septicemia in 
surgical cases are streptococci, staphylococcus, the pneumococcus, 
Bacillus coli communis, gonococcus, Bacillus pyocyaneus, Bacillus 
aerogenes capsulatus, and Bacillus anthracis. 
Symptoms.-There are certain general symptoms which are 
typical of cases of acute general sepsis. Variation from these and 
the degree of severity largely determine clinical diagnosis of the 
type. 
In toxemia there is usually a chill, although in some cases this 
symptom is not distinctly marked. The succeeding fever may be 
only a slight rise in temperature, varying from 100° to 101° or 
102° F., with a tendency to become higher in individuals of poor 
resistance or under other unfavorable conditions. The rapidity of 
the heart's action is increased, there is usually a feeling of general 
malaise, headache, disturbance of the digestive tract, and nervous 
symptoms which vary from slight restlessness to serious manifes- 
tations or delirium. The septicemic type may be ushered in by 
symptoms of intoxication, which may progress slowly or rapidly 
into those of the more serious form of sepsis, or there may be an 
initial chill of great severity with rapid progress to a fever of 102° 
to 104° F., or even higher. The pulse becomes rapid and irregu- 
lar, and there is great prostration with marked loss of flesh, due 
in part to the rapid wasting under high fever and in a measure 
to nausea, vomiting, diarrhea, albuminuria, and uremic symptoms 
that are quite commonly present. There is usually delirium, which, 
when conditions are beyond control, is rapidly succeeded by coma 
and death. Pyemia is sometimes preceded by symptoms of intoxi- 
cation and septicemia, which in due time may be followed by the 
metastatic abscesses which mark 'the pyemic type. Under these 
circumstances there is a tendency toward chronic pyemia, which is 
evidenced by the breaking out of abscesses in various parts of the 
body. These abscesses sometimes disappear and reappear during 
a long period of time without marked acute symptoms, such as are PYREXIA 
93 
generally incident to abscess formation, or acute pyemia may result 
more rapidly, with a series of chills, indicating new foci of inflam- 
mation. These symptoms are quickly followed by high fever, 
approximately 103° to 105° F.; profuse sweats; sallow skin; dis- 
orders of the intestinal tract, which may be indicated by inability 
of the stomach to retain food, diarrhea, or constipation; and other 
symptoms that from time to time mark the effect of abscesses of 
internal organs, especially the lungs, liver, kidneys, brain, and 
joints. Ulcerative endocarditis is also likely to occur with petechial 
hemorrhages. 
Treatment.-In all forms of general sepsis the first essential is 
to find and correct the source of the infection. If the focus be an 
abscess, and is so situated as to make opening and evacuation of 
pus possible, that should be done, proper drainage established, and 
suitable antiseptics applied. The amputation of a gangrenous 
extremity, the removal of diseased bone or of an organ that cannot 
safely be retained, is required when such condition exists. In a 
general way the treatment of all such cases requires therapeutic 
measures designed to assist the elimination of the poison and 
reestablish normal physiological processes. To this end saline 
purgatives, calomel, and the drinking of large quantities of water 
are indicated. Copious rectal irrigations are sometimes very 
beneficial, especially high bowel flushing with normal salt solution. 
Hypodermoclysis.-In extreme cases the saline must be given by 
hypodermoclysis or even by intravenous infusions in order to obtain 
a more direct effect. The author believes, as the technic becomes 
simplified and conditions governing hemolysis better understood, 
that the direct or the indirect transfusion of blood, will be more and 
more resorted to for overcoming the toxic effect of septicemia and 
kindred affections of the blood. 
Plondke1 recommends the old method of venesection, combined 
with the newer one of intravenous infusion of normal salt solution 
for the purpose of rapid elimination of the toxins and the neutrali- 
zation by dilution or otherwise of those which remain. He reports 
a number of cases, in all of which there was an immediate abate- 
ment of danger symptoms, followed by prompt recovery. He gave 
no other, treatment except a dose of salts every morning and a hot 
vapor bath daily for a week, as a matter of precaution. Figs. 
50 to 53 illustrate the technic of his method, which is described as 
follows: 
1 Jour. Am. Med. Assn., January 14, 1911, pp. 115 and 116. 94 
INFECTIOUS DISEASES 
"Any prominent superficial vein, preferably the median basilic 
on the anterior surface of the elbow, is selected. Constriction is 
made above by applying a bandage just tight enough to cause 
congestion sufficient to make the vein prominent. The parts are 
carefully cleansed and under local or general anesthesia an incision 
from 1 to 1| inches in length is made over the long axis of the 
vein, which is exposed by carefully dissecting it loose from the 
contiguous tissue. A double ligature of No. 1 or single 0 catgut 
is then carried under the vein by an aneurysm needle, tissue for- 
ceps, or other suitable instrument (Fig. 50, d), and the two liga- 
Fig. 50.-Plondke's method of combined venesection and intravenous transfusion of 
normal saline. Passing the ligature. 
tures tied around the vein with a single knot at either end of the 
incision, from | to f inch apart (Fig. 51, a, a). The external surface 
of the vein is then grasped with a small rat-toothed tissue forceps 
midway between the two ligatures (Fig. 51, b) and divided at this 
point (Fig. 51, c) transversely upward (or downward, as desired) 
about half-way through its circumference. The end of a thin- 
walled glass cannula, with the largest diameter that will be admitted, 
is then inserted downward into the distal end of the opening in 
the vein (Fig. 52, a); traction is then made on one end of the liga- PYREXIA 
95 
ture (Fig. 52, 6), when the single knot readily loosens, allowing 
the cannula to pass through the loop (Fig. 53, a); the ligature is 
again tied, this time around the vein containing the end of the 
cannula (Fig. 53, 6) (it is important that the lumen of the can- 
nula is not too small, otherwise the blood will coagulate and refuse 
to flow); the constriction is then removed and another cannula, 
which may be of smaller diameter, attached to a rubber tube 
coming from a receptacle containing a normal salt solution, is 
Fig. 51.-Plondke's method of combined venesection and intravenous transfusion of 
normal saline. Ligature tied. Cutting vessel. 
inserted (with the solution slowly escaping from the tube) upward 
into the other (proximal) end of the opening in the vein (Fig. 53, c) 
in exactly the same manner in which the first tube was introduced. 
When the desired amount of blood has escaped and a sufficient 
quantity of salt solution introduced the tubes are carefully with- 
drawn, while the assistant securely tightens the knot, obliterating 
the vein. The skin wound may be closed by any suture desired." 
Collargol (Crede's preparation of colloidal silver), 2 to 10 c.c. 
of a 2 per cent, solution of 500 to 1000 c.c. of a 0.1 per cent, solu- 
tion given by intravenous injection, is strongly recommended 96 
' INFECTIOUS DISEASES 
by some surgeons for its non-irritating and strongly bactericidal 
properties. 
Fig. 52.-Insertion of glass cannula into the distal end of the vein. 
Fig. 53.-Plondke's method of combined venesection and intravenous infusion. 
Glass cannulas inserted; one cannula attached to a rubber tube from the receptacle 
containing saline solution; the other allows control of the escaping blood. 
Vaccine Therapy.-Much study, experimentation, and clinical 
employment of bacteriolytic sera have taken place during recent 
years, with, as might be expected, much diversity of opinion as to 
the result. That treatment of this nature will bear an important 
part in the control of infectious diseases there is no good reason to 
doubt. At its present stage of development, however, the author 
feels that it would be unsafe to do more than present the following 
excerpts from recent literature as evidence of known facts and 
experiences. 
All serious cases of septicemia are treated by Hagermann by TETANUS 
97 
injections of antistreptococcus serum (10 to 20 c.c. in several 
doses). By repeated examinations of the blood and pus, he is 
convinced that the serum acts on all streptococci, but has no 
specific action on any one variety. Fromme stated that the most 
virulent streptococci give rise to most hemolysis; the determination 
of this takes thirty-five hours. 
Loberson has obtained 50 cures in septicemia out of 80 cases 
by the use of antistreptococcus serum. 
Thomas arrives at the following conclusions as a result of three 
years' experience in bacterial immunization.1 
"In all, 50 distinct diseases were treated. Both by desire and 
virtue of circumstances, the time-honored measures of proved 
worth were never abolished from treatment during the periods of 
bacterial inoculations, because he has always considered bacterin 
therapy as an accessory, not as a specific agent. It was never 
intended to be, nor will it ever be, a 'cure-all,' but should be 
regarded as an aid to assist nature, in properly selected cases, to 
combat infection by fortifying the organism through the produc- 
tion of immunization by antibodies. In many instances it has 
been a difficult matter to decide how much of the cure should be 
attributed to the usual method of treatment and how much to 
bacterial immunization. Nevertheless, in certain classes of cases 
the results have been consistently so striking that the value of 
inoculation by dead bacteria is undeniable. 
"Autogenous bacterins are always to be preferred over the stock 
preparations, and success or failure frequently depends on this 
fact. Although the duration of the period of greatest potency of 
bacterins is undetermined, the best results have been obtained 
when the pus has been recultured and a fresh bacterin prepared 
every two to four w'eeks. 
"It is believed that the best effects, therapeutically, particularly 
in chronic cases, occur when the quantity is slowly and cautiously 
increased, thereby, as has been thoroughly demonstrated in tuber- 
culin therapy, avoiding hypersusceptibility or anaphylaxis." 
TETANUS (LOCKJAW). 
Tetanus is an infectious disease due to the tetanus bacillus. 
It is characterized by tonic spasms of the muscles, which are first 
1 Jour. Am, Med, A§sn,, January 29, 191Q, 98 
INFECTIOUS DISEASES 
manifested in the jaws and neck and progress until the muscles 
of the back and extremities are also involved. 
Etiology.-The tetanus bacillus was first isolated by Kitasato in 
1889, but as early as 1884 Carle and Rattone had proved the 
infectious character of the disease by inoculation of animals with 
material from the wounds of afflicted individuals. 
Earth, especially garden soil, the dust of old barns, outhouses, 
and manure heaps, is the natural habitiat of the organism. 
It is anaerobic, and may develop spores after twenty-four hours. 
In a dry sta te the spores may retain their virulence for long periods 
of time. They can withstand boiling for five minutes, and offer 
considerable resistance to antiseptics. 
Cases of idiopathic tetanus have been reported, and a form of 
the disease affecting newborn infants (trismus nascentium) occurs 
somewhat frequently, but, nevertheless, it is believed that tetanus 
can only be induced by entrance of the organism through some 
form of inoculation. Injuries causing wounds of the skin or mucous 
membrane surfaces are usually responsible for the infection. 
The frequency of tetanus after accidental injury from firearms, 
fireworks, and powder explosions has led the Journal of the Ameri- 
can Medicalf Association to prepare an annual list showing the 
extent of such Fourth-of-July injuries, with a view to their preven- 
tion. This record, as shown by the following table, gives a trust- 
worthy indication of this etiological feature: 
Year. 
Blank 
cartridge. 
Giant 
cracker. 
Cannon. 
Firearms. 
Powder, 
etc. 
Total. 
1903 . 
. . 363 
17 
5 
3 
27 
415 
1904 . 
. . 74 
18 
5 
1 
7 
105 
1905 . 
. . 65 
17 
4 
5 
13 
104 
1906 . 
. . 54 
17 
1 
7 
10 
89 
1907 . 
. . 52 
8 
6 
4 
3 
73 
1908 . 
. . 58 
5 
4 
3 
6 
.76 
1909 . 
. . 130 • 
9 
1 
4 
6 
150 
1910 . 
. . 64 
2 
5 
1 
72 
CAUSES OF TETANUS CASES. 
Of the 72 cases in 1910, 67 (93.1 per cent.) ended fatally as 
compared with 84 per cent, in 1909, 72 per cent, in 1908, 85 per 
cent, in 1907, and 84 per cent, in 1906."x 
Symptoms.-The incubation period varies, but usually occupies 
ten to fifteen days. The forms in which the disease appears are 
acute, chronic, and cephalic. 
1 Jour. Am. Med. Assn., September 3, 1910. TETANUS 
99 
Acute tetanus is indicated by sudden onset of the symptoms of 
malaise, headache, chills, stiffness of the neck, and tightness of the 
jaws. Lockjaw, or tonic spasm of the masseter muscles, follows, 
and the contraction of the muscles of the eyebrows and of the 
angles of the mouth gives the appearance known as risus sardonicus. 
As the muscles of the body begin to be affected the back becomes 
curved and the body rests upon head and heels (opisthotonos); 
pleurosthotonos, or drawing of the body to one side, is less frequent; 
emprosthotonos, forward bending, occurs very rarely. 
The clinical picture is one of great distress, and, once seen, never 
to be forgotten. Paroxysms may succeed each other rapidly or 
slowly, and the length of their continuance be variable; dyspnea 
and cyanosis are usually quite marked; the pain is sometimes 
intense, and the fact that the mind remains clear adds in untold 
measure to the horrible agony of suffering. Fever may be slight 
or it may reach a high temperature, 105° F. or more. Failure of 
the heart, or asphyxia due to fixation of the respiratory muscles, 
may cause death, or it may occur from exhaustion within a few 
hours or after several days (approximately ten). 
In one case that came under the writer's notice, that of a boy 
who several days before had slept all night in a barn and had his 
fingers so badly frozen that they required amputation, death 
occurred within twenty-four hours after the operation, and less 
than that time after the first convulsive symptoms were 
noticed. 
Chronic Tetanus.-Chronic tetanus exhibits symptoms much the 
same as in acute cases, but with less severity. In such cases the 
disease sometimes continues for weeks, with gradual tendency 
toward decrease in the frequency of the spasmodic attacks, until 
finally recovery ensues. 
Cephalic Tetanus (Kopf Tetanus').-This form occurs after inju- 
ries in the region of the distribution of the twelve cranial nerves. 
It is accompanied by paralysis of one or more of the motor nerves, 
especially the facial, and occasionally by sensory disturbance of 
the trigeminal nerve. The tendency is to localization of the tetanic 
spasms in the lower jaw and neck and in the muscles concerned in 
deglutition and respiration. 
Diagnosis.-In well-developed cases diagnosis is ordinarily com- 
paratively simple. In tetany the symptoms of muscular contrac- 
tion are chiefly evident in the extremities, and since it is a neurosis 
associated with hysteria or the toxins of typhoid and similar fevers, 
there is absence of an abrasion or wound to account for the infec- 100 
INFECTIOUS DISEASES 
tion, and a clinical history which usually serves to complete the 
diagnosis. In strychnin poisoning involvement of the jaw muscles 
appears late, if at all, instead of being an early and constant 
symptom, as in tetanus, and muscular relaxation between paroxysms 
is complete. 
In the cephalic type, as the symptoms are chiefly manifested 
by spasmodic contraction of the lower jaw, a number of affections 
require differentiation, especially in cases of tooth impaction or 
after the extraction of teeth. In one of the author's cases of chronic 
tetanus the diagnosis was difficult, owing to the fact that the 
tetanus bacillus had gained an entrance through an abrasion of 
the cheek by jagged edges of diseased roots of teeth, while the 
symptoms readily might have indicated infection from abscesses 
at the apical ends of these roots. It is well known that direct 
irritation of the inferior dental branch of the fifth nerve may excite 
motor disturbance and cause spasmodic contraction of the muscles 
of mastication. Swelling in the region of the third molar or around 
the temporomaxillary articulation may interfere with jaw move- 
ment, and in nervous patients excites symptoms which might 
easily be confused with the premonitory symptoms of tetanus. 
Recognition of the true cause and the absence of more general 
symptoms makes the diagnosis complete. 
Prognosis.-The mortality is variously estimated at from 80 to 
90 per cent, before the introduction of modern methods of treat- 
ment, and approximately 40 per cent, at the present time. There 
seems to be a fatal tendency in cases in which the period of incuba- 
tion is short or less than the usual ten days; in those, however, in 
which the onset is slow, and which more nearly approach the chronic 
form, the prognosis is much more favorable. 
Treatment.-Death in tetanus occurs primarily as a result of the 
direct action of the toxin and because of the exhausting effects of 
the convulsions; contributing factors are the starvation, loss of sleep, 
and the horror suffered by the conscious patient. Treatment must 
include the following: 
1. The bacteria at the seat of infection should be destroyed to 
prevent further production and absorption of the toxins. To this 
end local disinfection and removal of diseased tissue must be 
prompt and as complete as possible. The agents chiefly used are 
bichloride of mercury, a 2.5 per cent, solution of carbolic acid, 
creosote, or other similar germicides. Thorough cleansing of the 
wound surface whenever possible should be supplemented by 
actual cauterization and swabbing with tincture of iodin or nitrate TETANUS 
101 
of silver. Balsam of Peru is recommended by Hessert1 as possessing 
"some antagonistic action on the tetanus toxin." 
2. The toxins already absorbed from the primary lesions should 
be eliminated from the body. Cathartics, diuretics, and sudorifics 
are used as aids. 
3. The circulating toxin should be neutralized, since it is at 
present impossible to reach the toxin already in combination with 
the nerve cells and to immunize the body after infection has taken 
place. The antitetanic serum is used for this purpose. Reports 
as to its value differ as its effectiveness is influenced by many 
factors, but notwithstanding, it is generally accepted as the most 
promising method of treatment. 
4. Every effort should be made to overcome the symptoms by 
inducing muscular relaxation and preventing the exhaustion of the 
tetanic spasms, thus conserving the patient's strength to counter- 
act the disease. The bromides and opium have been used more 
or less successfully for this purpose. 
Spinal injections of magnesium sulphate tend to eliminate the 
spasms, and seem to have helped many patients to recovery who 
might have died under serum treatment alone. McPhedran2 
recommends the use of a 25 per cent, sterilized solution of mag- 
nesium sulphate in distilled water, and injects it into the spinal 
canal between the third and fourth lumbar vertebrae without 
preliminary removal of spinal fluid. He reports 11 cases, with 5 
recoveries. 
Recently the use of chloretone, introduced per rectum in 30- 
grain doses with 2 ounces of olive oil, has been highly recommended.3 
Chloretone is said to markedly decrease the rigidity within a 
definite period after administration. Thus by relieving the trismus 
it enables the patient to take nourishment and retain strength. 
Hutchins reports 5 cases in which chloretone was used in con- 
nection with antitoxic serum injections. Recovery took place in 
all except 1 case, in which death ensued from peritonitis following 
an intestinal perforation. 
Large doses of antitoxin seem to be required in successful treat- 
ment of tetanus. Charles H. Lemon, of Milwaukee, reports an 
interesting case of a boy, aged twelve years, who stepped on a 
chicken-bone in a barnyard and was given 3000-unit doses every 
three hours. In his case a total of 42,000 units were given. The 
1 Suig., Gynec. and Obst., 1909. 
2 Canadian Jour. Med. and Surg., June, 1909. 
3 Surg., Gynec. and Obst., 1909. 102 
INFECTIOUS DISEASES 
boy recovered. Another case that he treated in association with 
Caffrey has been reported and published in the Journal of the 
American Medical Association, November 5, 1910, as follows: 
"A case was successfully treated by Dr. A. J. Caffrey1 with large 
quantities of antitoxin. The patient was a youth, aged eighteen 
years, and symptoms appeared about twelve days after running 
a splinter in the big toe while barefoot. In all, 112,500 units were 
administered. The temperature never ran higher than 103° F. A 
rash, not unlike that of scarlatina, with intense pruritus appeared. 
Morphin was resorted to with good effect, but to Caffrey it 
appeared the antitoxin effected the cure, and without it he believes 
the patient would have died September 9, as on that day the 
dyspnea was intense and the patient became cyanosed, but after 
each dose he regained his color and got the needed rest." 
Prophylaxis.-Much attention is now being given to the prophy- 
lactic injection of serum in suspicious cases. Murphy2 states that 
"The public should be taught that all punctured wounds of soiled 
hands, feet, or face should have a prophylactic dose of antitetanus 
serum. Every patient with a lacerated or contused wound brought 
to Mercy Hospital receives an injection of serum in the admission 
dressing room. We have not had a single case of tetanus following 
this treatment." 
In view of the record of the Journal of the American Medical 
Association, it would seem that the victims of injuries from fire- 
works or firearms must be given promptly a prophylactic dose of 
antitoxic serum as a precautionary measure. 
For further reference to this affection see Chapter XIV. 
TUBERCULOSIS. 
Tuberculosis is an infectious disease caused by the Bacillus 
tuberculosis. The characteristic tubercles may or may not be 
present. 
Etiology.-The sputum of consumptives is the chief medium in 
the transmission of tubercle bacilli. An advanced consumptive 
expectorates several billions of bacilli in a day. The bacilli dry, 
the particles separate, and they are carried upon currents of air 
and thus form an almost unlimited infectious influence. 
Sputum accidentally forced out in coughing or sneezing, the 
careless placing of sputum-laden handkerchiefs in pockets, kissing, 
1 Jour. Am. Med. Assn., November 5, 1910. 
2 Practical Medicine Series, 1911; General Surgery, ii, 140. TUBERCULOSIS 
103 
sputum-soiled hands, infected articles of clothing, and similar 
means of conveying the bacilli, that can only be prevented by the 
exercise of scrupulous care, are in the vast majority of cases 
responsible for the transference of the infection. 
Flies are now recognized as active agents in the spread of tubercle 
bacilli. Dr. Ch. Andre1 has found that after feeding on tubercu- 
lous sputum they evacuate bacilli after six hours, and some may 
be found in feces as long as five or six days afterward. Food thus 
polluted by flies will affect guinea-pigs. Foodstuffs may also be 
polluted with bacilli adhering to the feet of flies after contact with 
sputum. 
Bovine tubercle bacilli undoubtedly play a more or less impor- 
tant part in spreading the disease. Koch denied this in 1901, but 
Ravanel has produced the disease in cattle with the bacillus from 
human sources, and reports cases of men infected accidentally 
from animals, and maintains that "human and bovine tuberculosis 
are but slightly different manifestations of one and the same 
disease, and that they are intercommunicable." 
Tubercular lesions in monkeys and other animals are in many 
respects unlike those of man. The tubercle bacilli in fowls, the 
so-called avian tubercle bacillus, for instance, is more club-shaped 
and branching, and shows distinct differences with regard to 
culture media and toleration of temperature. 
Fish, notably carp, that are supposed to have come in contact 
with human sputum in the water in which they were raised also 
show distinct differences in temperature toleration. 
The consensus of opinion, however, is that all of these are 
different forms of the same disease, and due to practicallp the same 
bacillus. 
Portals of Entrance.-The four distinct modes by which the 
tubercle bacilli gain entrance to the body are: (1) Inhalation; 
(2) through the digestive tract by means of food containing the 
bacilli, and otherwise; (3) direct inoculation through the skin or 
mucous membrane surface; and (4) intra-uterine infection through 
the placental circulation. 
Pulmonary entrance through the respiratory tract has long been 
believed to be by far the most frequent mode of infection, but 
experimentation and clinical observations are causing a much 
increased realization of the importance of the digestive tract in this 
regard. 
1 Krebs: Tuberculosis, p. 49. 104 
INFECTIOUS DISEASES 
Owing to the bacteria-laden sputum, the oral cavity in phthi- 
sical patients is constantly filled with tubercle bacilli, and it has 
been proved over and over again by Cooke, Latham, and many 
bacteriologists that these bacilli are frequently found in the 
mouths of individuals who have no sign of tuberculosis. It is also 
true that carious teeth, diseased tooth pulps, and gums frequently 
contain tubercle bacilli. But in spite of all, primary infection in 
this region is comparatively rare. 
The tonsils appear to bear an important part in the causation 
of the disease, and their crypts are frequently the sites of primary 
infection. 
Intestinal tuberculosis, according to Osler,1 occurs in about 30 
per cent, of all cases. How many of these were primary it is diffi- 
cult to say. The pharynx, esophagus, and stomach are rarely 
primarily involved. In children under fifteen years the lymph 
nodes are the most frequent locations of primary tuberculosis. 
Direct inoculation through abrasions or wounds occurs frequently. 
Heredity.-Experimentation has proved that tuberculosis can be 
produced through the semen and through the placental circulation, 
and therefore hereditary tuberculosis can no longer be absolutely 
denied as it has been in the past. These cases, however, deserve 
slight consideration, because of their rarity in comparison with 
cases in which, perhaps, an hereditary predisposition gives increased 
susceptibility to infection by the tubercle bacillus, and in compar- 
ison with cases affected through the usual channels. 
Pathology.-Miliary tubercles are small, grayish-yellow or white 
tubercular nodules, usually varying from 1 mm. in diameter to 
the size of buckshot. Many of them are undoubtedly microscopic. 
They appear in the course of acute miliary tuberculosis, and may 
be found in great numbers throughout the principal internal 
organs, membranes of the brain, bone marrow, etc. The formations 
are not necessarily tubercular, as such nodules are sometimes 
found in other diseases. 
The inflammatory lesions occur in the tissue between and sur- 
rounding tubercles, although such inflammatory processes some- 
times develop without recognizable tubercle formation. Caseous 
change takes place in the form of areas having a dull, opaque, 
lusterless, grayish-white appearance. Liquefaction occurs in the 
necrotic tissue thus formed, with resulting characteristic cavities. 
In tuberculosis of bone, cavities which may be quite extensive are 
1 Krebs: Tuberculosis, p. 38. TUBERCULOSIS 
105 
formed. These are found to be filled with liquefied, caseous material, 
and are known as cold abscesses. The tendency to encapsulation 
of tubercular foci by the formation of fibrous tissue is an impor- 
tant feature of the disease and one upon which the possibility of 
cure is largely dependent. 
Tubercular lesions that have become encapsulated may remain 
inactive, or at least without general invasion of the tissues, for 
long periods of time, and yet through loss of integrity of the sur- 
rounding fibrous tissue capsule, by infection or otherwise, the 
disease may become general. 
Undoubtedly through the self-limiting influence of tuberculosis 
many individuals who have been believed to be free from the 
infection have at one time or another been affected by some one 
of the several forms of tuberculosis. 
It has been claimed that all people at some time have been 
subject to this infection. 
Mixed infection of tubercle bacilli with pneumococci, strepto- 
cocci, staphylococci, and other pathogenic bacteria has been 
proved by examination of the blood and diseased areas. 
Special Forms of Tuberculosis.-Organs Affected.-Ihe lungs, 
pleura, lymph nodes, peritoneum, bones, joints, and testicles are 
most commonly the seats of the disease. More rarely it affects 
the ovaries, liver, spleen, pancreas, and muscular tissues. Osler 
found 275 tubercular cases in 1000 autopsies, and in these, with 
few exceptions, the lungs were involved. 
The order of frequency of the disease in other parts, with special 
reference to surgical tuberculosis, based upon an estimate made 
from clinical reports, is approximately as follows: Bones and 
joints, 78 per cent.; lymph nodes, 14 per cent.; skin and connective 
tissues, 5 per cent.; genito-urinary organs, 2 per cent.; and mucous 
membrane, 1 per cent. 
Tuberculosis of Bone.-As already stated, the pathological 
changes which occur in bone in the course of this disease are 
much the same as in other parts. Through circulatory channels or 
leukocytic agency the bacilli become arrested in the bones, either 
in the arterioles or in the blind cul-de-sacs of the venous terminals, 
which rest against the epiphyseal cartilages, the sluggish circula- 
tion of which favors their lodgment. In this way tubercular foci 
are formed, and the usual degenerative processes of tubercular 
lesions occur. Bone destruction and absorption, caseous degenera- 
tion, and the formation of sequestra may take place, or the infarct 
so formed may become enclosed by a capsule which is exceedingly 106 
INFECTIOUS DISEASES 
hard and is called an eburnated infarct. In the rare instances in 
which the tubercular process occurs primarily in the shaft, it forms 
the so-called tuberculous osteomyelitis (osteitis sicca tuberculosa), 
which is usually progressive in character and of serious prognosis. 
The abscesses are called cold abscess, as in other tissues. 
Joint Tuberculosis.-This occurs through invasion from the 
neighboring bone or direct affection of the synovial membrane. 
It is believed that the cartilages, ligaments, and capsules are never 
the primary seats of the infection. 
According to Konig's classification, there are three varieties of 
tubercular joint affection: (1) Hydrops (hydrops serosus, hydrops 
fibrinosus); (2) tumor albus (fungous, granulating joints, "white 
swelling"-a late form of hydrops); and (3) tuberculous suppurative 
arthritis. 
Symptoms.-The symptoms are those of chronic inflammation. 
Local temperature, pain, redness, and swelling are usually absent 
or very slightly marked. Naturally the conditions are modified 
when there is mixed infection, and the streptococci or staphylo- 
cocci become active in the inflammatory processes. 
Pottinger classifies the symptoms and physical signs of tuber- 
culosis in three groups: 
1. Those due to toxemia. 
2. Those due to reflex action. 
3. Those due to tuberculous processes per se. 
When the skin is involved in connection with tuberculous bone 
abscess, its color is altered to a dull red, sometimes having a bluish 
tinge, and fistulae form in the vicinity of the diseased area. 
Cicatrization following the healing of these fistulous openings 
is very marked. 
The characteristic deformities incident to caries of the vertebrse 
are well known. The cranial bones, ribs, sternum, jaws, maxillary, 
and other bones may be affected. 
Diagnosis.-In tuberculosis of bones and joints there is an even- 
ing rise of temperature, which is to some extent characteristic of 
all forms of tuberculosis. Pain is not a sufficiently marked or 
regular symptom to be of much diagnostic value. Tenderness to 
pressure over the affected areas of bones or joints is usually found. 
■ In bones the presence of a tubercular lesion may sometimes be 
tested by passing a needle through the diseased portion, and in 
joints fibrinous deposits and miliary granulations are to some 
extent pathognomonic. These small fibrous bodies which have been 
likened to rice or sago grains are quite commonly present, and the TUBERCULOSIS 
107 
sensation to touch that they give when sliding between the syno- 
vial layers under pressure with the fingers sometimes assists in 
making a diagnosis. 
The most trustworthy diagnostic method in the early stages is 
to withdraw some of the fluid or caseous matter and to demon- 
strate the presence of the bacillus therein. Yet, as will be shown 
from the following quotation; even this test is not always trust- 
worthy. 
"The examination of fluid taken from 25 operative cases several 
days before operation, all of which were diseases of the joints, and 
some of which required excisions of the major joints, showed 60 
contained tubercle bacilli, 6 pyogenic organisms, and 12 were 
sterile. Among the organisms found were streptococci, staphy- 
lococci, Bacillus pyocyaneus, and pneumococci. Of the sterile 
abscesses, inoculation showed two negative and one positive for 
tuberculosis."1 
Any stiffening of a joint, whether from slight muscular spasm, 
or inflammatory adhesions, when not otherwise satisfactorily 
accounted for by diagnostic indications, should be viewed with 
suspicion until it may be demonstrated that the cause is not tuber- 
cular. The x-rays are valuable in ascertaining the extent and char- 
acter of bone or joint disease and as a guide in determining the 
advisability of operation. 
The maxillary bones are generally regarded as being rarely 
affected by tuberculosis. How true this may be is perhaps a matter 
of uncertainty, because the tubercular periostitis and ostitis, with 
subsequent suppuration and sequestration, so often closely resemble 
necrosis from other infections to which the maxillee are prone that 
it is extremely doubtful if correct diagnosis could be made in many 
of these cases except by the exercise of unusual care. A careful 
demonstration of tubercle bacilli in every such case, if this were 
possible, would, in the author's opinion, alter the record consider- 
ably, but whether the result would indicate an increase or decrease 
of frequency is difficult to- say. 
Typical tuberculous bone lesions in this region are most com- 
monly noted at the orbital margin of the superior maxillary or 
at its junction with the malar bone. The nasal and palatal bones 
are sometimes included by extension of the destructive process. 
After clinical observation of large numbers of these cases the author 
feels that only actual demonstration of tubercle bacilli in the 
1 J. K. Young: Am. Jour. Med. Assn., August, 1910. 108 
INFECTIOUS DISEASES 
diseased tissue can be looked upon as conclusive. Even then the 
actual cause may be doubtful because there is always a likelihood 
of mixed infection, and because it is also in this situation that 
periostitis, caries, and necrosis of bone occur so often, more espe- 
cially in young children. As has already been stated in the dis- 
cussion of necrosis, it frequently follows as a sequel of the acute 
infectious diseases which are common in childhood. Dento-alveolar 
abscesses are almost always present during this period of life in 
connection with carious deciduous teeth. Such suppurative foci 
form an almost constant source from which infection may at any 
time be communicated to surrounding osseous structures. The 
weakened resistance of the maxiltee, owing to their filling up with 
crowns of teeth in the course of development and eruption at this 
time, renders them more than ordinarily unresisting to the inflam- 
matory processes incident to such infections. 
Ulcerative and other destructive forms of stomatitis are likely 
to be causative factors, and hereditary syphilis not infrequently 
gives rise to active manifestations at this time of life. 
This opinion is warranted by abundant clinical experience in 
cases of simple infection-as proved by their prompt recovery 
under proper treatment-that have been allowed to progress and 
cause extensive bone destruction through the mistaken idea that 
they were syphilitic or tuberculous. 
General Symptoms and Diagnosis.-A detailed study of the 
general symptoms and diagnosis of tuberculosis would be outside 
the province of this work. 
A brief resume of the subject sufficient to protect against error 
in determining the existence of this disease may, however, bear an 
important relation to the therapeusis or surgery of pathological 
conditions requiring treatment within our special field. 
It should be remembered that the term scrofula, for many 
years so popular with the medical profession and the laity, is no 
longer used. 
In addition to indications which may be revealed by careful 
family history and the usual methods of physical diagnosis, sup- 
plemented by x-ray examination, the following symptoms are 
important: Fever which shows a persistent though not marked 
afternoon rise of temperature; chills and cyanosis, although not 
constant, may indicate acute conditions of this nature; persistent 
languor is always suspicious; digestive disturbances, if accompanied 
by marked wasting and without distinctively demonstrable reasons 
for the loss of weight, are important symptoms; sweats, dyspnea, TUBERCULOSIS 
109 
and emaciation are usually symptoms of the more advanced stages 
of the disease; persistent hoarseness may indicate lung or laryngeal 
involvement; circulatory disturbance is commonly noted in tachy- 
cardia, which is unaffected by change of position, the pulse run- 
ning persistently from 90 to 100; pain may or may not be distinc- 
tive in its manifestations; the characteristic cough, expectoration 
and hemorrhage are not likely to be overlooked. Careful examina- 
tion of the mouth, nose, and throat should be given to exclude 
local causes of hemorrhage. In sputum examination it should be 
remembered that tubercle bacilli are frequently found in the oral 
secretions of healthy people. On the other hand, the finding may' 
be negative, because it is usually only in the advanced stages of 
the disease that the tubercle bacilli are found in the sputum. 
Tubercular affections of the glands related to the mouth and 
neck, which are so common in children, are often troublesome 
in diagnosis, because infection from a dento-alveolar abscess may 
lead to chronic enlargement of the nodes, which closely resembles 
the result of tubercular infection. It is useful to remember that 
dento-alveolar abscess and other septic conditions of the inferior 
maxilla are adherent, whereas an enlarged lymph node, even 
though it may be situated close to the inner side of the jaw, is 
more or less freely movable. This distinction does not follow when 
the lymph node is secondarily infected from a tooth abscess and 
independently enlarged. It is a good rule in such cases to examine 
carefully not only the teeth for evidence of caries and septic con- 
ditions, but the portions of the jaws in which the crowns of erupt- 
ing teeth may lie, because these are sometimes causes of septic 
infection when the outward symptoms of pus are not noticeable. 
Differentiation must also be made from malignant and other tumors 
affecting the jaw and neck, from cysts, syphilis, and Hodgkin's 
disease. Distinction in such cases must depend upon recognition 
of positive evidences of tuberculosis, or the symptoms by which 
the other diseases may be recognized and enumerated in the 
description of these subjects. 
Tests for Tuberculosis.--The Tuberculin Test.-After the first 
period of enthusiasm with regard to its curative virtues when 
brought forward by Koch in 1891, tuberculin was generally, and, 
as is now known, undeservedly, condemned, because of its improper 
and unscientific use. At the present time its value as a diagnostic 
agent is universally recognized and its therapeutic possibilities 
appear to be constantly advancing. 
Tuberculin (old) prepared according to Koch's original process 110 
INFECTIOUS DISEASES 
is now almost universally used for diagnostic purposes. Its injec- 
tion gives a local reaction believed to be due to a combination of 
the tuberculin in the blood with the antibodies in the focus, mani- 
fested by swelling and redness in the tubercular lesions. The 
general reaction, which is similar to that of other bacterial toxins, 
includes fever, malaise, sensations of chilliness and pain in the 
head and joints, alterations in the pulse, and possibly nausea and 
vomiting. The rise in temperature may be slight or quite marked, 
and indeed, there may be almost complete absence of active 
manifestations of the other symptoms. Small doses are advisable 
for many reasons.1 
Cutaneous Reaction.-Von Pirquet's method is to scrape away 
the epithelium, as in vaccination, in two areas an inch or more 
apart. One is moistened with tuberculin, one part; five parts car- 
bolic glycerin, and two parts normal salt solution. The other is 
left as a control. In non-tuberculous individuals the reaction 
is alike at both points. With tuberculous subjects a reddened 
area, becoming more or less encrusted, appears during the first 
twenty-four hours. 
Inunction Test.-Ligniere and Moro found that rubbing a strong 
solution of tuberculin on the skin produced reaction, without 
abrasion. For this purpose tuberculin ointment is now prepared 
by reducing tuberculin (old) to an anhydrous condition and incor- 
porating it in a lanoline base. This should be rubbed for four or 
five minutes over an area of several inches. In from twenty-four 
to forty-eight hours a zone of redness appears with slight swelling 
and papular formation. 
Wright's Opsonic Index Test.-By comparing the serum of one 
suspected of being tuberculous with mixed sera of several individ- 
uals known to be free from tuberculosis, there is obtained an index 
to the diagnosis and the treatment. It is believed that the phago- 
cytic activity of the tuberculous person's leukocytes varies from 
the normal with regard to tubercle bacilli. 
The Ophthalmic Reaction.-A 1 per cent, solution of dried tuber- 
culin, alcohol precipitate, in sterile water is dropped into the con- 
junctival sac. In from twenty-four to forty-eight hours, with a 
tuberculous patient, the reaction will be experienced in a feeling 
of discomfort in the eye, which is quickly followed by conjuncti- 
vitis. Profuse lacrimation takes place and a fibrinous exudate 
collects in the region of the inner canthus. The reaction reaches its 
height in the course of eight to ten hours and lasts two or three days. 
1 Charles L. Minor: Krebs's Tuberculosis, p. 343. TUBERCULOSIS 
111 
All the tuberculin tests must be considered in connection with 
other symptoms, because there is so much variation in individual 
cases that wrong conclusions may easily be reached. The author's 
experience with the ophthalmic test, based upon observation, and 
the results as reported to him from a number of institutions in 
which this test has been more or less extensively applied, is as 
follows: While there can be no doubt that the reaction does take 
place in tuberculous patients, there is danger of exciting serious 
ocular disturbance, and it is unnecessary to incur this risk, since 
it is admitted that the cutaneous and other methods of tuberculin 
diagnosis are equally if not more trustworthy and do not have 
this element of danger. While serious eye results may be excep- 
tional, it is generally admitted that any inflammatory disease of 
the eye contra-indicates the test, and since only oculists can safely 
determine the existence of such conditions with sufficient accuracy, 
it is obviously not a method for general application. 
Prophylaxis.-Notwithstanding its terrible ravages in spite of 
the efforts to control the devastation it causes, tuberculosis is a 
preventable disease. Enumeration of the methods that are being 
projected and adopted for its control would mean a complete 
resume of the history of modern sanitary science. 
It is sufficient to state that all depend for their usefulness upon 
a few simple basal principles. 
Destruction and prevention of the propagation of the germs 
constitute the first principal division. The increase of individual 
health, in order that the human body may be in the best possible 
condition to resist and throw off the infection, covers the second 
group of important considerations. 
Direct sunlight is the great enemy of tubercle bacilli, destroy- 
ing them in from two to ten minutes. A diffused light, according 
to Weinzirl,1 destroys them in from twenty-four hours to one week. 
Moist cultures are much more readily affected than dry ones. In 
the dark corners of rooms tubercle bacilli retain their vitality for 
long periods of time. 
Oral hygiene, as commonly considered, in providing for proper 
mouth disinfection, the cleansing of ■ the teeth, the prevention of 
dental caries and other diseased conditions of the teeth, alveolar 
structures and gums, is now becoming more and more recognized, 
as its possibilities are demonstrated in the course of development 
of the now world-wide movement in this direction. 
1 Krebs: Tuberculosis, p. 49. 112 
INFECTIOUS DISEASES 
The value of these measures in contributing to more widespread 
general health, and particularly to the prevention of tubercular 
affections, is as yet only half-appreciated. With full recognition 
of this it must still be urged that there is, however, a broader and 
more important aspect of the subject which should be directly 
under the control of those who treat diseases of the mouth and 
teeth. As has been shown in the discussion of the subject of max- 
illary readjustment, this consists in the prevention and correction 
of defective nasal development (see pp. 625 and 635). 
Through the early loss of teeth, or by permitting individuals to 
reach maturity with irregular or contracted dental arches and the 
high, narrow palatal vaults that are associated with these defects, 
both the size and form of the nares are directly affected, as 
evidenced by the sections of dogs' heads on page 639. 
It seems hardly necessary to urge that proper nasal respiration 
and the free oxygenation which depends upon the proper exercise 
of this function lie at the very base of the whole structure of 
prophylaxis with regard to tuberculosis, even more than other 
affections. No better general remedy can be instituted than the 
improvement which invariably follows the widening of the nares 
by mouth expansion, as described on page 627, and the immediate 
increase in the supply of nature's most dependable agent in com- 
bating this infectious disease. This should be a routine measure 
with children, and even young adults whose upper dental arches 
and palatal vaults are narrow. 
Figs. 54 and 55 are photographs of a boy patient nine years 
old who was referred by Dr. G. L. Bellis, of Muirdale Sanitarium, 
Milwaukee, with all the symptoms of acute pulmonary tubeicu- 
losis-temperature, night-sweats, loss of flesh, hoarseness, and all 
the classical symptoms of this affection were present. An appli- 
ance was inserted and his upper dental arch spread. Thirty days 
later his mother reported that he had gained in weight and in 
height; one inch in chest measurement and one inch around the 
waist. He is now quite well (Fig. 56). 
In summary it may be said that among the most important 
measures to be adopted in the prophylactic treatment of tuber- 
culosis, there should be included all methods known to dentists 
and oral surgeons whereby the cleanliness of the mouth and its 
secretions, the life and the usefulness of the teeth, and the preser- 
vation of the perfect form of palates and dental arches, together 
with the developmental effect of these upon other parts, may be 
enhanced. TUBERCULOSIS 
113 
Treatment.-The local treatment of tubercular abscess or nec- 
rosis in the maxillae does not differ materially from other similar 
affections due to any other cause. The removal of diseased tissue 
or bone and of sequestra, if present, with packing and treatment, 
as described under the general heading of Necrosis of the Jaws 
(p. 381), is indicated. To supplement this all the influences which 
are known to be beneficial in other forms of tuberculosis should be 
brought to bear in assisting the overthrow of the local infection. 
Fresh air, highly nourishing food, and the best possible hygiene 
that the circumstances of the patient will permit are important. 
Fig. 54.-Front view of the tubercular 
boy described in text (p. 112). 
Fig. 55.-Back view of tubercular boy 
in Figs. 54 and 56. 
How far the general treatment of patients may in the future 
be incorporated as routine treatment in connection with surgical 
tubercular cases, it is difficult to say. But the Stevens Point 
Sanitarium, which is the first institution regularly to adopt the 
combination of surgical hospital treatment in connection with 
institutional methods in the treatment of individuals ordinarily 
considered as strictly surgical cases, may by its example and results 
lead to the general adoption of this combination. 
Removal of tubercular glands is not as generally resorted to at 
present as formerly, although complete and extensive dissections 114 
INFECTIOUS DISEASES 
were generally effective. Tuberculin treatment, curettement, 
drainage, and local applications to the affected glands are found 
in most cases to be sufficient. 
Murphy1 states that he has not made a typical cervical adenitis 
operation in over six years. All except the suppurating nodes are 
cured with tuberculin. The 
suppurating nodes should be 
drained and curetted, not 
dissected. 
Summary.-As an important 
matter of general information, 
especially for those who treat 
pathological conditions, tuber- 
cular or other, in any part of 
the human body, it seems best 
to include the following sum- 
mary:2 
The following leaflet, by 
Dr. George H. Krebs, of Los 
Angeles, California, submitted 
in competition for the best 
educational leaflet for mothers, 
was awarded a gold medal at 
the International Congress on 
Tuberculosis in 1908: 
Tuberculosis a Disease Re- 
sponsible for Untold Sorrow to 
Mothers. - Tuberculosis, or 
consumption, is a disease which 
robs the mothers of the world 
of one outof every ten children. 
The causes of this disease are known, likewise the means whereby 
it may be prevented. 
Every mother owes it to herself and her family to know about 
tuberculosis, so that the lives of her children may not be placed 
in peril. 
The Frequency of Tuberculosis .-In the United States more than 
150,000 persons die every year from tuberculosis. The great 
majority of these persons are in the prime of life. Many of these 
persons are married, and their untimely death means dependent 
families to be cared for by the State. 
Fig. 56.-Same boy in Figs. 54 and 55 
after recovery. 
1 Editor Practical Medicine Series, 1911, ii, 134. 
2Krebs: Tuberculosis, Appendix, pp. 808, 809 and 810. TUBERCULOSIS 
115 
The loss in money to the United States from these preventable 
deaths every year amounts to more than three hundred million 
dollars. The suffering caused by the disease is impossible to 
estimate. 
Two Important Facts about Tuberculosis.--Tuberculosis is pre- 
ventable. Tuberculosis is curable. 
These are most important facts worthy of widest circulation, 
especially since contrary ideas prevail. 
Universal prevention and cure of this disease will result only 
when there is universal effort against it. 
In this work of prevention and cure the mothers of the world 
can wield a tremendous influence. . 
The world counts on the aid of the mothers, for what mother 
would condemn either her own or any other child to an unnecessary 
death? 
What Are the Causes of Tuberculosis?-First, there is an exciting 
cause, which is a very small plant called a germ. There can be no 
tuberculosis unless this germ be present in the body. 
Secondly, the person who takes this disease has a body that is 
favorable to it. Any person whose health and strength are run 
down is predisposed to tuberculosis, because in such a person there 
is not much resistance. 
The two things necessary then for tuberculosis are the presence 
of a certain germ in the body of a person whose health for any 
reason has been run down. 
What the Germ Does, in the Lungs.-When the germ gets into the 
body of a person who is run down in health, it finds a soil suitable 
for its growth and produces the disease called tuberculosis. 
The germs produce little granules called tubercles, which may 
later become little ulcers or abscesses. 
Poisons are also thrown out by the germs and get into the blood, 
and these poisons cause most of the symptoms of the disease. 
What Are the Symptoms of Tuberculosis ?-The symptoms are 
different, according to the stage. 
It is the symptoms of the early stages that should be learned, 
for it is then that cure can be brought about and lives saved. 
What are these symptoms? 
The disease usually comes on in very slow and mild fashion. 
That is what throws the persons infected off their guard. There 
may be nothing more than a tired feeling, especially after work, 
a lessened appetite, some loss of weight, and perhaps an occasional 
cough. 116 
INFECTIOUS DISEASES 
As the disease grows worse, these symptoms do likewise. The 
loss of weight may be very noticeable; there may be fever and 
night-sweats. With the more frequent cough much sputum may 
be expectorated. 
In the far-advanced stages some of these symptoms, like cough, 
loss of weight, and fever, may be very pronounced. Then we have 
the picture of the "consumptive." 
How May Tuberculosis be Prevented?-Tuberculosis may be 
prevented by doing two things: (1) Killing the germs that cause 
the disease. (2) Having people become healthy, so that they will 
not be predisposed to the disease. 
How Are the Germs to be Destroyed?-The germs are scattered 
far and wide in the sputum which is coughed up by consumptives. 
One consumptive can cough up in a single day several billions of 
these germs. 
When this sputum dries as dust the germs are blown about in all 
directions; they get into the air we breathe and on the food and 
things we eat and handle. In this way every person at some time 
in life probably gets the germs into his body. 
To destroy these germs, all that is necessary is to destroy the 
sputum. 
If sputum be coughed into paper cups or napkins, these can be 
burned and the germs destroyed. For spittoons, disinfectant 
solutions like lye should be used. 
Coughing in people's faces or spitting on the streets, and espe- 
cially on floors, is dangerous. 
How May the Predisposition of a Weakened Body be Overcome?- 
Bodily weakness, that is, the predisposition to tuberculosis, may 
be overcome by right living, particularly by breathing pure air, 
eating nourishing food, and getting the proper proportion of rest 
and exercise. 
A child weak at birth should be guarded, and as it grows older 
made to spend much time outdoors. 
Children weak from diseases like measles or whooping-cough 
should not be neglected. These and kindred diseases are often 
responsible for tuberculosis being set up later on in life. 
Children should not be made to work at too early an age, or 
allowed to study so hard as to interfere with health. 
The food should be eaten slowly, and should always be nourish- 
ing. If cow's milk is used, it should be obtained, if possible, from 
a dairy having no tuberculous cattle. 
The living and sleeping rooms of the family should always be SYPHILIS 
117 
well ventilated. The human body, if it is to be in a healthy state, 
must have pure air. Bedrooms should not be overcrowded, and 
single beds are advisable. 
The above rules should be observed by grown-up persons as 
well. 
These simple rules are worth observing, because a healthy body 
is usually able to overcome tuberculosis, but a weakened body is 
not. 
How May Tuberculosis be Cured?-Tuberculosis may be cured 
by the same measures which prevent it, namely, by making the 
body stronger so that it will be able to kill the germs that have 
gotten into the tissues. 
Pure air, good food, plenty of rest treatment, cures more people 
of tuberculosis than all the medicines that are known. 
Avoid patent medicines for tuberculosis, particularly cough 
medicines, as these usually contain alcohol and opiates, which, 
though they may make the patient feel better, usually allow the 
disease to grow worse. 
The above methods should be carried out under the advice of 
a private or dispensary physician who has made a study of the 
disease. "Develop healthy bodies." 
SYPHILIS. 
Syphilis is an infectious disease caused by the Spirocheta (trepo- 
nema) pallida. It is ' a constitutional affection that becomes 
chronic, and is of indefinite duration. Its manifestations affect 
almost every part of the body, and in a general way are said to 
represent primary, secondary, and tertiary stages, to which some 
writers add a parasyphilitic stage. 
Syphilis May be Hereditary or Acquired. 
Hereditary Syphilis.-In the transmission of syphilis by heredity 
the infection takes place in the following different ways: 
The fetus may be infected by the semen of a syphilitic father at 
the moment of conception, or similarly by the ovum of a syphilitic 
mother. It may also be infected through the placental circulation; 
or receive infection in parturition from lesions of the mother's 
genitals. 
The conditions governing the hereditary transmission of syphilis 
vary greatly. A syphilitic father may infect both wife and child, 118 
INFECTIOUS DISEASES 
or he may infect either without the other. A syphilitic mother 
may bear an untainted child, although this is admitted to be of 
rare occurrence; and the appearance of late tertiary symptoms in 
such mothers lends color to the assumption that freedom from 
infection was only apparent. Colles' law, "that the apparently 
healthy mother of a syphilitic child cannot be infected by the 
child," is subject to occasional exception in cases that have been 
reported of mothers who have developed chancre of the nipple 
and general syphilis after nursing their infants. 
The danger of infection from the syphilitic father becomes 
markedly less after two years and seldom occurs after five years, 
but even then there is no certainty of safety. When proper treat- 
ment is given the danger is practically nil after five years, and 
it is claimed that in many cases infection is not transmitted after 
two years. 
A syphilitic mother may give birth to syphilitic children long 
after her own symptoms have ceased to be evident. There appears 
to be a gradual tendency toward lessening of the virulence of the 
infection with each succeeding childbirth; but no rule can be 
established in this respect, because with the syphilitic mother 
there may occur in almost any order, death in utero, monstrosities, 
abortions, children born with syphilitic lesions, or without notice- 
able imperfection at birth, but which may develop luetic symptoms 
at a later period. 
Symptoms.-There are no primary lesions or chancres in heredi- 
tary syphilis; but in many other respects its manifestations are 
much the same as in accprired syphilis, except for such differences 
as are caused by interference with both intra- and extra-uterine 
development. These influences, however, are usually responsible 
for clinical symptoms which vary considerably from the results of 
the same virus in acquired cases. 
The destructive influence of syphilis as affecting fetal and post- 
natal development is characterized by deformities of the cranium, 
spine, extremities, chest, and other parts. 
Syphilitic children are often born prematurely. The wrinkled 
appearance of their faces marks the type of one of the stages of 
development which gives a senile appearance, the old man's 
countenance. The skin is creased and loose, and a macular erup- 
tion often occurs. Extreme susceptibility to snuffles in infants 
indicates inflammation in the nasal mucous membrane. The eyes 
are apt to be inflamed and sunken. Lesions of the nervous system 
may manifest themselves in many forms. SYPHILIS 
119 
Digestive disturbances assist in causing restlessness, anemic 
appearance, insufficiency of growth and weight. All these symp- 
toms are characteristic, but not necessarily indicative of syphilis. 
The skin is affected by various forms of eruption. These are 
maculopapular eruptions, squamous, bullous, or pustular, and show 
a tendency to regional distribution or to become confluent. 
These indications are not always present, but syphilitic children 
may be born quite healthy in appearance and yet develop late 
symptoms of the tertiary type, or may appear to be perfect and 
yet have visceral defects that will lead to fatal lesions shortly after 
birth. 
Although the lining membrane of the nose is highly susceptible, 
the mucous membrane of the mouth is not so commonly affected. 
There may be ulcers upon its surfaces that are difficult to distin- 
guish from aphthous stomatitis, or a notable tendency to fissures 
and crust-covered cracks upon the corners of the mouth. 
The scars from these cracks when healed are important indica- 
tions of hereditary syphilis. 
The Teeth.-The teeth bear the stigmata of hereditary syphilis 
chiefly in two recognized forms; although it is admitted that this 
disease may be accountable for many dental malformations and 
abnormalities. 
Hutchinson's Teeth.-They are named after Jonathan Hutchin- 
son, Sr., who first directed attention to them as evidence of syphi- 
litic heredity. They are small, peg-shaped, 
and marked upon the- incisal surfaces with 
crescent-shaped notches (Fig. 57). The cen- 
tral incisors are most affected and inclined 
toward each other. 
Fournier's Teeth.-This is a descriptive 
term sometimes applied to the more common 
appearance of erosion principally affecting 
the first molars, which has been represented 
as one of the stigmata of hereditary syphilis. 
That the peculiar form of the tooth crowns and other marks of 
arrested development upon their enamelled surfaces, vffiich are 
typical of Hutchinson's teeth, or even the defects described by 
Fournier, might be and doubtless are often due to syphilis, is 
beyond dispute. This is ow'ing to the fact that syphilis is usually 
most active at that stage in the development of the central incisors 
and first molars when arrested development might be expected to 
affect them at these points. On the other hand, it is well known 
Fig. 57.-The teeth of 
hereditary syphilis at 
maturity. 120 
INFECTIOUS DISEASES 
that there are many causes of arrested development, other than 
syphilis, which leave the record of their occurrence upon teeth in 
the form of grooves, pits, eroded surfaces, and otherwise. 
Patients having such teeth are commonly met with in the practice 
of most dentists. 
Much harm has already been done through misjudgment in 
making an attempted diagnosis of hereditary syphilis, without 
other corroborative indications. 
Faulty metabolism-, due to many causes which may affect the 
mother, and later the diseases of infancy, may be accountable 
for the imperfect form of tooth crowns and marks upon their sur- 
faces, which in some cases might easily simulate those dogmatically 
stated to be pathognomonic of syphilis alone. 
As one of the diagnostic indications to be considered only when 
other signs of hereditary syphilis are present, Hutchinson's teeth 
have a place; but beyond this their significance should not be 
relied upon. 
Bones.-The bones are chiefly affected by osteochondritis, which 
leads to distortions and enlargements of bones at the epiphyseal 
line and periostitis, which may cause enlargement or destruction. 
Less commonly all the other lesions of bone that occur in acquired 
syphilis are also active. 
Dactylitis, an enlargement of the phalanges of fingers or toes, 
occurs more frequently than in acquired syphilis. 
Joints.-Arthritis appears, if at all, as a complication of 
osteochondritis. 
Muscles.-The muscles sometimes suffer fixation through exten- 
sion of inflammatory processes originating in periostitis. 
Lymph Nodes.-These are not usually affected except secondarily 
to other lesions. 
Diseases of the ear are common among these children, and are 
caused by pathological conditions of the nose. 
The liver, spleen, lungs, and testicles usually bear evidence of 
their involvement. 
Syphilis of the Third Generation.-A safe clinical position with 
regard to the transmission of herediary syphilis to the third genera- 
tion is to assume that it can be so transmitted, and may be respon- 
sible for dystrophic stigmata similar to those of hereditary syphilis 
of the second generation. 
At the same time due allowance must be made for the rarity of 
such cases, as generally acknowledged, and the almost prohibitive 
difficulties that lie in the way of definite proof that the affected 
offspring of a third generation is absolutely free from suspicion of SYPHILIS 
121 
acquired syphilis; that both the parents were likewise proved 
never to have acquired this infection; that one or both of the 
grandparents actually had syphilis, and finally that the lesion 
or dystrophy of the individual in question is undeniably due to 
syphilis. 
It is these questions that have led to differences of opinion 
between such authorities as Hutchinson, who does not, and Taylor 
and Fournier, who do believe that syphilis is transmissible to the 
third generation, and the many syphilographers whose opinions 
upon this subject are less extreme. 
Acquired Syphilis.-Etiology.-Syphilitic infection is acquired by 
sexual intercourse, or extragenitally by non-sexual inoculation. 
A syphilitic lesion in contact with the most minute abrasion, 
even though it be microscopic, its presence unsuspected, and the 
contact momentary, may be sufficient for the infection to be 
transmitted. 
It is claimed to be impossible to inoculate by subcutaneous 
injection. The virus from chancres and mucous patches is the 
most active in infection. But inoculation may take place from 
the blood or semen of a syphilitic, from gumma, and from any of the 
secretions. Even when the inoculating fluid does not appear to 
contain Spirochetse pallidse, inoculations have been successfully 
made with spirochetse in the resulting lesions. 
Extragenital Inoculation.-An attempted recital of many of the 
infinite number of different and often surprisingly unusual means 
by which the syphilitic virus has been transmitted without sexual 
intercourse, and the anatomical situations in which the initial 
lesions have from time to time been found, would be quite useless. 
But the following table, prepared by Bulkley and reported by 
Keyes,1 may serve to give an idea of the relative frequency with 
which such inoculations have occurred in different parts of the 
bodv. 
Cases. 
Lip 1810 
Breast and nipple .... 1148 
Buccal cavity 734 
Fingers and hand .... 462 
Eyelids and conjunctiva . . 372 
Tonsils 307 
Throat (deep oral and nasal) . 264 
Tongue 157 
Chin 146 
Check 145 
Trunk 100 
Nose 95 
Anus 87 
Cases. 
Perigenital region .... 77 
Legs and thigh 73 
Forearm 59 
Neck 47 
Gums 42 
Forehead and temple ... 37 
Ears 27 
By vaccination 1863 
By cupping and phlebotomy . 745 
By circumcision 179 
By tatooing 82 
Total 9058 
1 Syphilis, p. 56. 122 
INFECTIOUS DISEASES 
The striking lesson to be gleaned by study of this chart is that 
the lip, buccal cavity, fingers, and hand, so greatly outnumber all 
other sources of infection save vaccination (which under modern 
methods is no longer a matter of common occurrence), and the 
breast and nipple. . 
Thus it will be seen how constantly oral surgeons and dentists 
are in the presence of the danger, either of infecting themselves, 
or of transmitting the disease through their instruments, or hands 
to patients. 
Dr. William Carr, of New York, who has had wide experience 
in dealing with syphilitic mouth affections, was able in one of his 
cases to trace the extragenital infection to a dentist, who being 
the only one practising in a small town, had under his care at the 
same time one of Dr. Carr's patients who was syphilitic, and another 
one who came for treatment afterward. In the latter the initial 
sore appeared in the mouth and was undoubtedly the result of 
infection by the dentist's instruments. 
Many such cases have been previously reported, but it is not 
always possible to have such an uncomplicated record. of proof 
as was offered in this instance. 
Infections of dentists, physicians, and surgeons by patients are 
much more easily proved, and have been of sufficiently frequent 
occurrence to warrant every precaution that may serve to guard 
against inoculation in the course of operations, or treatment of 
patients, whether known to be syphilitic or otherwise. 
Kissing, the introduction into the mouth of instruments, pencils, 
spoons, pipes, cigars, or cigarettes that have touched the lips or 
mouths of luetic individuals, and the pernicious use of public 
drinking cups, and other similar means of spreading the infection 
are too well understood to require elaboration. 
It is more important to attempt to measure the exact danger of 
such opportunities for conveying the virus a§ may occur in ordinary 
social intercourse. 
On every hand there is evidence of the uncertainty of establishing 
fixed rules. 
The great majority of syphilitics cease to be infectious after 
three years. After four years the chance of trasmitting infection 
is estimated to be one in a hundred, and after five years the danger 
is believed to be so slight as to be hardly worthy of consideration, 
and yet even the possibility of infection, no matter how vague, 
must be deemed a social menace until more definite limitation 
in this respect may be established. SYPHILIS 
123 
The marital relation for syphilitics is governed by the rule that 
"marriage of a syphilitic is permissible only after five years, during 
the last two of which he has been without symptoms." 
Three years of proper treatment with conscientious cooperation 
upon the part of the patient is generally believed to assure safety 
in marriage, but doubt in this respect is suggested by cases reported 
in which infection has occurred after longer periods of time. 
Marriage, while not necessarily forbidden, should only be con- 
tracted after two years, absolute freedom from symptoms, and 
then only under careful medical supervision. 
Immunity, in some degree at least, has been claimed for certain 
races and individuals, as indicated by the negro race, which seems 
to suffer less severely than the white, and authentic reports of 
men who have cohabited with women during the actively dan- 
gerous stage, and vice versa, without acquiring the disease, although 
others who have had coitus with the same individuals were infected. 
But even these examples are subject to so many modifying circum- 
stances that positive conclusions appear to be unwarranted. 
Efforts to create an artificial immunity by the injection of blood 
serum of syphilitics, or the juices of their lesions, have thus far 
been unavailing. 
Symptoms.-Following sexual intercourse, a slight abrasion or 
several herpetic vesicles may or may not be apparent, or, if the 
infection be extragenital, the lesion through which the virus gains 
entrance may be noticeable or such as not to attract notice. Fol- 
lowing this there are no unusual symptoms until after the chancre 
appears upon the glans penis or foreskin, or at any other part 
of the body where inoculation has taken place. 
Period of Primary Incubation.-The period of primary incu- 
bation is the time between the inoculation and the appearance 
of the chancre or initial sore. This varies from ten days to six 
weeks. Usually* in from three to five weeks a single sore, at first 
resembling a pimple, is developed at the point of inoculation. This 
increases in size, becomes indurated, and later eroded or ulcerated 
upon its surface. About ten days later, in typical cases, the glands 
in one or both groins begin to swell. Neither of these symptoms 
may be such as to create much discomfort, as the chancre is not 
very sore, and the glands may not attain sufficient size to give 
trouble. In this way these symptoms sometimes pass unnoticed. 
In the course of three or four weeks the chancre heals and leaves 
a hard lump under the epidermis, which is typical of these cases. 124 
INFECTIOUS DISEASES 
In women the chancre is often so insignificant in appearance 
and symptoms as to attract no notice whatever, and it is only 
with the beginning of the next stage that such patients become 
aware of their own condition. 
Secondary Incubation Period/-The secondary incubation 
period begins with the chancre and ends with the appearance of 
the secondary symptoms, one to three months later in ordinary 
cases, but sometimes not until five months afterward. 
Secondary symptoms may not develop if proper treatment has 
been promptly instituted, or may even be overlooked under other 
conditions. The secondary manifestations of syphilis are in the 
nature of an acute toxemia and local lesions. 
Secondary toxemia is noted in variable degree in the form of 
secondary anemia, general anemia, loss of body weight, slight 
fever, prostration, and other symptoms which might easily be 
confused with typhoid fever, malaria, and similar affections, until 
the secondary lesions become noticeable. 
Secondary Lesions.-In typical cases the characteristic skin 
lesion appears in the form of a macular or maculopapular 
eruption. 
The scalp is covered with moist encrusted papules or scabs. 
The mucous membrane of the mouth and throat is more or less 
affected by erosions. 
The lymph nodes of the neck become enlarged, and there is the 
usual symptom of sore throat. 
Headache of general or neuralgic character and painful affec- 
tions of th£ muscles and bones, particularly in the regions of the 
joints, are more or less marked. 
At a subsequent period, after the first outbreak of secondary 
symptoms has entirely disappeared, other lesions are likely to 
appear. These are exceedingly variable, both as to time of appear- 
ance and character, and may affect almost any tissue or organ 
of the body. Quite often they do not appear at all, especially 
with patients under treatment. No accurate estimate can be 
made of the length of time that must elapse before the secondary 
symptoms cease to recur. 
All these features are well covered in the following tables prepared 
by Keyes: SYPHILIS 
125 
DURATION OF SECONDARY SYMPTOMS IN 280 CASES. 
Cases 
Less than 1 year 17 
1 to 2 years 82 
2 to 3 " 79 
3 to 4 " 25 
Less than 4 years1 . 49 
4 years 17 
5 " 6 
6 " 2 
7 " 1 
8 " 1 
9 " 1 
Total 280 
LATE SECONDARIES AMONG 2000 CASES. 
Cases. 
4 years 51 
5 " 44 
6 " 34 
7 " 13 
8 " 11 
9 " 14 
10 " 9 
11 " 8 
12 " 11 
13 " 8 
14 " 1 
15 " ...... 4 
16 " 2 
Cases 
17 years 1 
18 " 2 
19 " 1 
20 " . .... 4 
21 " ... 1 
23 " 2 
24 " 1 
25 " 4 
30 " 1 
10 to 30 years 60 
4 to 9 " 167 
Total . . . .227 
Tertiary Symptoms.-At any time after the secondary incu- 
bation period the tertiary lesions may occur. (Some authors 
claim that in rare cases the tertiary may even precede secondary 
symptoms.) Or they may not develop for many years, as indi- 
cated by the results of both Fournier's and Keyes' experiences, 
which have been tabulated by cases in the following form: 
Fournier. 
Keye 
First year 
. 278 
112 
Second year .' 
. 453 
149 
Third year 
. 471 
142 
Fourth year 
. 388 
79 
Fifth year 
. 357 
61 
Sixth year 
. 326 
64 
Seventh year 
. 274 
39 
Eighth year 
. 211 
25 
Ninth year 
. 195 
20 
Tenth to fourteenth years 
. 736 
80 
Fifteenth to nineteenth years 
. 423 
26 
Twentieth to twenty-ninth years 
. 304 
23 
After the twenty-ninth year 
83 
4 
Total 
. 4499 
824 
INCIDENCE OF TERTIARISM. 
1 Duration not quite accurately known. 126 
INFECTIOUS DISEASES 
These are the actively destructive manifestations of syphilis. 
They differ from the secondary lesions in being less infectious 
(are commonly believed to be non-infectious); in having greater 
malignancy, and a tendency to attack the deep in preference to 
superficial structures. Any organ in the body may be affected. 
Tertiary syphilis occurs in the form of a syphilitic granuloma 
(gumma), or as a diffuse, interstitial sclerosis; in the mouth ulcerat- 
ing syphilis of the soft palate, and tonsil; necrosis of the maxil- 
lary bones, and particularly of the hard palate with the usual 
perforation. 
Gumma of the tongue and cheek is a frequent result of tertiary 
syphilitic processes. 
Syphilitic Dystrophies or Parasyphilides.-These are func- 
tional derangements of apparently toxic origin, and while they 
are common among patients affected by syphilis of long standing, 
yet the fact is that similar affections appear as the result of other 
systemic diseases. It necessarily follows that they are not always 
'syphilitic, and their inclusion in description of late syphilitic 
manifestations must be accepted with this understanding. 
Arteriosclerosis, aneurysm, spinal paralysis, and other neuroses 
and trophic changes of various kinds affecting organs or divisions 
of the body are examples of parasyphilides. 
Diagnosis'.-The subject of the diagnosis of syphilis in its pre- 
sentation to practitioners of all divisions of medicine demands an 
advance word of caution, and for many reasons this is especially 
necessary for those who treat diseases of the mouth. Not only 
are luetic lesions in all stages frequently evident in the oral region, 
but outbreaks of many other affections as well, and many times 
these simulate lues so closely as to make diagnosis extremely 
difficult. There is a predisposition to diagnostic error which may 
influence either patient or operator in this regard, and frequently 
leads to grave results. 
Too often physicians and dentists are prone to consider as 
syphilitic almost any affection that may resemble a syphilitic 
lesion, if its etiology be obscure, and it resists ordinary therapeutic 
or surgical measures. On the other hand, patients who know 
themselves to have been exposed, or who may at a previous time 
have had symptoms of syphilis, are often in a panic of fear over 
any slight manifestation of disease that may be so construed, and 
thus through an excited imagination mislead the diagnostician 
by exaggerated descriptions of their conditions. Over and over 
again in the author's practice cases such as the following have 
occurred: SYPHILIS 
127 
A young man about town had been under treatment for sore 
throat and ulcers upon the mucous membrane of his mouth that 
were assumed to be of syphilitic origin and were so treated. It 
was found to be an ulcerative stomatitis primarily induced by 
uncleanly, ill-fitting dental bridge-work, which caused pericemental 
inflammation and infection of the surrounding mucous membrane, 
aided by excessive cigarette smoking and a generally depleted 
systemic condition. The symptoms promptly responded to local 
treatment as soon as the irritating bridge-work was removed. 
During several years' observation of the case no syphilitic symp- 
toms appeared to cast doubt upon this diagnosis. 
Another case was that of a vaudeville actor who had been affected 
with syphilis for many years and was at the time suffering from 
necrosis of his lower jaw, which had steadily become worse under 
previous antisyphilitic treatment. Careful review of the case led 
the author to believe that excessive use of mercury was responsible 
for the trouble, and not syphilis. 
All administration of mercury was stopped, and the case treated' 
as one of ordinary necrosis, with prompt recovery. In this case 
what proved to be mercurial necrosis, aggravated by increased 
doses of mercury, cost the patient about two and one-half inches 
of his mandible, which came out in the form of a sequestrum as 
completely as if resected. Admitting that the findings of this case 
rest wholly upon clinical evidence, it is at least fairly certain that 
the case would have become much more serious if mercury had not 
been stopped, and still more so if it had been continued in increased 
doses. If space permitted, the moral and social sides of the question 
of ill results following wrong diagnosis due to syphilophobia might 
be just as strongly illustrated as its clinical aspect. 
On the other hand, whole pages might be filled with examples 
of disaster following failure to diagnosticate syphilis, and of treat- 
ment given for other affections when this was the real disease. 
Diagnostic Indications and Methods.-Clinical.-History: Scars 
or other evidence of previous lesion, present symptoms, and the 
effect of treatment. 
Laboratory.-Identification of Spirocheta pallida, specific reac- 
tion, examination of blood and tissue, and inoculation of monkeys. 
To facilitate differential diagnosis, the immediate indications 
of syphilis can best be studied in comparison with those of other 
affections, having objective symptoms likely to cause confusion. 
Clinical Diagnosis.-Chancre.-This is also known as hard 
chancre, Hunterian chancre, indurated chancre, syphilitic chancre, 
and primary sore. 128 
INFECTIOUS DISEASES 
This lesion appears at the point of inoculation. 
In a large percentage of cases the surface becomes eroded, the 
color varying from dark red to dark gray, and it is covered by a 
slight seropurulent discharge. All chancres have an indurated 
base, which may be felt by pressure between thumb and finger, 
but in the eroded form this is much less noticeable than in the 
typical Hunterian chancre, which has a large base surmounted by 
a distinct ulcer. A rarer form than either of the other two is the 
indurated papule, which is usually found on thick-skinned surfaces. 
These papules are small, dark, red, and flat, with a scaly surface 
when healing. Other differences in the appearance of chancres 
are noted in accordance with the different situations in which 
they may be found. Mixed infection, inflammatory results in 
various forms, and vegetation may complicate and alter both the 
course and appearance of chancre. 
Chancres of the lip (Plate II, Fig. 1) are the most common 
of all extragenital chancres. They affect the lower lip most fre- 
quently, and are extremely variable in size. Such a lesion may be 
a tiny papule, or a large, crust-covered mass that gives the patient 
much distress. Chancre upon the tongue is not uncommon, and 
is usually upon the dorsum or the anterior border (Plate III). 
More rarely the lesion is found upon the tonsil, and still less fre- 
quently upon the gum. 
Generally there is a single initial sore in syphilis, but two or 
more may be found if the inoculation at several points has been 
simultaneous or has taken place within a sufficiently short space 
of time to permit infection at different places. Multiple true 
chancres have been reported to occur in about 25 per cent, of 
all cases. Chancre is not auto-inoculable once the lesion has 
appeared, but it has been proved both clinically and experimentally 
that after several hours, or even a few days, auto-inoculation is 
possible. 
A very important diagnostic indication is the lymph node, so- 
called "satellite gland," or, as McKey1 designates it, the "pilot 
gland." This is the more or less enlarged gland that is found in 
the chain of slightly involved lymph nodes that drain the region 
in which the chancre is situated. The induration often remains, 
and can be distinguished when traces of the chancre have so far 
disappeared as to cause them to be overlooked unless attention 
is directed to the part through recognition of the affected gland. 
The following table sums up the differential diagnosis.2 
1 Dental Cosmos, August, 1911, p. 921. 
2 Keyes: Syphilis, pp. 246 to 248. PLATE II 
FIG. 1 
Chancre of the Lip. 
FIG. 2 
Mucous Patch. PLATE III 
FIG. 1 
Chancre of the Tongue. 
FIG. 2 
Gumma of the Tongue. SYPHILIS 
129 
Syphilitic chancre. 
Chancroid. 
Herpes. 
Gumma. 
1. History: Sexual 
contact, kissing, medi- 
ate infection, vaccina- 
tion. etc. 
1. Sexual contact. 
1. Relapsing herpes. 
1. Syphilitic. 
2. Incubation: Two 
to six weeks. 
2. Three to seven 
days. 
2. None. 
2. None. 
3. Microscope shows 
3. Streptobacillus, 
3. Nothing charac- 
3. Nothing charac- 
treponema often. 
not always. 
teristic. 
teristic. 
4. Auto-inoculabil- 
ity: Uncertain and 
atypical. 
4. Produces typical 
chancroid on third day. 
From this strepto- 
bacillus may be readily 
obtained. 
4. No. 
4. No. 
5. Commencement: 
5. Begins as a pus- 
5. Begins as a group 
5. Begins as a tumor 
Begins as an erosion or 
a papule, and remains 
an erosion or ulcerates. 
tule or ulcer; and in- 
variably remains as 
an ulcer. 
of vesicles, rarely as 
a single vesicle, and 
becomes an ulcer. 
which ulcerates later. 
6. Number: Usually 
6. Usually multiple, 
6. Usually multiple, 
6. Usually single. 
unique or simultane- 
ously multiple; rarely 
multiple by successive 
autoinoculation; never 
confluent. 
both simultaneously 
and by successive au- 
to-inoculation ; often 
confluent. 
simultaneously and by 
successive crops of 
vesicles; sometimes 
confluent. 
Confluent if multiple. 
7. Physiognomy:(a) 
Shape: Round, oval or 
symmetrically irregu- 
lar. 
7. (a) Shape: Round 
oval, or unsymmetri- 
cally irregular, with 
border described by 
segments of large cir- 
cles. 
7. (a) Shape: Irreg- 
ularly rounded, with 
borders described by 
segments of small cir- 
cles left by the con- 
fluent vesicles. 
7. (a) Like chancre. 
(b) Lesion is habitu- 
ally flat, capped by 
erosion or superficial 
ulceration; or scooped 
out; or a deep, funnel- 
shaped ulcer with slop- 
ing edges. Sometimes 
the papule is dry and 
scaly. 
(b) Always a true 
ulcer, excavated, hol- 
lowed out. 
(b) Ulcer unusually 
superficial; sometimes 
in solitary herpes there 
is but one absolutely 
circular vesicle. There 
are usually neighbor- 
ing groups of vesicles 
to clear up the diag- 
nosis. 
(b) Like chancre. 
(c) Edges sloping 
(c) Edges sharply 
(c) Edges sharp, not 
(c) Edges like 
and adherent, some- 
times prominently ele- 
vated. 
cut, abrupt, often un- 
dermined. 
undermined. 
chancre. 
(d) Bottom smooth, 
shining. 
(d) Bottom uneven, 
warty, irregular, with- 
out luster. 
(d) Bottom even, 
inflammatory. 
(d) Like chancre. 
(e) Color: Somber, 
darkish red, gray, or 
black; sometimes livid 
and scaly, occasionally 
scabbed. 
(e) Color: Yellow, 
tawny, false-membran- 
ous-looking; some- 
times bright. 
(e) Like chancre. 
(e) Like chancre. 
(/) Secretion: Slight, 
serosanguinolent, un- 
less irritation provokes 
suppuration. 
(/) Secretion: Abun- 
dant and purulent. 
(/) Secretion: Slight, 
seropurulent. 
(/) Like chancre. 
8. Induration: Con- 
8. Absent in typical 
8. Inflammatory in- 
8. Same as chancre. 
stant, parchment-like, 
cases. An induration 
duration, capable of 
Induration always ex- 
and very faint, or car- 
tilaginous and ex- 
tensive terminating 
abruptly, not shading 
off into parts around, 
movable upon parts 
beneath the skin, and 
not adherent to the 
latter; may disappear 
in a few days, usually 
outlasts the sore and 
may remain for 
months. 
may be caused by irri- 
tants or by inflamma- 
tion. It is boggy, not 
elastic, shades off into 
surrounding tissues, is 
adherent to parts 
around, disappears 
promptly on healing of 
the sore, or before that 
time. 
being produced by 
the same causes as 
in chancroid, and be- 
having in a precisely 
similar manner. 
tensive. 
9. Sensitiveness ab- 
sent. 
9. Painful and sen- 
sitive. 
9. Beginning heat. 
9. Absent. 
10. Duration: At 
10. Varies from a 
10. Rarely more 
10. At least a fort- 
least a fortnight. 
few days to many 
weeks. 
than ten days. 
night. Usually much 
longer. 
11. Phagedena: Ex- 
tremely rare. 
11. Rare. 
11. No. 
11. Uncommon. 
12. Lymphangitis: 
Syphilitic. 
12. Inflammatory. 
12. Same. 
12. None. 
13. Lymphadenitis: 
Syphilitic, constant. 
13. Chancroidal; or 
inflammatory in one- 
third of all cases. 
13. Rare; inflamma- 
tory. 
13. None. 130 
INFECTIOUS DISEASES 
The final test is the advent of secondary symptoms. 
Vincent's angina is sometimes confused with chancre in diag- 
nosis. The difference may be established by recognition of the 
characteristic bacillus of Vincent's angina. This affection is 
accompanied by much greater tenderness and its sore is more 
superficial than chancre. It does not heal spontaneously as does 
the primary syphilitic sore, and improves under local treatment, 
which chancre does not. 
Irritation by mouth habits, and irregular or sharp-edged teeth 
and roots may make sores upon the tongue or buccal mucous 
surfaces that simulate the appearance of chancre very closely 
and these may also alter the appearance of true chancre. Removal 
of the cause and local treatment usually give prompt relief. 
Tuberculosis is demonstrated by the presence of tubercle bacilli, 
the absence of other signs of syphilis, and the irregular hyper- 
sensitive character of the ulcer as compared with the shape, indura- 
tion, and painlessness of chancre. 
The Secondary Syphilitic Oral Lesions.-Sore throat is 
caused by ulcerative syphilids (the ulceration papule). These 
ulcers form principally about the tonsils and pharynx. 
The mucous patch is an erosive or papulo-erosive syphilid or 
mucous papule (Plate II, Fig. 2, and Plate VIII, Fig. 2). 
Squamous syphilid, or syphilitic leukoplakia, is unusual in 
secondary syphilis, and is a more constant tertiary manifestation. 
(See Leukoplakia, Plate VII, Fig. 2, and Plate VIII, Fig. 1.) 
Mercurial stomatitis, when salivation is not a marked symptom, 
is occasionally difficult to differentiate from the ulceration of 
secondary syphilis. As has been described in one of the author's 
cases (p. 127), the confusion may lead to serious consequences. 
The author is convinced that there is no constant feature of the 
appearance of this form of ulceration which may be depended upon 
for safe diagnosis. The best test is to stop the administration 
of mercury and observe results. (For other forms of stomatitis 
which might be mistaken for syphilis, see pp. 172-174.) 
Tertiary Oral Symptoms.-The onset of tertiaries about the 
mouth and associated parts may occur at any period between 
one and forty years after contraction of the disease. 
Diffuse tubercular syphilitic infiltrations on the lips are caused 
by confluence of the papules in the form of thick, dark red, scaly, 
or ulcerated infiltrations of the skin. The administration of mer- 
cury, potassium iodid, or other antisyphilitic treatment is the 
best distinguishing test. SYPHILIS 
131 
Vegetations or small condylomata also appear upon the lips, 
and their nature is tested in the same manner. 
Thickening of the lips without gummatous degeneration, and 
showing no surface lesion, sometimes results from a diffuse inter- 
stitial sclerosis. 
The tongue during this stage may be affected by leukoplakia 
(Plate VII, Fig. 2, and Plate VIII, Fig. 1); interstitial glossitis 
(Plate XIX, Fig. 3) and gumma may also occur (Plate III, Fig. 2). 
From a diagnostic point of view it is claimed that the only 
safe course to pursue when leukoplakia is present is to consider 
that it is syphilitic until proved otherwise. 
The exact distinction cannot at this time be clearly defined 
between leukoplakia, which is so often evidence of syphilis, and 
the same affection which is also so frequently a forerunner of 
epithelioma as to be considered a precancerous stage of that disease. 
Sclerosis of the tongue causes it to become thickened, lobulated, 
and shining, and more or less abnormally white. As the process 
advances, fissures and excoriations occur which are followed by 
shrinking of the scar tissue with marked decrease in the size of 
the tongue. 
Gumma of the tongue occurs rarely, and when it does it is often 
associated with sclerosis (Plate III, Fig. 2). 
The test of these affections, as of the preceding symptoms, is 
antisyphilitic treatment. 
The objective symptoms, when compared with those of epithe- 
lioma, admit consideration only in a very general way, because 
both of these affections are so variable in their characteristics. 
Epithelioma is more likely to occur after the fortieth year of 
age, and affects men most frequently. It may be on the under 
surface as well as other portions of the tongue, is single, and may 
be preceded by leukoplakia. In appearance it is a shallow ulcer 
with thick, everted edges upon a very much hardened base. It 
bleeds readily and has a foul discharge. The pain is usually severe. 
The lymph nodes are apt to be enlarged at an early stage, with 
tendency toward progression in this respect. Medicinal treatment 
is practically useless. 
Gumma has a history of syphilis; it is not confined to either 
age or sex; it never appears on the under surface of the tongue; 
it may be single or multiple, and accompanied by leukoplakia. 
In appearance it is a deep, sloughing ulcer, with its edges under- 
mined and more or less sharp. The induration of its base is not 
as marked as with epithelioma. There is less tendency to bleed, 132 
INFECTIOUS DISEASES 
and the discharge is not quite so offensive. There is usually little 
or no pain. Lymphatic enlargement is not a marked feature. 
Mixed treatment is beneficial. 
The microscope and other laboratory methods offer a final test 
in these affections. 
The tonsils, pharynx, and soft palate are frequently involved 
by destructive tertiary lesions in all forms (Fig. 58). 
Destruction of tissue by ulcers and resulting cicatricial con- 
traction furnish common examples of syphilitic results that are 
difficult to overcome. 
Syphilitic treatment in these cases furnishes both a test of 
and a check upon the destructive process. 
Fig. 58.-Syphilitic destruction of the soft palate, 
Perforations through the hard palate, resulting from gummatous 
destruction, which usually begin in the nose, are familiar to all 
who treat diseases of the mouth. 
Their diagnosis is usually simple, but the author has had many 
cases in which portions of the hard palate have been lost, which 
left a communicative opening between mouth and nose in the 
region of the hard palate. No history of syphilis could be estab- 
lished, and upon discovery and proper surgical treatment of infec- 
tion from septic conditions there was recovery, with total disap- 
pearance of the constitutional symptoms, which were often more 
confusing than the local symptoms. 
The involvement of the maxillary sinus in these cases, even when SYPHILIS 
133 
there is no opening through the hard palate, is always a matter 
of importance. 
Differentiation in these cases, in the absence of clear history 
of syphilis, and without external lesions to act as guides, is some- 
times difficult. 
Intranasal examination usually discloses ulcerative conditions 
in the region of the ostium; or the nasal discharges may give the 
desired evidence. 
Carefully taken radiographs will sometimes enable the diagnosis 
of gumma of the antrum to be made when other methods fail. 
The characteristic shape of the bridge of the nose, through loss 
of its supporting structures, is an unmistakable sign of syphilis, 
except where accidental injury or necrosis from other causes has 
brought about a similar destruction. These conditions are usually 
so clearly understood that there is little difficulty in getting a correct 
history upon which judgment may be based. 
Brain lesions of syphilis, insofar as the mouth and its associated 
parts are concerned, have been quite fully covered in the chapter 
on Diseases of the Nervous System. 
Destruction of the maxillary bones may occur as with other 
osseous structures, through expansion of lesions affecting the 
soft tissue in the early stages of distinctly tertiary disease which 
affects bone generally. 
Osteoperiostitis, gummatous osteoperiostitis, and osteomyelitis may 
cause destruction of bone in the form of syphilitic necrosis with 
exfoliation of a sequestrum; or by slower necrotic processes, by 
which the bone surface may be destroyed or left in a carious 
condition. 
Osteoperiostitis may cause enlargement, thickening, and altera- 
tions in the form of bony growths. - 
Tuberculosis, neoplasms, and other septic conditions which may 
lead to osteomyelitis, or chronic irritations from which periosteal 
thickening or alterations in the form and structure of bones may 
occur, must all be differential by the recognition of the special 
cause of irritation or infection, microscopic or other examination 
of tissue, and by the usual indications of syphilis and the effect of 
treatment. 
Laboratory Diagnosis.-The identification of the Spirocheta 
pallida is most easily accomplished during the early stages of 
syphilis. McKee recommends Burrie's method, according to 
which a drop of serum from the initial lesion, mixed with Indian 
ink, is employed, "which makes the finding of the organism almost 134 
INFECTIOUS DISEASES 
as easy as when the dark field illuminator is employed." He says 
that there is no difficulty in differentiating the long spiral delicate 
pallida from the coarser spirochetae that are found in the mouth, 
except the Spirocheta dentium, with which it may possibly be 
confused. They may also be examined alive from the secretion 
of an infectious syphilitic lesion, in the hanging drop or under a 
cover-glass; but staining facilitates their identification. 
The process of preparing and staining tissue requires much time 
and skill, and for this reason smears are much more satisfactory 
in the examination for Spirochete pallidee. 
Chancres, moist papules, and mouth lesions are most satis- 
factory for spirochete examination. In the secondary syphilitic 
lesions the spirochete are much fewer in number and more difficult 
to identify. In the later tertiary lesions there are practically none. 
The Wassermann Test.-The Wassermann test seems to outshine 
all others at the present time in its efficiency. No mention has 
been made of this in the clinical diagnosis, although it might 
properly have been added to each and all methods of differential 
diagnosis. The reason for this is that the Wassermann test is 
reliable only in the hands of one who is skilful and experienced 
in its use, and unless carefully made it may be misleading. 
R. Weiss1 describes an easy method for Wassermann's serum, 
which is as follows: 
"The method is based on Wassermann's test, which consists in 
combining the serum (amboceptor) with organ extract (antigen) 
and complement-holding serum, and by allowing the mixture to 
stand for a little while. To recognize whether the complement 
has been bound or not, blood corpuscles are afterward added 
and the necessary immune bodies. Usually sheep's blood and the 
serum of a rabbit treated with sheep's blood are used. If the 
complement has been used up under the influence of the combina- 
tion of syphilitic serum and organ extract no hemolysis will take 
place. If, however, the complement is still free, it will attach 
itself to the sensitized blood corpuscles and will dissolve them. 
For the modified method it is therefore necessary to have the 
following materials for the test: 
"Physiological salt solution, prepared by dissolving one salt 
tablet in 12 c.c. of water. 
"Antigen (alcoholic organ extract). 
"Complement (guinea-pig serum, dried upon filter-paper). 
1 Pacific Med. Jour., August, 1910. SYPHILIS 
135 
" Amboceptor (hemolytic immune serum prepared against human 
red corpuscles). 
"Patient's serum. 
"Emulsion of human red cells (obtained by collecting 10 or 12 
drops of blood from the patient, transferring it to the defibrinator, 
and shaking vigorously until filaments of fibrin are seen attached 
to the beads). 
"Open the bottle containing antigen and draw the fluid up into 
the dark amber glass pipette to the graduation. Eject this into 
tube No. 1. Add 2 c.c. of salt solution to the antigen in tube No. 1. 
Place 2 c.c. of salt solution in tube No. 2. (This tube from the 
'Control.') Place two complements in each test-tube. These 
must be completely immersed in fluid. Take up the defibrinated 
blood in the light brown pipette to the graduation mark. Transfer 
this to tube No. 1. Put an equivalent amount of defibrinated 
blood in tube No. 2. Let the two tubes remain in at the tem- 
perature of the room for an hour. Shake from time to time. 
"By means of the ungraduated pipette transfer the contents of 
one amboceptor bulb to tube No. 1 and a similar quantity of 
amboceptor to tube No. 2. Shake well. Ten to fifteen minutes 
later again shake. In a short time the control tube (No. 2) will 
show solution of the blood corpuscles and the liquid will become 
red. 
"In tube No. 1, if the reaction is negative, the appearance will 
be identical with those in the control tube (either at the same time 
or a little later). If the reaction is positive, tube No. 2 will show a 
sedimentation of the red corpuscles, but no solution, and in about 
thirty minutes the blood corpuscles will have settled to the bottom 
of the tube without the blood cells being dissolved, and the super- 
natant liquid will be clean and light. A certain amount of solution 
of the red corpuscles may take place in tube No. 1 if it is allowed 
to stand for some hours." 
This appears to be a modification in part of the simplified 
Wassermann reaction proposed and demonstrated by Hideyo 
Noguchi in 1909. 
According to recent writers1 the Wassermann test is not absolute, 
because it is said to occur in a number of other affections. 
Baum2 states that the reaction occurs in scarlatina, pellagra, 
Hodgkin's disease, leprosy, and in a number of other affections, 
and does not always occur in syphilis. 
iFox: New York Med. Jour., December 18, 1909; Am. Jour. Med. Sc., May, 
1910; Kahn: Am. Med. Record, June 18, 1910. 
2 Editor Practical Medicine, Series 9, 1910, p. 100. 136 
INFECTIOUS DISEASES 
Prophylaxis.-Experimentation has proved that syphilitic secre- 
tions cease to be infectious after twelve to twenty-four hours, 
and in approximately six hours if dry. 
The importance of this cannot be overestimated when consider- 
ing the frequency of exposure to extragenital infection and its 
prevention. The general substitution of individual for public 
drinking cups, and the installation of bubblers at fountains, with 
other similar efforts toward protection now being instituted by 
health boards, are useful prophylactic measures in fighting syphilis 
in common with other infectious diseases. Prevention of exposure 
to sexual infection does not seem to make satisfactory progress 
in spite of much agitation. Control of the social evil at present 
seems to be beyond municipal regulations, and until this problem 
is solved, syphilis cannot be wholly prevented. 
Prophylactic Treatment.-No radical treatment of the chancre 
alone can prevent the development of subsequent symptoms, 
and even wide excision of tissue at the point of inoculation has 
been proved to be futile. Antiseptics also are useless. 
The only satisfactory means of aborting the disease appears 
to be by inunction with mercurial ointment within one hour, 
certainly not later than six hours, after inoculation. A salve of 
calomel 20 and lanoline 40 has been proved to be a preventative 
when applied experimentally to monkeys and man. 
Treatment.-Early Treatment.-In the beginning of treatment 
patience and firmness must be combined with much diagnostic 
skill. It seems needless to call attention to the importance of 
great care in endeavoring to avoid error in diagnosis, and the 
difficulties in this direction have already been explained. Once 
the existence of the disease is established the whole scheme of 
treatment should be gone over carefully with the patient. 
Instructions to Patients.-1. The idea must be impressed upon 
the mind that the condition is not hopeless; but in time, by con- 
scientiously following instructions, much may be done to avoid 
the evils that might otherwise ensue. 
2. It must be made plain that successful treatment depends 
largely upon self-control and patience to continue the necessary 
restrictions and therapeutic measures steadily through a period 
of at least two or three years; that general hygiene demands that 
there be an abstinence from the use of alcohol and the excessive 
use of tobacco; that the hours of sleep be sufficient and regular; 
and that bathing, exercise, moderation in work, and careful selec- 
tion of simple, wholesome, highly nourishing food be made matters 
of routine habit. SYPHILIS 
137 
3. Habits and rules of life which may serve to protect others 
from becoming infected must be taught. 
4. Oral hygiene must be properly explained. Instructions 
should be given, making possible an immediate or early detection 
of any syphilitic lesion that may appear in this region. Such 
instructions may also be expected to reduce the danger of trans- 
mission of the infection through the oral secretions, and aid in 
the preservation of the teeth and the prevention of local lesions. 
They should include directions as to the proper use of the tooth- 
brush, disinfection of the mouth secretions with suitable mouth 
washes, and the habit of daily inspection of the teeth, gums, tongue, 
and the buccal mucosa generally. 
During the administration of mercury the first manifestations 
of salivation appear in the mouth and around the teeth at the 
gingival margins. It is of the utmost importance that calculi 
and bacteria-laden concretions, which, unless properly removed, 
have a tendency to lodge between and at the necks of the teeth, 
should not be allowed to excite gingivitis, as this might be mis- 
taken for the beginning of excessive mercurialization, and lead 
to reduction of the dosage of mercury at a time when it properly 
should be increased. The effect of such an error might be serious. 
The proper care of the teeth must also be urged in the light 
of a more indirect but not less important benefit in maintaining 
a healthy condition of the stomach and intestinal tract. This 
is most necessary in assisting the system to do battle with the 
infection and to hasten its overthrow, as well as to overcome the 
ill effects that so often follow the administration of remedies. 
Finally, it may be said that with intelligent oral hygienic pre- 
cautions practically all of the very serious destructive processes 
which have already been described as affecting both bone and soft 
tissues may be avoided. 
Next to general and oral hygienic treatment tonics are indicated, 
for keeping up the highest state of bodily health and activity is 
an important factor in preventing the progress of the disease. 
Administration of Mercury.-For a long time mercury has been 
the one dependable agent in the treatment of early syphilis. It 
may be administered by mouth, inunction, inhalation or injection, 
with varying estimates of its value. 
Internal Administration.-The remedies generally used are: (1) 
The protoiodide (hydrarg. iodid. flav.), 6 granules of a centigram 
each, given daily for a minimum dose and gradually increased 
as indicated; (2) gray powder (pulv. hydrarg. cum creta.), 6 grains 138 
INFECTIOUS DISEASES 
daily in 1 -to 2-grain tablets;and (3) bichloride of mercury (hydrarg. 
chlorid. corrosiv.), in j^-grain doses in pill or capsule to avoid 
its irritating effect. 
Many combinations of mercury with tonics are recommended, 
according to the fancy of their special advocates. An example 
of these is the well-known pill of mercury and iron. 
-Mass® hydrargyri, 
Ferri reducti, 
Gum tragacanth aa 3j (4 grams) 
Glycerin . , q. s. aa 
M. et fiant pil. no. lx. 
Sig.-One pill after each meal. 
Intramuscular Injections.-To avoid the digestive disturbances 
which sometimes result from the internal administration of mer- 
cury and in the hope of securing a more prompt effect, injections 
into the substance of some thick muscle are employed. The fol- 
lowing prescription is among the best of the soluble preparations 
for this purpose: 
P-Hydrarg. chlorid. corrosiv gr. xv-xxx (1-2 grams) 
Sodii chlorid . . gr. x (0.6 gram) 
Aquae destillat giij (100 c.c.) 
Dose.-1 c. c. (hlxv). 
Gray oil, according to G. S. Walton,1 is extensively used with 
satisfactory results in the Liverpool Skin Hospital for intramuscular 
injections, and has entirely superseded the oral administration of 
drugs in these cases. The formula is: 
1$-Purified mercury 40 grams 
Sterilized anhydrous wool fat 12 " 
Sterilized white petrolatum 13 " 
Sterilized liquid petrolatum 35 " 
Five minims of the dose employed are equivalent to 2.5 grains 
of mercury. As a substitute for gray oil, an emulsion of metallic 
mercury is employed in the form of a thick mixture of 50 per cent, 
strength. The following formula is offered by Lafay as being 
equally as good and much more easily prepared: 
P-Hydrarg. bidestillat Siiss (10.0 grams) 
Albolin giij (13.5 grams) 
Lanolin giss (46.5 grams) 
Sig.-Shake. Dose: Flij to vj (0.1-0.4 c.c.).2 
1 New York Med. Jour., March 26, 1910. 
2 Keyes: Syphilis, p. 176. SYPHILIS 
139 
These injections are repeated at intervals of from one to two 
weeks for a year or longer if indicated. Later they are repeated at 
intervals of several months, according to indications of the case. 
The objections to intramuscular injections are pain, the tendency 
to poisoning, and embolism. 
Inunctions:-Inunctions of blue ointment or any of the mercu- 
rial ointments are rubbed upon different portions of the body 
upon successive days to avoid irritation and poisoning. This is 
continued daily for a period of several weeks or until the patient 
begins to show slight salivation. 
Fumigation.-Biweekly fumigations with black oxide Sij^iiss 
(8 to 10 gm.) is sometimes employed, or calomel may be used for 
the same purpose. These vapor baths are useful if properly given, 
but otherwise are not satisfactory. 
Intravenous Injections.-Intravenous injection is usually given 
according to Bacelli's formula:1 
-Hydrarg. bichlorid 1 gram 
Sod. chlorid 3 grams 
Aquse destillat 1000 " 
However valuable this method of treatment may be, the well- 
known objections and dangers incident to intravenous injections 
would preclude its recommendation except for cases in which 
there is some urgent objection to other means of administration. 
Potassium Iodide and Mercury.-In the later stages of syphilis 
the mixed treatment of potassium iodide and bichloride of mercury, 
according to the following formula or some similar combination, 
has long held sway. 
3-Hydrarg. chlorid. corrosiv. ..... gr. j-ij (0- 1.2 grams) 
Potass, iodid 3ij- 5 j (8-30.0 grams) 
Syr. sarsaparillae comp ad giv (ad 130 c.c.)-M. 
Sig.-One teaspoonful two hours after meals. 
In the tertiary stage the author has frequently obtained good 
results by the use of potassium iodide given in the saturated solu- 
tion in drop doses. He begins with 5 drops three times a day, 
increasing 1 drop each time until the limit of endurance appears 
to be approaching or until 15 minims has been reached; then he 
gradually goes back to the original number; again increasing 
to a point slightly beyond the last maximum dose. This pro- 
cedure is repeated throughout treatment. In this way the danger 
1 Keyes: Syphilis, p. 189. 140 
INFECTIOUS DISEASES 
of iodism is to some extent avoided and the individual tolerance 
measured. It is well known that both mercury and potassium 
iodide, particularly the latter, must be administered with due 
regard for the extreme susceptibility to poisoning that is occa- 
sionally encountered in certain patients. 
Mercurialism and Iodism.-When mercury is administered the 
appearance of the dark, inflamed, slightly everted gum borders, 
loosening of the teeth, increased flow of saliva, and distur' ance 
of the intestinal tract, as well as the ulcerative conditions which 
sometimes occur when these premonitory symptoms are not noticed, 
must be constantly watched for, and the dosage must be regulated 
in accordance with these indications. With potassium iodide, 
indigestion, the characteristic eruption, tendency to neuralgic 
pain, localized edema, and congestion of the salivary glands, with 
symptoms of salivation and albuminuria, are among the symp- 
toms that must be taken as a warning in regulating the dosage of 
this drug. 
Arsenic.-The use of arsenic has been actively urged by many 
syphilographers during recent years. Sodium cacodylate is recom- 
mended by Murphy in doses of 1 to 2 grains hypodermically into 
the muscles. He claims a striking effect of this treatment upon 
syphilis, mucous patches, and primary chancre, and that the 
treponemata disappear completely in forty-eight hours. Ulcers 
of the palate and posterior wall of the pharynx heal as healthy 
granulating wounds in from three to six days. 
Salvarsan.-The most recent as well as the most promising 
preparation is the widely heralded Ehrlich's salvarsan ("606") or 
dioxydiamidoarsenobenzol. This remedy undoubtedly does give 
a decidedly alterative effect from a single intramuscular or intra- 
venous injection. Its influence upon latent luetic lesions appears 
to be unquestioned. That it could not cure all cases and all condi- 
tions of syphilis in one treatment is to be expected; that its proper 
employment in the future will give good results as its possibilities 
and limitations become better understood is also unquestioned. 
How far the criticisms that seem to be supported by reports of 
untoward effects may prove to be well founded, and how many 
of the ill results that appear to have been occasioned by its use 
may be due to faulty technic is a matter that the future will 
undoubtedly settle. Many cases have been reported as receiving 
marked and immediate relief from symptoms when doses of 0.3 
to 0.6 gram have been given by the intramuscular or intravenous 
routes, or a combination of the two. CHANCROID 
141 
Fordyce recommends the intravenous injection of "606," to 
be followed by mercurial injections for a period of from four to 
six weeks. At the expiration of this interval a second intravenous 
injection of salvarsan is given and followed by another similar 
period of mercurial treatment. After a rest of one month a Wasser- 
mann test is given, and if negative the serum reactions are made 
at intervals of several months; and as long as they remain negative 
no treatment is given. If at any time the Wassermann reaction 
becomes positive, the intravenous injection of salvarsan and the 
supplementary course of mercury are repeated. 
Skill in the diagnosis of syphilitic manifestations is of the utmost 
importance to dentists and oral surgeons for their own protection 
and the welfare of their patients, both syphilitic and non-syphilitic. 
They may or may not undertake the treatment of these cases, 
but the menace of the presence of syphilis cannot be avoided except 
by care and intelligent understanding of the symptoms. 
CHANCROID. 
Chancroid or soft chancre is a specific, local, contagious, auto- 
infectious venereal ulcer. Its nature is quite unlike the hard or 
syphilitic chancre with which it is sometimes confused. 
Etiology.-Chancroid is caused by the streptobacillus of Ducrey, 
although it is often a mixed infection, and microscopic examina- 
tion may show pyogenic and other bacteria. It is almost never 
acquired except in sexual intercourse. There must be an abrasion 
of the skin at the point of infection in order to transmit the affec- 
tion, except in cases where many hours of constant contact make 
it possible. 
Symptoms.-The lesion is local, and is not accompanied by 
systemic reaction or infection. After a single ulcer upon the male 
or female genitals others soon appear. These may spread by 
contact or extension to other regions. The anus, thighs, abdomen, 
or any other part of the body that the infection reaches may 
become infected. 
The period of incubation is usually from three to five days. 
Occasionally it may be as long as ten days when actual infection 
is delayed. 
Chancroid, when uncomplicated, is a round ulcer with sharply 
defined, often undermined and everted edges. It is surrounded 
by an inflamed base that is not indurated. In color it is grayish 
yellow, with abundant purulent secretion. 142 
INFECTIOUS DISEASES 
The Mixed Sore.-Much difficulty in diagnosis arises when 
chancroid and syphilis occur at the same time. The chancroid 
may be evident, and the syphilis not so much. The natural result 
of such a condition might easily be an error in diagnosis, with 
serious consequences. 
Bubo.-Bubo follows chancroid, according to Keyes, in about 
one out of every three cases. This inflammatory condition of 
the inguinal glands may gradually disappear by resolution, or 
suppuration may take place. The pus from these virulent buboes 
is auto-inoculable. 
Diagnosis.-Chancroid is diagnosticated by recognition of its 
bacillus with the microscope, and by auto-inoculation if the history 
and symptoms are not sufficiently clear. Its differentiation from 
chancre may be determined by the clinical features set forth in the 
table on page 129. 
Prognosis.-Simple, uncomplicated chancroid is controlled with 
comparative ease. When, however, phagedena occurs through 
mixed streptococcus infection, the prognosis is less favorable, and 
cases have been reported with destruction of the urethra, followed 
by extension of the disease up the penis until the mucous mem- 
brane of the bladder was attacked, and death followed. Fortu- 
nately such cases are very rare. 
Treatment.-Cauterization in the treatment of newly formed 
chancroids is useful if all the sores be thoroughly treated. Fol- 
lowing the cauterizing agent, the sore is cleaned with dioxogen, 
and a soothing dressing applied. 
Recently the tendency has been to treat chancroid as any other 
local infection would be treated, by the use of suitable bactericidal 
agent and mildly antiseptic dusting powder, without resort to 
cauterization by silver nitrate, nitric and carbolic acid, and similar 
agents. Effort should be made to prevent extension to the groin 
by keeping the patient quiet and making hot applications the 
moment inflammatory symptoms in this region are noted. 
ACTINOMYCOSIS. 
Actinomycosis is a chronic infectious disease, characterized 
by inflammatory reaction of the tissues, with a tendency to the 
formation of suppurative foci; it affects man and domestic animals, 
and is caused by the Streptothrix actinomycosis or ray fungus. 
On account of the frequency with which cattle are affected by 
lumpy jaw, an attempt has been made to distinguish actinomycosis ACTINOMYCOSIS 
143 
bovis from that which affects man; but this distinction does not 
seem to hold, as the organisms are practically identical. 
Etiology.-Actinomyces are found upon oat seed, the rust-covered 
straws of wheat and other grains. 
It has commonly been accepted that infection must occur through 
some such medium, but as the fungus is also found upon vegetable 
substances, it has been suggested that salads and uncooked vege- 
tables may be responsible for infection. 
The suggestion of recent writers, notably Stengel, that the 
organism is a rigid anaerobe and grows only at body temperature, 
tends to disprove these views. He says: "It is likely that the 
actinomyces is a normal inhabitant of the mouth and gastro- 
intestinal tract, and that it is always derived from these sources. 
Carious teeth and lesions of the mucous membranes play a part 
in the etiology." 
The presence of portions of straw, the husk of grains, and similar 
substances that have been reported as being found within the 
suppurative foci of this disease, lend color to the former theory; 
while the great frequency with which the disease is found to have 
its beginning in the mouth and associated structures gives clinical 
support to the latter. 
Coplin1 states that studies of the last few years appear to have 
established that "actinomycosis may be due to any one of several 
closely related parasites." 
Wright2 and other investigators maintain that the independence 
of the true actinomyces has been established. 
Pathology.-The actinomyces cause round-celled infiltration and 
proliferation in the connective tissues surrounding the parasite. 
This may lead on to softening, necrosis, and suppuration. In man 
the gums, cheeks, and floor of the mouth, as well as the lungs, 
intestines, and other internal organs, may be affected. There 
seems to be an alternate tendency to suppuration and repair, 
which is accompanied by cicatrization with marked induration of 
the tissues. In the jaw-bone there is progressive decalcification 
of the osseous structures, with tendency to the formation of nodular 
masses in the surrounding soft tissue. Metastases sometimes 
occur through penetration of the bloodvessels or lymph channels, 
and thus any organ of the body may become involved. 
Symptoms.-As a rule, actinomycosis becomes chronic and con- 
tinues over periods varying from months to years. According to 
1 Manual of Pathology, p. 167. 
2 Jour. Med. Research, May, 1905. Stengel: Text-book of Pathology, pp. 298, 
299. 144 
INFECTIOUS DISEASES 
Coplin,1 in over 50 per cent, of the cases in man the lesion is located 
in the tissues of the head and neck. Poncet Berard suggested 
division of actinomycotic affections into four regions: (1) Cervical- 
facial; (2) thoracic; (3) abdominal; and (4) cutaneous. Its appear- 
ance in other regions, such as the brain, spinal column, genito- 
urinary tract, and in the various special organs is chiefly accepted 
as an indication of complications by metastatic extension. 
When the face and neck are affected the point of beginning 
usually appears in the vicinity of a diseased tooth. There is swell- 
ing upon the affected side over and around the jaw, sometimes 
including the adjacent glands of the neck. A number of fistulous 
Fig. 59.-Fistulse of actinomycosis. (After von Bergmann.) 
openings often discharge from the point of suppuration (Fig. 59), 
and in long-standing cases these are surrounded by firm nodular 
masses (Fig. 60) which represent the sites of previous inflammatory 
foci. The characteristic discharge contains sulphur-like granules, 
which have sometimes been likened to mustard seeds in appearance. 
When these are spread upon a microscopic slide, the typical ray 
shape of the fungus becomes noticeable (Fig. 61). 
Pain.-Pain may or may not be an important symptom. Many 
times the condition is practically painless. In other cases chronic 
pain may be complained of through pressure or involvement 
1 Manual of Pathology, p. 169. ACTINOMYCOSIS 
145 
of nerve structures. Fever is seldom observed. In view of the 
often extensive and serious character of the lesions, the general 
symptoms are comparatively slight if at all noticeable. 
Fig. 60.-Actinomycosis of cheek, showing nodular masses. (Illich.) 
Fig. 61.-Actinomyces. (After von Bergmann.) 146 
INFECTIOUS DISEASES 
These symptoms are of course subject to complications such 
as may arise in the course of any inflammatory process. 
Trismus-Trismus is a quite common symptom in cases of 
actinomycosis which affect the jaws, because the inflammatory 
infiltration quickly involves the muscles of mastication. Even 
from the neck and cheek the masseter, temporal, and pterygoid 
muscles may be affected. As the disease extends, the hardened 
masses becdme fixed, and the difficulty of jaw movement is increased. 
Diagnosis.-The description of the symptoms of actinomycosis 
might lead to the expectation that the disease would be easily 
recognized, but, as a matter of fact, clinical experience often demon- 
strates that there is much difficulty in differentiating its symptoms 
from those of a number of other affections. The swelling and 
extensive induration in the region of the malar bone and cheek, 
when fistulse are absent, are sometimes not easily distinguished 
from malignant growths or even gumma. Of course, time will 
usually demonstrate the tendency to break down and the forma- 
tion of pus; but time in dealing with neoplasms in that region is a 
matter of first importance. Microscopic sections of tissue in 
these cases must be made to complete differentiation. Sometimes 
the greater density of the actinomycotic mass and the history of 
the case may serve to give reasonable assurance of its character. 
Necrosis of the jaws, chronic dento-alveolar abscesses, especially 
when there has been an extensive diffuse suppurative periostitis, 
or if a number of chronic dento-alveolar abscesses are involved, 
a series of fistula discharging through the neck and the induration 
from repeated acute inflammations, in chronic cases of long standing, 
may produce conditions the external appearance of which it is 
difficult to distinguish from actinomycosis. Tubercular affections 
in the same region are also occasionally of such character as to 
make their identification difficult, except by determining the pres- 
ence of tubercle bacilli. If the yellow granules which so readily 
display the ray fungus were constantly present in the pus, the 
difficulty would not be so great; but they do not appear to be 
constant in the discharge at all stages; doubtless because there 
is so frequently a mixed infection in which the pathogenic micro- 
organisms largely supersede the actinomyces, and under these 
conditions render difficult their recognition. 
Widal1 has applied the principles of his well-known agglutina- 
tion test for typhoid to secure a similar reaction in actinomycosis, 
1 Jour, de Chirurg., July, 1910. ACTINOMYCOSIS 
147 
and to ascertain whether the spores of Sporotrichum beurmanni, 
which, in contact with serum from subjects with sporotrichosis, 
give rise to intense agglutinations at 1 to 400, 1 to 500, and over, 
might not also be agglutinated by the serum from individuals 
with actinomycosis (coagglutination). 
"This hypothesis was verified in practice, 8 patients of different 
ages and with different types of actinomycosis, all exhibited mani- 
fest coagglutination on contact with the spores of the sporotrichum, 
varying from 1 to 50 to 1 to 51. Moreover, they all showed well- 
marked cofixation. When this phenomenon is obtained it shows 
we are dealing with a mycosis belonging to the same family as the 
actinomycosis; once this is established, the clinical course should 
enable actinomycosis to be differentiated from other mycoses 
caused by the same family." 
Prognosis.-The prognosis is good when the foci of infection 
can be completely removed and the surrounding areas properly 
treated. 
Treatment.-The surgical treatment consists of the removal of 
the diseased tissue as effectively as possible, The extensive resec- 
tions of the jaw, which were formerly thought necessary, are now 
practically discarded. Removal of a portion of the jaw-bone and 
the thorough curettement of the diseased surface with a bone 
curette, as in cases of caries and necrosis of bone from other causes, 
is sufficient. The excision of the fistulous tracts and thorough 
destruction of the inflammatory foci, with removal of the indurated 
tissue masses, is found to be sufficient when supplemented by 
proper local internal treatment. Potassium iodide taken internally, 
and the direct application of iodin to the wound surfaces, formerly 
gave the most satisfactory results. Experiments of the Agricultural 
Department of the University of Wisconsin showed that when grains 
before planting were washed in sulphate of copper, there was freedom 
from rust. The same remedy was applied in the treatment of actino- 
mycosis by Bevan, of Chicago, and others. The internal adminis- 
tration of sulphate of copper and its application directly to the 
lesion were found to give the most satisfactory results. This method 
of treatment was first reported to the dental profession by Dr. 
T. W. Brophy, of Chicago, with the description of some interesting 
cases and results. 
A suggestion from the author's experience may perhaps simplify 
these cases to those unfamiliar with their appearance and treat- 
ment. The all-important differentiation of neoplasm by the 
microscope gives the operator a considerable measure of freedom. 148 
INFECTIOUS DISEASES 
The use of potassium iodide internally and local applications of 
tincture of iodin would be beneficial rather than harmful, even 
though the disease chanced to be syphilis or even tuberculosis, 
and thorough surgical removal of diseased tissue ought to facilitate 
recovery in any one of several pathological affections with which 
this disease might probably be confused. Continued observation 
of the cases; examination of the contents of the fistulous tracts; 
microscopic study of the diseased tissue; the application of diag- 
nostic'methods which would be likely to lead to the detection or 
exclusion of other diseases if the symptoms of actinomycosis were 
not sufficiently positive to be depended upon; might one or all be 
relied upon for differentiation during the progress of the disease; 
and in the meantime the treatment would be helpful rather than 
harmful. 
Stengel1 describes a case of actinomycosis of the cheek, which is 
of particular interest because of the definite recognition of its 
point of origin, as well as for his description of symptoms and 
treatment: 
"A week later" (than the injury, which occurred November 1) 
"the patient felt a slight elevation and hardness at the spot of 
injury. His first impression of it was a swelling of the mouth of 
Steno's duct, such as occasionally occurs. The induration, how- 
ever, remained and seemed to be increasing during the next three 
weeks. On December 3 the mother discovered a slight purplish 
spot on the outside of the cheek opposite the growth within, and 
on examination the whole cheek was found occupied by a resilient 
mass that seemed attached to the skin on the outside and the 
mucosa within. J. W. White advised incision on the inner side. 
At operation the mass was found to be uniform, pinkish, with no 
sign of breaking down within. Portions were found to be made up 
of round cells, which suggested an inflammatory process or sar- 
coma. No actinomyces were discovered. Though drainage with 
gauze was maintained on the inside, the growth extended out, and 
soon an abscess-like projection formed at the side of the purplish 
area. The danger of extensive involvement of the skin now led 
to an incision where the growth pointed externally. A small 
amount of broken-down yellowish material was obtained and por- 
tions of the growth were removed. In the latter, after a number 
of sections were studied, actinomyces were detected. The patient 
had in the meantime been given increasing doses of KI on account 
1 Med. Record, June 4, 1910. GLANDERS 
149 
of the suspicions of actinomycosis after the first appearance of 
the purplish discoloration and external projection. Another abscess- 
like formation developed on January 15, and was opened January 
18. Increasing doses of KI, up to 60 grains daily, were given with- 
out materially influencing the progress. At this time, on the sug- 
gestion of A. C. Wood, diluted tincture of iodin was used in each 
of the incisions or sinuses. Almost immediately there was a mani- 
fest improvement, and within a fortnight the whole infiltration had 
resolved. Subsequently the incisions healed. The patient never 
suffered any recurrence, and is now in good health." 
GLANDERS. 
Glanders is an infectious and contagious disease due to a specific 
bacillus, which chiefly affects horses and asses, though it may 
be communicated to other animals and to man. 
Etiology.-Glanders infection is caused by the Bacillus mallei. 
When involving only the skin and adjacent glands it is called 
farcy. When the mucous membrane is affected, the condition 
is termed glanders. Usually it is communicated to man from the 
horse, although it affects a considerable variety of domestic and 
wild animals. The bacilli commonly gain entrance through some 
abraded or wounded surface in the skin or mucous membrane. 
Pathology.-It first appears in the form of a small nodule which 
contains the almost pure leukocytic infiltrate, a few giant cells, 
and the characteristic bacilli. This increases and produces an ulcer, 
which usually results in a series of ulcers that may or may not 
become confluent. Extension through the lymphatic system some- 
times leads to a chronic condition. In acute cases multiple abscesses 
throughout the body may cause death from exhaustion and toxemia. 
Symptoms.-Glanders may be acute or chronic. Farcy also 
appears in both acute and chronic forms, although according to 
some authorities farcy is applied to a chronic form of this affection; 
but this somewhat arbitrary classification does not seem to be 
borne out by clinical manifestations. 
In acute glanders there is a period of incubation of approximately 
three or four days. Two recorded cases, in which the symptoms 
appeared in six days and six weeks respectively, serve to show the 
wide limits within which the incubation period varies. 
Swelling, redness, and the usual signs of lymphatic involve- 
ment appear at the point of inoculation. The mucous membranes 
of the nose are attacked in the course of a few days. When the 150 
INFECTIOUS DISEASES 
nodules which form there break down there is a discharge of muco- 
pus. The nose and lymph nodes of the neck may become consider- 
ably swollen, and there is usually an eruption of papules and 
pustules upon the face. 
The duration of the disease is about ten days, and it terminates 
fatally, usually from involvement of the lungs. 
In chronic glanders the chief symptoms are those of chronic 
nasal catarrh, with ulcers upon the surface of the mucous membrane. 
In acute farcy the skin is affected by intense local inflammation. 
Nodules called farcy buds are felt along the course of the lym- 
phatics, because of their involvement. Suppuration may ensue 
as with other lymphatic affections. Papular eruption sometimes 
appears upon the skin. Fever occurs, resembling that of typhoid 
or septic infection. Pains and swelling in the joints are often a 
marked feature. Prognosis in these cases is almost as discouraging 
as that of acute glanders, death usually ensuing in the course of 
two weeks. 
In chronic farcy the lymphatics are not specially involved; but 
nodular tumors form in the extremities. These may break down 
and give rise to abscesses or ulcers. 
Diagnosis.-One method of diagnosis is made by the peritoneal 
inoculation of male guinea-pigs with the suspected discharges 
according to Strauss' test. If the Bacilli mallei are present there 
will be swelling of the testes, followed by swelling and ulceration 
of the scrotum before the fifth or sixth day. 
Mallein is prepared from the bacilli and used for diagnostic 
purposes in the same manner as tuberculin for tuberculosis.1 
The Agglutination Test.-This procedure for the diagnosis of 
glanders is based upon the phenomena of agglutination and pre- 
cipitation. When the blood serum of a horse affected with glanders 
is brought into contact with certain cultures of either live or dead 
bacteria, which are the specific cause of the disease, a clumping 
or formation of the flocculent masses of the organisms will take place. 
The glanders germs which before the addition of glandular horse 
serum are scattered singly through the liquid, when placed under 
the influence of glandular serum become so changed that they 
gradually adhere one to another and form small flakes, which settle 
at the bottom of the container, or, in other words, precipitate. 
These bacteria are taken from the culture, killed by heating, and 
placed in suspension in a germicidal or preserving fluid, thus form- 
1 Coplin: Manual of Pathology, p. 161. ANTHRAX, WOOLSORTER'S DISEASE 
151 
ing an emulsion or suspension of dead glandular germs. To a given 
amount of this suspension of glandular organisms, or test fluid, 
given amounts of glandular horse serum are added. Serum from 
an animal affected with glanders causes the dead suspended germs 
to agglutinate or clump, and flocculent masses of the dead germs 
are formed throughout the suspension fluid. This is called a posi- 
tive reaction. When the reaction or agglutination is complete, 
the flocculent masses of agglutinated bacteria will have settled at 
the bottom of the tube. 
To facilitate making this test the department of experimental 
medicine of the Parke-Davis Laboratory has devised a simplified 
apparatus, with control tubes, containing the test fluid to which 
no serum has been added; and other tubes which contain respec- 
tively 1 part of serum to 200, 500, 800, and 1200 parts of test 
fluid. 
The conclusions from these tests, are that all horses whose blood 
agglutinates in solutions of 1 to 1000 or higher should be destroyed; 
all those that show agglutination as low as 1 to 500, if they show 
symptoms of glanders, should be destroyed; below that they may 
be considered safe. 
Bernstein and Carling1 refer to 5 cases of glanders that were 
admitted to the Westminster Hospital in London; and state that 
reports which show glanders to be a rare affection are misleading. 
They hold that it is much more common than is generally sup- 
posed, so much so that "whenever there is a chronic inflammatory 
lesion of the oral or nasal mucosa, or an inflammatory mass in 
the subcutaneous or muscular tissue, if it is known that the patient 
has been brought into contact with sick horses, the diagnostician 
should be on the alert for glanders." 
Treatment.-If seen early, cauterization or excision of the lesion 
may be helpful. The enlarged glands or farcy buds may be opened 
and disinfected. 
Beyond measures of this character and treatment to relieve 
the symptoms there seem to be no known satisfactory therapeutic 
methods with which to combat this disease. 
ANTHRAX, WOOLSORTERS' DISEASE, MALIGNANT PUSTULE, 
SPLENIC FEVER. 
Anthrax is an acute infectious disease, which, although other 
animals may be affected, attacks sheep and cattle most frequently, 
1 British Med. Jour., February 6, 1909. 152 
INFECTIOUS DISEASES 
and from these is often communicated directly or indirectly to 
man. Dogs, cats, birds, and cold-blooded animals appear to be 
quite immune. 
Etiology.-It is caused by anthrax bacillus, a more than ordi- 
narily resistant, readily spore-forming bacillus. These bacilli will 
withstand a boiling temperature of water for several minutes; to 
destroy them requires prolonged immersion in a solution as strong 
as 5 per cent, carbolic acid; they are not killed by the gastric 
juices, and the spores are believed to be capable of living for a 
long period of time outside of the body. Those who handle hides 
are frequently infected on the hands and face, as are butchers, 
through contaminated meat, and woolsorters by inhalation of 
infection. 
Symptoms.-A swelling develops at the site of the infection, 
which is intensely inflammatory, surrounded by slight bullous 
vesicles and usually attended with considerable edema. A sanious 
liquid is discharged when erosion of the surface takes place, and 
there may be more or less pus formation. Bacilli are found in all 
of the local lesions and are eventually carried into the blood, and 
thus reach the spleen, liver, kidneys, lungs, and other organs. 
They are also discharged from the body in the stools and urine, 
and thus give opportunity for the infection of other animals. 
Infection through the gastro-intestinal tract causes hemorrhagic 
extravasation, ulceration of the mucous surfaces, and profuse 
diarrhea with bloody discharges. 
The pustules which form on the hands, arms, face, and neck 
in the external variety of this disease usually follow an incubation 
period of two or three days. The characteristic malignant anthrax 
edema in many cases follows in the course of a few hours. Death 
sometimes occurs within three or four days. 
Intestinal anthrax is ushered in by a chill, followed by diarrhea, 
fever, and other evidences of acute infection. 
The disease in the respiratory tract is accompanied by severe 
symptoms, of which chills, pains in the chest, back, and legs, 
respiratory difficulties, fever, and cough are marked indications. 
Death sometimes occurs within thirty-six hours of the onset 
of the disease. 
Brewer1 reports the mortality in cases in which infection has 
occurred in the extremities at less than 5 per cent., but when the 
lesion is on the neck or face the mortality rises to about 30 per 
cent., with a much higher mortality in the internal cases. 
1 Text-book of Surgery, p. 54 ANTHRAX, WOOLSORTER'S DISEASE 
153 
Diagnosis.-Although the symptoms may sometimes be con- 
fusing, the diagnosis is readily made by recognition of the bacillus. 
Prognosis.-In cases of external anthrax the mortality does not 
usually exceed 5 per cent. When the lesion is situated on the neck 
or face the death rate is about 30 per cent.; in internal anthrax 
it is much higher. 
Treatment.-Wide excision of the primary lesion should be made 
without an instant's avoidable delay. Adjacent lymph nodes 
that may be involved should also be removed, and the wound 
disinfected by some powerful germicide. Cauterization is some- 
times effective, but not so much so as excision. The advocates 
of less radical methods- urge that the cauterization is equally 
effective, and that it does not give opportunity for fatal general 
infection, which they believe is likely to follow in malignant cases 
when the bloodvessels are opened up by the incisions. Defects 
of the lips which are sometimes occasioned by the scars of these 
lesions may be remedied, if necessary, by plastic operations after 
recovery is complete. In other respects the disease should be 
treated as a toxemia, and all the natural forces should be stimu- 
lated by activity and nourished to the highest possible degree, 
to increase resistance to infection. 
The following table by Royer and Holmes1 gives a compre- 
hensive description of the manner of infection, and the results of 
treatment: 
Occupation. 
Location of lesion. 
Day of disease. 
Treatment. 
Results. 
Farmer 
Forearm (left) 
Eighth 
Surgical and phenol 
Cured. 
Hide sorter 
Right neck 
Third 
injection 
Serum only 
Died. 
Hide scraper 
Right ring finger 
Fourteenth 
Local antiseptic 
Cured. 
Teamster 
Right forearm 
Third 
Surgical and 
Died. 
Morocco worker 
Neck (left) 
Fifth 
antiseptic 
Serum and surgical 
Cured. 
Hair sorter 
Left neck 
Third 
Serum and surgical 
Cured. 
Hide sorter 
Lower lip (right) 
Fifth 
Surgical 
Cured. 
Hide stacker 
Forehead (right) 
Twelfth 
Serum and surgical 
Cured. 
Hide stacker 
Face (left side) 
Twenty-first 
Serum only 
Cured. 
Stevedore 
Neck (left) 
Fourth . 
Serum and late 
pied. 
Hair sorter 
Neck (right) 
Fourth 
surgical 
Serum only 
Cured. 
Hair washer 
Right cheek 
Fourth 
Serum only 
Cured. 
Hair comber 
Right cheek 
Fifth 
Serum and surgical 
Cured. 
Clerk and hair 
Chin (left side) 
Third 
Serum and surgical 
Cured. 
dealer 
Hair spinner 
Right cheek 
Second 
Serum and surgical 
Cured. 
The conclusions of these authors with regard to treatment are 
also of interest: 
1 Therap. Gaz., January, 1908. 154 
INFECTIOUS DISEASES 
"Only general conclusions regarding the treatment may be 
drawn from these cases, and these chiefly from individual cases. 
Serum treatment alone in certain cases seems to be curative. 
Serum combined with excision and cauterization with bichloride 
would seem to give best results in severe cases, while excision and 
cauterization will undoubtedly cure many." 
Two cases reported by Clarke1 illustrate important features. 
These "occurred simultaneously in a farmer and a butcher's 
assistant respectively, who had four days previously killed and 
dressed a diseased bull, apparently neither having the least idea 
of the cause of the animal's illness. Four days after each noticed 
a pimple on his arm. 
"The farmer, aged twenty-eight years, called with a sore. The 
site was the upper antero-external surface of the left forearm; it 
was about one inch in diameter, with a depressed center and a 
ring of low vesicles around; the central depression was purplish 
red but not black-it could not have been described as a typical 
pustule. There was no edema and no pain. The axillary glands 
were enlarged. The temperature was 100.4° F., and he complained 
of frontal headache; his tongue was furred and there was some 
general constitutional disturbance. This patient had attempted 
no local treatment. Slides were promptly prepared from the 
vesicles and stained. A few large bacilli were seen, occurring 
singly and in chains. That night the pustule was excised with a 
margin of sound skin, the subjacent fatty tissue being removed 
at the same time; pure carbolic was then applied and the wound 
dressed with sal alembroth gauze soaked in bichloride lotion. 
"In Case 2 the lesion was on the back of the wrist and was only 
the size of a dime. The pustule was far more typical; there was a 
dark central eschar. There had been considerable pain in the 
sore, coming on a day or so after he first noticed the pimple, which 
had led the patient to poultice it. He had no consitutional symp- 
toms and had continued at his work. When seen the wrist was 
slightly edematous and there was some redness around the sore; 
the axillary glands were enlarged. In this case the pustule was 
drawn forward and frozen with ethyl chloride; its base trans- 
fixed and the sore was excised. The after-treatment was the same. 
Both healed up well." 
1 Lancet, February 29, 1908. 155 
LEPROSY, LEPRA, ELEPHANTIASIS GRECO RUM 
LEPROSY, LEPRA, ELEPHANTIASIS GRECORLM. 
This is a chronic infectious disease caused by the Bacillus leprae. 
Etiology.-The bacillus of leprosy, recognized as the cause of 
the disease, has been demonstrated in the blood, in the leprous 
lesions, and in the nasal mucus, without regard to the presence or 
absence of ulcerative conditions in the nose. 
Fig. 62 
Fig. 63 
Fig. 62.-Case I. Leprosy of the anesthetic type. Man, aged nineteen years, a 
Greek, who had been in this country about four years. The lesions were on the flexors 
and extensors of the thighs, the buttock, the flexors, and extensors of the forearms 
and elbows. Diagnosis was made by incision into an anesthetic patch over the left 
elbow, and this smear showed lepra bacilli in the blood. (Dr. Daniel Hopkinson and 
Dr. E. L. Tharinger.) 
Fig. 63.-Same man shown in Case I, Fig. 62. 
The disease has been transmitted to a condemned criminal by 
direct inoculation, and there has been much experimentation with- 
out absolutely definite results in the direction of attempting to 
inoculate animals with leprous tissue. 
How far the conditions of countries and localities may influence 
the frequency of the disease, and whether fish or certain other 156 
INFECTIOUS DISEASES 
articles of diet, to which attention has been called, may be regarded 
as factors in causation or predisposition, is not clear at the present 
time. Intimate association for a considerable period seems to 
be necessary to transmit the disease. It is believed to be heredi- 
tary, but whether it is the disease or the predisposition that is 
inherited is still a matter of doubt. 
Fig. 65 
Fig. 64.-Case II. Nodular type of leprosy. Subject was a Greek, aged twenty- 
three years, in this country about six years; has had the lesions about eight months. 
Nodules distributed over face, hands, and extremities. He had a rhinitis for about 
three months, when the lesions first appeared. The nodules developed in consider- 
able numbers and then receded. Diagnosis was made by excising a nodule in the 
forearm. The blood smear showed typical lepra bacilli, as illustrated in Figs. 66 
and 67. It is significant that both of these men appeared to have contracted the 
disease in this country, unless the inoculation period is really much longer than is 
generally believed. (Dr. Daniel Hopkinson and Dr. E. L. Tharinger.) 
Fig. 65.-Same patient as in Case II, Fig. 64. 
Fig. 64 
Symptoms.-It appears in two forms, the tubercular and the 
anesthetic. 
In the tubercular form are found the characteristic skin lesions 
which appear in the early stages, and which have a reddish color, 
with slight inflammatory reaction in the beginning. The latter LEPROSY, LEPRA, ELEPHANTIASIS GRECORUM 
157 
Fig. 66.-Lepra bacilli. Smear from incised nodule. From case illustrated in 
Fig. 62. 
Fig. 67.-Lepra nodule containing lepra bacilli. From case illustrated in Fig. 64. 158 
INFECTIOUS DISEASES 
lose the redness of color, and as the disease progresses may show 
tendency to break down and form ulcerations which heal slowly 
or become converted into fibrous, cicatricial masses that cause 
marked and unsightly deformities. The mucous membranes and 
internal organs may also be involved. 
In the anesthetic form, hyperesthesia and neuralgic pains and 
ulcerations due to trophic changes are notable features. 
Discolored spots appear upon the skin surface, and these may 
be followed by ulcerations. Both forms may be found together. 
Secondary infection may lead to ulceration and gangrene, with 
extensive destruction of tissue-the so-called lepra mutilans or 
lepra gangrenosa. 
These cases were rarely met with in this country, and there was 
much confusion with regard to both diagnosis and treatment. 
In recent years many cases have been discovered in the Central 
States, as, for example, the two in Milwaukee, illustrations of 
which are shown in Figs. 62 to 65. Nevertheless the interest 
they may have for the oral surgeon is largely academic, and a 
more extended description of cases would therefore seem to be 
unnecessary. 
FOCAL INFECTION OF ORAL ORIGIN. 
For clinical purposes it seems best to group for consideration in 
this relation some affections of the oral cavity that might otherwise 
have been described in other chapters, with their several pathological 
classificatiojis. 
Since Rosenow brought to light the theory of the transmutation 
of microorganisms in 1913, the etiological and pathological impor- 
tance of the diseases of the teeth and other oral structures has been 
greatly emphasized. All investigators do not entirely agree with 
Rosenow's findings, but the vast amount of clinical data recorded 
with reference to diseases of the mouth and dental organs that 
seem to bear a vital relation to general and remote local affections, 
leans so strongly in this direction that the more or less technical 
character of the objections that have been raised fall naturally to 
the background of secondary consideration. As is usual under such 
circumstances the pendulum of methods of practice immediately 
swung from one extreme far over to the opposite one, and the sacri- 
fice of teeth at once became the price of insufficient general diag- 
nosis. When the real cause of a pathological condition situated in 
almost any part of the body, and of almost any character, was FOCAL INFECTION OF ORAL ORIGIN 
159 
not very clear, in many instances every tooth that was not like 
"Caesar's wife" was summarily extracted. The natural result is 
that many people have fewer teeth, and often suffer great disad- 
vantage from this cause, but they still have their original patho- 
logical affections. On the other hand, there can be no doubt of 
the inestimable importance of diseases of the mouth and the thera- 
peutic value of proper disposal of these foci of infection. 
According to Billings the recognition and removal of the focus 
is imperative as a fundamental principle to stop the progression of 
ill health. 
Rosenow1 gives the following conclusions: 
"The experiments on mutation show that when these and other 
streptococci are grown in symbiosis with other bacteria, and under 
a low oxygen pressure, they may acquire new features, and that 
sometimes they undergo marked changes on passage through ani- 
mals. The places in the human body where such conditions pre- 
vail, and where special features are likely to be acquired, are parts 
of infection such as in the tonsils, various sinuses, the appendix, 
and about the gums and teeth. 
"The strains from muscular rheumatism, especially after one or 
two animal passages, as well as other streptococci when they have 
attained a similar grade of virulence, show a marked affinity for the 
mucous membrane of the stomach, the pelvic mucous membrane 
and medullary portion of the kidney and the gall-bladder. Ulcer 
of the stomach, the picture of an 'ascending' nephritis, cholecys- 
titis with beginning formation of gall-stones, caused by strepto- 
cocci, have been found repeatedly in rabbits and dogs injected with 
strains, especially after one or more animal passages. 
"The essential element in favor of the mutation of pathogenic 
microorganisms in the human body is that the foci may be suitable 
for their long continuance in these situations. 
"Obviously then acute inflammatory conditions, the cardinal 
symptoms of which demand more or less immediate relief, or 
abscesses in which a sinus gives an exit to the pus, distressing or 
even alarming as these often appear to be, are not, as a rule, the 
affections that are of most serious etiological importance. 
"Hence the comparative general limitation of acute diseases of 
the periosteal, osseous, or other tissues of the mouth as causative 
factors to the effects of acute infections. It is the so-called blind 
abscesses, the granulomata, which seldom give rise to noticeable 
1 Jour. Infect. Dis., January, 1914. 160 
INFECTIOUS DISEASES 
symptoms that favor the continuance of bacteria in these foci, 
which gradually increase in size as surrounding bone absorption 
takes place, that may so often be held accountable for remote 
chronic diseased conditions. Many authorities now agree that focal 
infections of this character may have an important relation to cases 
of rheumatoid arthritis, iritis, endocarditis, myocarditis, ulcer of 
the stomach, disease of the kidneys, or anemia, leukemia, and other 
affections manifesting themselves through blood disturbances; 
chorea and many similar disorders of almost unlimited extent, or 
pathological manifestations touching the brain, spinal cord and 
nerve structures in which infection may play a part." (See Fig. 70.) 
Hebble has presented, in an article in the Dental Summary, some 
facts and figures gleaned from the work of important writers which 
give an adequate idea of the general pathological relation of oral 
infectious foci. 
"According to Irons1 an unselected group of 329 patients in a 
ward in Cook County Hospital, Chicago, was studied and the rela- 
tions of all discoverable infectious processes tabulated for each 
patient. The patients were then classified, according to final diag- 
nosis, and the percentage of each type of infection in each group 
calculated. Roentgen-ray studies, most of which were confirmed 
by consultation with dental surgeons, were obtained of 124 of the 
329 patients. In 44 per cent, of the 124 patients alveolar abscesses 
were found. In the arthritic group 76 per cent, had alveolar 
abscesses. In the group of nephritis and cardiovascular disease, 
47 per cent.; other diseases, including pneumonias, 23 per cent., or 
less than one-third of the percentage in the arthritic group. Abnor- 
malities in tonsils as expressed by hypertrophy were present in 45 
per cent, of the arthritic groups, in 24 per cent, of the cardiovascular 
group, and in 19 per cent, of the remainder. Other chronic infec- 
tions, such as those of sinuses or genito-urinary tract, were found in 
21 per cent, of the arthritic group, 13 per cent, in the cardiovascular 
group, and 11 per cent, of the other diseases. Syphilis, either from 
the history, clinical evidence, or Wassermann, was found in 23 per 
cent, of the arthritic group, 39 per cent, of the cardiovascular group, 
and 13 per cent, of other diseases. 
In experiments conducted at the University of Minnesota Hos- 
pital by Ulrich2 a little over 61 per cent, of all artificially devitalized 
teeth were found with apical abscesses, and the total number of 
abscesses on 1350 teeth, including those found on non-vital teeth 
1 Jour. Am. Med. Assn., September 16, 1916. 
2 Ibid., November, 1915. PLATE IV 
Dentin Impregnated with Rosin-chloropercha Solution. 
(Callahan.) PLATE V 
Illustration of a Section of a Tooth with the Dental Tubuli 
Stained by Injection of the Tooth Pulp. A Rare Result Accom- 
plished by Dr. V. A. Latham, of Chicago. 
Illustration of a Section of a Tooth with the Dentinal Tubuli 
Stained by Injection of the Dental Pulp. It also Shows the 
Result of a Pericemental Abscess. (Dr. V. A. Latham.) FOCAL INFECTION OF ORAL ORIGIN 
161 
due to caries or trauma, was 83 per cent. One hundred and fifty- 
nine of these cases had bacteriological review. Henrici reported 
107 cases from the university clinic, of which 100 gave the Strepto- 
coccus viridans; 52 were from the private clinic of Ulrich, 50 of which 
gave Streptococcus viridans or Streptococcus hemolyticus. Occa- 
sionally Streptococcus mucosa was recovered. Thus of 500 cases 
examined 150 gave evidence of streptococcus either in pure culture 
or as the dominant organism. Occasionally the Staphylococcus 
aureus or albus or the Micrococcus catarrhalis was also observed 
in conjunction with streptococcus. Gilmer and Moody1 report 
Fig. 68.-Alveolar abscessed teeth showing granulomatous and other ill effects of 
dento-alveolar abscess upon the roots of teeth and the hopelessness of endeavoring to 
save roots of this character. (Latham.) 
streptococci, both Streptococcus viridans and Streptococcus hemo- 
lyticus, as well as other organisms, such as Staphylococcus aureus, 
Micrococcus catarrhalis, the Bacillus fusiformis, and in two 
instances, diphtheroid bacilli. Hartzell and Henrici2 found in 162 
cases that 150 yielded streptococci. They report inoculation of 24 
rabbits with Streptococcus viridans isolated from apical abscesses, 
with the following results: heart lesions were found in 5, kidney 
lesions in 7, those of the aorta in 3, and of the joints 2. 
1 Jour. Am. Med. Assn., December 5, 1914. 
2 Ibid., March, 1915. 162 
INFECTIOUS DISEASES 
By actual weight and count Kligler1 has shown that human tooth 
scrapings from healthy mouths contain from 6,000,000 to 8,000,000 
bacteria to the milligram. By weight and count he has shown that 
44 per cent, of this enormous mass of bacteria is streptococci and 
from 18 per cent, to 22 per cent, is staphylococci." 
DENTO-ALVEOLAR ABSCESSES. 
For clinical as well as pathological reasons it is necessary to dis- 
tinguish between dento-alveolar apical abscesses in which there is 
an accumulation of pus surrounding or associated with the apical 
end of the root of a devitalized tooth and pericemental abscesses 
which may occur in connection with the roots of teeth having vital 
pulps. 
Etiology.-A tooth pulp may become devitalized through its ex- 
posure in the course of dental caries, whereby it is subjected to irri- 
tation by the secretions of the mouth, bacterial invasion and other 
vicious influences. Severe traumatic injury may destroy the integ- 
rity of the bloodvessels and nerves as they enter the apical foramina 
and thus cause loss of vitality in the tooth pulps. This may also 
occur from severe pericemental inflammation or infection in this 
region. Septic agents are then forced through the apex of the root 
by the confined gases within the pulp chamber of the tooth, and-thus 
infection of the alveolar structures surrounding the apex of the root 
results in due course in the formation of a typical abscess at that 
point. This may extend until the pus finds an exit through a fis- 
tulous opening in the mouth, or failing this, becomes what is known 
as a blind abscess, or the pus may find its way through channels 
of bone until it reaches some more distant point of exit, such as the 
maxillary sinus or the nasal cavity. The so-called blind abscess, 
the granuloma, with its protective wall in the form of an enclosing 
fibrous sac, containing lymphocytes and leukocytes, is apparently 
partly due to proliferation of the pericementum in response to 
chronic inflammation and also to the usual lymph protection thrown 
out in the course of abscess formation. 
Diagnosis.-In discovering the existence of these foci no other 
agent is so useful as the a-rays. Radiographs such as in Figs. 69 
and 70 usually show quite distinctly the dark areas surrounding 
the affected portion of the root. The essential feature in testing the 
teeth is to determine if the pulp be vital. This may be accomplished 
1 Jour. Allied Societies, September, 1915. DEN TO-A'LV EOLAR ABSCESSES 
163 
by the aid of the interrupted current, or the application of heat or 
cold to determine the sensitiveness to thermal changes, will often 
lead in the direction of the discovery of these foci. 
Treatment.--The author does not hold with Rosenow that every 
devitalized tooth root is necessarily a menace because the tubuli 
of the dentin may harbor microorganisms even though the root 
canal be completely filled. He does believe that once septic condi- 
tions have taken place within the pulp chamber of the tooth that 
it is not only necessary to have the root canal properly filled to the 
apex with gutta-percha or some equally suitable root-filling material, 
but that it is also in the highest degree necessary that the dentinal 
tubuli should be sealed according to the Callahan or some equally 
effective method. Figs. 71 and 72 illustrate the importance of 
this statement. It can only be determined that this has been 
successfully accomplished by taking other radiograms to show the 
actual condition of the root after it has been filled. 
Exsection of the Roots of Teeth.-The amputation of the apical 
end of the root of a tooth, the so-called apiectomy, is very generally 
practised among dentists. In some cases this treatment is war- 
ranted and many useful dental organs have thus been preserved 
without prejudice to general health; on the other hand, the indis- 
criminate application of this method may occasionally result in 
the retention of a focus of infection of somewhat more serious char- 
acter than before treatment. Very careful discrimination is neces- 
sary to determine in serious cases whether the root should be 
extracted or retained through the assistance of this type of operative 
treatment. No matter what individual opinion might dictate it is 
only safe to prove the result by a radiographic picture after suffi- 
cient time has elapsed to permit the obliteration of the cavity in 
the bone by new tissue formation. If this is found to be the case 
one year or longer after operation, and the original symptoms of 
focal infection seem to have permanently disappeared, then the 
retention of the root is warranted, otherwise the grave pathological 
possibilities for which such a condition may be responsible are too 
great to weigh in the balance against the retention or loss of one or 
even all the teeth. What is true of dento-alveolar abscesses as a 
menace to general health, is also true in regard to roots of teeth 
affected by pyorrhea alveolaris. In these cases it is sometimes diffi- 
cult to determine whether the pyorrhea is the result of some kidney 
or other affection or if the nephritic disease be the direct result of 
the effect of the oral condition. It is safe, however, to say that under 
all circumstances every effort should be made to completely eradi- 164 
INFECTIOUS DISEASES 
cate the mouth disease. If this can be done safely by keeping the 
progress of the pyorrhea sufficiently in check to prevent continu- 
ance of infection from that region then such teeth may be safely 
retained; if not, then the removal of the dental organs is the only 
Fig. 69.-Dento-alveolar abscess associated with pernicious anemia. 
Fig. 70.-Defective root fillings from the mouth of a business man with extensive 
interests, who broke down so completely that he was obliged to give up work and with- 
draw from active participation in the direction of the institutions with which he was 
connected. Travel abroad, trips to Carlsbad and other watering places, with consulta- 
tion by prominent internists in this country and Europe gave no relief and no definite 
diagnosis. Urinalyses and blood examinations gave every evidence of diseased condi- 
tions, but no light as to the cause. Complete recovery followed the treatment and 
extraction of several diseased teeth. 
Fig. 69 
Fig. 70 
safe procedure. It must be remembered that once the pericemen- 
tum is destroyed from a root surface it has never been successfully 
proved that this membrane would regenerate sufficiently to again 
cover that surface perfectly, whether it be an area of denuded root 
Fig. 71 
Fig. 72 
Fig. 71.-Large dento-alveolar abscess associated with a devitalized gangrenous 
pulp in the lateral incisor, the root of which was not filled, and imperfectly filled root 
canals in the first bicuspid and central incisor teeth. In this case the maxillary sinus 
was also involved. 
Fig. 72.-Dento-alveolar abscess and bone destruction due to pyorrhea alveolaris. 
The maxillary sinus was involved in this case. 
surface at the apical portion from a dento-alveolar abscess or upon 
some aspect of the side of the root from pyorrhea alveolaris. In 
either case there will be predisposition to the continuance of the 
focus of infection unless this can be surgically obliterated. DENTO-ALVEOLAR ABSCESSES 
165 
The occasional necessity of recognizing an association of chronic 
affections and giving relief through complete obliteration of other 
factors as well as those concerning the teeth is illustrated in Fig 73. 
The author has given the following rules for the guidance of phy- 
sicians and surgeons and dentists in his article in Ochsner's Surgery: 
"1. It must be admitted that the value of a tooth or teeth can- 
not be allowed to weigh in the balance against the reasonable possi- 
bility of serious general affections. Extraction should therefore be 
insisted upon unless complete security in this respect can be given 
by the treatment of the roots of such teeth. 
"2. If an attempt be made to treat the root canals of suspicious 
teeth under these circumstances the sealing of the tubuli according 
to the Callahan or some similar method should be insisted upon. 
Fig. 73 
Fig. 74 
Fig. 73.-Radiogram showing the result of a dento-alveolar abscess. In this case 
there was an acute arthritic affection of the left shoulder, severe long-continued 
headache and progressive loss of vision. All these symptoms were relieved after 
surgical treatment of the diseased area, and proper filling of the root canals of the 
affected teeth. 
Fig. 74.-Radiogram taken approximately one year after the one shown in Fig. 
73 for the same patient Bone regeneration in the diseased area is evident. 
" 3. There should not only be radiograms to show the condition 
before treatment but immediately after also to prove that the root 
filling has reached the apical end of the root. If the root canal fill- 
ing is imperfect it should be made perfect or the tooth extracted. 
"4. After a sufficient interval has elapsed another radiogram 
should be taken if necessary to demonstrate beyond the question 
of a doubt that there has been complete regeneration of the bone 
and pericemental structures surrounding the end of the root, with 
total obliteration of the abscess. With such care many teeth could 
undoubtedly be saved with safety. Without such precaution the 
only safe procedure is to extract the teeth in order to remove the 
risk of continuation of the disease. 166 
INFECTIOUS DISEASES 
" 5. It must not be forgotten that in many instances the indis- 
criminate extraction of teeth to relieve remote affections in the 
absence of complete diagnosis for the exclusion of other causes is a 
doubtful endeavor to relieve present ills with almost certain invita- 
tion of future disturbance. The extraction of even one tooth from 
Fig. 75.-Illustration of the case of a young girl who had for some time been bed- 
ridden with arthritis. Vaccines and other methods of treatment had been tried 
without avail. Her mouth and teeth were put in order at the clinic of the Southern 
Dental College and maxillary separation to widen her nose and give better drainage 
to the nasal accessory sinuses was performed under the direction of Dr. S. W. Foster, 
of Atlanta. The result was complete recovery. At the last report, a year or more 
after treatment, she was able to wear a No. 3 instead of a No. 5 shoe, and was able 
to run up stairs as well as anybody. 
a perfect dental arch paves the way for malocclusion which may 
lead to pyorrhea alveolaris or some similar affection in the future. 
The loss of a number of teeth destroys the functional activity of 
the jaws and may make itself felt in the disarrangement of the 
digestive tract at some later period. Moreover, the effect upon DEN TO-ALVEOLAR ABSCESSES 
167 
metabolism of proper or improper mastication of food is one that 
cannot lightly be overlooked." 
Fig. 76.-This girl is the subject of the illustration of arthritis in Fig. 75. The 
narrow appearance of the nose is important. 
With the foregoing rules for guidance much may be done with 
safety for the simultaneous relief of focal infections and tooth 
preservation. CHAPTER IV. 
DISEASES OF THE MUCOUS MEMBRANE OF THE 
MOUTH. 
STOMATITIS. 
Inflammation of the mucous membrane of the mouth. This 
term is used to include all inflammatory conditions affecting the 
mucous surfaces of the gums, cheeks, lips, and tongue. 
Marginal Gingivitis.-Marginal gingivitis is for clinical purposes 
assumed to be a slight inflammatory condition apparently confined 
to the border of the gums at the necks of the teeth. 
Etiology.-It may be evidence of some general condition of 
disturbed digestive or other function; most frequently it is caused 
by uncleanliness, favoring the collection of food particles, bacteria, 
and salivary calculus in this region. 
Symptoms.-The gum margins are red and inflamed, and may 
also become more or less everted. 
Treatment.-The treatment consists in the restoration of health- 
ful conditions by cleaning and scaling the teeth, the removal 
of any local irritant that may be a factor, and the application of 
tincture of iodin to the inflamed gum borders. 
Interstitial Gingivitis.-The term interstitial gingivitis includes 
not only the gum borders, but the interstitial tissues as well, and 
involves all the alveolar structures, including the pericementum, 
connective tissue, gums, and bone. Talbot, who introduced this 
term, designed it to include all of a considerable variety of terms 
which technically represent different stages of the same disease, 
although by adoption they are accepted in a more general sense. 
Examples of these are: Calcic pericementitis, phagedenic peri- 
cementitis, pyorrhea alveolaris, Rigg's disease, chronic alveolitis, 
etc. 
Etiology.-Its causes are predisposing and exciting, local and 
general, or constitutional. 
Talbot holds that on account of the transitory nature of the 
alveolar structures there is a natural predisposition to their early 
absorption. For this reason and because of the peculiar nature STOMA TITIS 
169 
of the circulatory conditions in this region they are unusually 
susceptible to all constitutional toxic influences. Therefore the 
effect of the administration of mercury, lead, iodin, and other 
poisons of similar nature gives early manifestation at the gum 
margins, and in like manner these structures are influenced by 
auto-intoxication from gastro-intestinal leukomains and toxemias; 
from acute infectious diseases as well as faulty metabolism due 
to chronic nutritional disturbances; organic affections leading 
to diseased conditions of the blood, and disorders of the central 
nerve system. Indican, the product of indol, resulting from intes- 
tinal fermentation, Talbot has shown to be almost constantly in 
excess in the urine of patients suffering from this affection, as is 
also acidosis evidenced by excess acidity above 40 per cent., or 
acidity below 30 per cent., an indication of insufficiency of renal 
elimination. 
Symptoms.-Cases of interstitial gingivitis, in which the symp- 
toms are chiefly confined to the roots of the teeth and the structures 
immediately surrounding them, are successfully treated by dentists, 
although they usually require constitutional treatment, that 
should be directed toward the cure of the underlying causes, and 
do not demand consideration from a surgical point of view. When, 
however, such conditions menace and involve adjacent bone and 
soft tissues extensively, they may lead to serious pathological 
nervous conditions of quite general nature by reason of the con- 
tinued irritation of the loosened teeth. Disturbance of the digestive 
tract may be brought about through insufficient mastication and 
insalivation, or through swallowing pyogenic microorganisms 
which sometimes seriously affect the stomach and intestines. 
Extensive necrosis of the jaws or infectious conditions may penetrate 
the cavities of the nose or maxillary antra, affect the glands of the 
lymphatic system and the salivary glands, or lead to gangrenous 
affections of the mouth. These conditions require surgical attention. 
Treatment.-General treatment of these cases should be correc- 
tive by administration of cathartics, regulation of the quantity of 
water to be taken during each twenty-four hours, administration 
of diuretics if required; the adoption of suitable dietetic rules 
by the increase of vegetable food if there be tendency to scurvy, 
limiting the amount of red meat, and additions to control the carbo- 
hydrates. Careful attention should be given to secure nourishment 
that will be strengthening and at the same time easily assimilated, 
and effort should be made to overcome directly the condition 
of acidosis. 170 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
The loose teeth, if the possibility of their retention be hope- 
less, should be removed; those that can be retained should be 
fastened by retaining appliances, or bridge-work which will attach 
them to other teeth in the mouth. Malocclusion is invariably 
present whether the teeth are regular in form and position or not. 
The occlusal surfaces must for this reason be ground, and the 
teeth protected by appliances against movement in all directions. 
The distributions of the stress so that in closure of the jaws it will 
be divided among a number of teeth instead of being applied to 
each single one, gives a steadiness that not only relieves the local 
irritation, and helps constructive cell efforts to restore and enable 
.the tissues immediately surrounding the roots to become tightened 
and more healthful, but causes at the same time an abatement 
of nervous symptoms which is quite generally beneficial. 
One of the most-' common causes of failure to respond to treat- 
ment in these cases, and at the same time a most active factor 
in extending destructive pathological processes, is the fact that 
extension of the inflammatory condition along the pericementum 
finally reaches the apical end of the root and attacks the nerve 
and bloodvessels as they pass through the apical foramen to join 
the general supply, thus causing strangulation at this point, which 
leads to devitalization and ultimately through infection to gan- 
grenous conditions of the tooth pulp. On account of the fact that 
there is frequently no cavity or external imperfection noticeable 
in the crown of the tooth, this condition may not be properly 
diagnosticated and the pulp chambers of such teeth then become 
veritable wells of pus, discharging a more or less continuous supply 
of infection to continue abscesses and necrotic conditions almost 
indefinitely. Opening through the tooth crown, cleansing and dis- 
infection of the roots are simple measures to be adopted in treatment, 
but without this care other treatment is absolutely useless. Necrosis 
and other pathological results, as evidenced in the oral cavity, or 
extension of disease to other regions, require treatment appropriate 
to the pathological state, whatever it may be. 
For local application the tincture of iodin, or Talbot's iodo- 
glycerol, may be used with benefit: 
Zinc iodide 15 parts 
Distilled water 10 " 
lodin 25 " 
Glycerin 50 " 
Since the first edition of this work was written the excitement 
occasioned by the theory of the Endameba buccalis as an etiological STOMA TITIS 
171 
factor per se, and the use of emetin as a positive curative agent has 
come and gone, leaving behind it a measure of truth and some 
interesting facts that when properly applied may have therapeutic 
value. Since the publication in the August, 1914, number of the 
Dental Cosmos of the article by Dr. Allen J. Smith, professor of 
pathology in the school of medicine of the University of Pennsyl- 
vania, and M. T. Barrett, D.D.S., instructor of normal histology 
in the same institution, relating to the presence of parasitic amebae 
in pyorrhea alveolaris and their belief in the use of emetin for its 
treatment, much has been written by Bass and Johns and other 
writers, the effect of which, coming as it did from men in high 
authority, has been almost vicious in its influence upon methods of 
treatment of this disease. The theory of the efficacy of emetin is 
largely based upon the findings of Col. Leonard Rogers, of the Indian 
Medical Service in Calcutta, who in 1912 demonstrated this to be a 
useful as well as specific remedy against endameba. In justice to 
Drs. Smith and Barrett, who have been so widely misquoted, the 
following extract from a personal letter from Dr. J. Allen Smith 
to the author, which is quoted from the author's article in Ochsner's 
Surgery, should be considered. 
"There are two forms of these parasites which may be found 
in and about the mouth, viz., endameba gingivalis (Gross in 1849 
appears to have been the first to publish and discover the amebic 
parasites in the soft material on and about the teeth) and Endameba 
pyogenes.1 Apparently either of these two amebae may be met in 
pyorrhea pus, but the first is the only one Dr. Barrett and I have 
found therein. We do not believe that these are alone responsible 
for pyorrhea suppurations, and do believe pyorrhea may occur 
without their presence, but we do believe they are present in the 
great majority of such lesions, which we speak of therefore as amebic 
pyorrhea. We think their importance comes especially from a 
symbiosis with the vegetable microorganisms therein found, and 
we believe we break one link of that symbiotic chain when we use 
emetin, which is an efficient amebicide, but (so far as known) only 
a poor bactericide. The chain broken in this wise the suppuration 
stops. But the same result might be obtained by cleaning out both 
the amebae and the bacteria by proper mechanical and antiseptic 
work, or it might be obtained by efficient bactericides as the exactly 
suitable vaccine for the individual case. To attack the amebic 
end of this symbiotic chain by emetin is the easy method, and seems 
1 Verdam and Bryant: L'ficho Med. du Nord., 1907, xl, 375. 172 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
to be providing commonly the most efficient method; but we would 
be improperly quoted if we were held to regard it as the only 
method." 
The frequent presence of endameba in the discharges from 
pyorrheal pockets is generally admitted. Their importance as 
primary etiological factors has, however, been very generally dis- 
proved. There seems to be no good objection to the introduction 
into the pyorrhea pockets with an ordinary hypodermic syringe 
properly used of any of the various preparations of emetin hydro- 
chloride solution in addition to other methods of treatment that 
have been given. There are, however, many good and sufficient 
reasons why the general use of the hypodermic administration of 
half-grain doses of emetin hydrochloride hypodermically each day 
for three to six days, as recommended by Bass and Johns, should be 
avoided, except when there is some unusual general indication for 
such treatment. 
Stomatitis Simplex.-A slight more or less transient eruption 
affecting the buccal mucous membrane. Eruptions of this char- 
acter are usually coincident with similar affections upon skin 
surfaces. These, as is well known, are the outward expressions 
of digestive disturbances, contagious infections, and specific 
diseases, and the simplest of all forms of stomatitis, which chiefly 
affects young infants is also due to gastro-intestinal disarrangement. 
Symptoms.-The symptoms are red elevated patches on the 
mucous membrane of the mouth. They are of bright color, appear 
suddenly, and usually disappear in the course of a few hours or 
a few days. Infants so affected usually show other symptoms 
indicative of disturbed nervous and digestive function, such as 
unusual flow of saliva, occasional rise of temperature, restless- 
ness, undigested matter, or greenish color of stools, etc. 
Treatment.-Treatment consists of correction of unhygienic 
conditions. If the child be bottle-fed, there should be careful 
sterilization of the bottle, nipple, etc., and readjustment of the 
formula of its food to conform to the digestive requirements. 
Plenty of fresh air, cleansing of the digestive tract by administra- 
tion of castor oil, and high bowel flushing if necessary are also 
indicated. The mouth should be cleansed with boric or other 
mildly antiseptic solutions. 
Stomatitis Catarrhalis (Catarrh of the Oral Mucous Membrane'). 
-Etiology.-Stomatitis catarrhalis occurs more commonly in chil- 
dren than adults. Neglected cases of simple stomatitis, direct 
irritation by heat, liquid or chemical substances, uncleanly con- STOMATITIS 
173 
ditions of the mouth, chronic disorders of the general system, 
mouth-breathing, and catarrh of the nasal mucous membrane 
may predispose or act as direct etiological factors. 
Symptoms.-The mucous membrane of the mouth is red and 
frequently covered with considerable liquid exudate; small vesic- 
ular cysts may form from distention of the mucous glands, and 
sometimes grayish erosions appear. 
Treatment.-Treatment requires correction of the general causes 
by hygienic care, which embraces cleansing of the mouth and body, 
both externally and internally, and the administration of cathar- 
tics, attention to digestive conditions, fresh air, use of mild anti- 
septic mouth washes. Infants or young children suffering from 
either simple or catarrhal form of stomatitis should be given care- 
ful attention with regard to erupting teeth, and to gums freely 
lanced, if necessary. Any disadvantageous conditions that may 
impede the progress of teeth in course of eruption must also be 
overcome and carious or otherwise diseased teeth properly dis- 
infected and treated. 
Aphthous Stomatitis.-Aphthous stomatitis occurs in both chil- 
dren and adults, but more frequentlv in the former. 
Etiology.-It is the result of malhygiene or of gastro-intestinal 
or other disease. Quite frequently when found in adult cases it 
is merely an indication of some passing digestive disturbance of 
temporary nature. 
Symptoms.-The little aphthae or cankers form usually in the 
folds at the junction of the mucous membrane of gum and lips, 
or cheeks. Little oval, bright red spots are usually first noticed 
because of the fact that they are highly sensitive to touch and to 
sweet and sour substances taken into the mouth. These points 
of irritation quickly assume a gravish-white appearance, because 
of the degeneration of epithelium that takes place upon the sur- 
faces. A number of these may occur in the same locality and by 
confluence become joined into a single large one, but the inflamed 
outline of the border retains either the original oval form or its 
shape indicates the joining together of one or more individual 
oval patches. The lesions are superficial and do not have a ten- 
dency to penetrate deeply and to affect the underlying bone 
structures (Plate VI, Fig. 1). 
Treatment.-The local treatment consists of touching the cankers 
with caustic nitrate of silver or 95 per cent, carbolic acid, followed 
by alcohol or nitric acid to cauterize the surfaces. Thorough 
cleansing of the mouth, the use of suitable mouth washes, and, if 174 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
necessary, correction of the predisposing gastro-intestinal condi- 
tion. 
Bednar's Aphthae.-These are small ulcers found in the mouths 
of sucking infants, situated at the lateral portions of the palate 
and in other places where the surfaces would be likely to be affected 
by traumatism during the act of sucking, which is their probable 
cause. 
Treatment.-The only remedies suggested in these cases, if the 
child be bottle-fed, are the administration of nourishment by 
spoon or with a medicine dropper, and if possible the correction 
of any irritating habit that may have been acquired, such as thumb 
sucking or sucking at an empty nipple, as is sometimes allowed. 
Ulcerative Stomatitis.-Ulcerative stomatitis is the most diffi- 
cult of all forms of stomatitis to differentiate from other types 
of this affection, because the inflamed areas between and around 
the necks of the teeth affecting the gums and other surfaces of 
the buccal cavity may be associated with symptoms of many 
varieties of inflammation of these structures. 
Etiology.-It may be the direct result of interstitial gingivitis 
or may be due to causative factors such as general infection, 
mineral poisons, disorders of the general system, local irritation, 
etc., which are usually accompanied by quite similar ulcerative 
and destructive processes. For clinical purposes it is necessary 
to make a more or less arbitrary distinction by which we recognize 
this condition as a disease affecting both children and adults, 
the former chiefly under conditions of malhygiene, insufficient 
nourishment, and depletion of the system by long-continued fevers 
or the effect of the various eruptive diseases common to early life 
and older persons from general uncleanliness, dissipation, excessive 
smoking or drinking, and similarly induced factors. 
Symptoms.-This form of stomatitis is noted for its grayish- 
white slough of irregular outline; it usually begins at or close to the 
gum margins and extends until it includes adjacent tissues. It 
is distinguished from aphthous ulcers by its irregular outline and 
the tendency to begin upon the gum rather than the cheek or 
lip surfaces, and by the fact that it attacks the bone and deeper 
structures; from pvorrhea alveolaris because instead of clearly 
defined pockets with pus secretion it spreads out upon the surface 
and the process is an ulcerative one; from mercurial, syphilitic, 
and other diseases of the mucous membrane of the mouth by 
recognition of their special etiological factors. It frequently leads 
to extensive necrosis of the maxillary bones in children, particu- STOMATITIS 
175 
larly between the ages of five and twelve years. This is doubtless 
due to the fact that the jaws are, at this particular time, so filled 
with developing teeth that the actual bone resistance and blood 
circulation are reduced, and also because at this period the diseases 
incident to childhood, both local and general, predispose to affec- 
tions of this character. 
Prognosis.-If the underlying cause has been properly reached, 
the recovery and improvement should be prompt. When it occurs 
slowly, one should be on guard against some factor that may have 
been overlooked. 
Treatment.-Clean the teeth, remove the tartar and other irri- 
tating substances from between and about their necks. Remove 
or disinfect diseased roots of teeth, curette sloughing gum margins, 
and smooth with a bone curette or dental engine bur the roughened 
borders of the alveolar process. Paint the gum border and entire 
diseased surfaces with tincture of iodin; correct the etiological 
factors whatever they may be. (For treatment of necrosis of the 
jaw resulting from this disease, see Necrosis, page 368.) Direct 
improvement of dietetic and hygienic conditions. In young chil- 
dren attention should be given to developing unerupted teeth 
which may become involved and through their devitalization act 
as complicating factors aiding in continuing infection. Appro- 
priate treatment is demanded in all cases showing enlarged tonsils, 
adenoid vegetations in the nasopharynx, irregular and contracted 
dental arches, and deflected nasal septa, all of which are usually 
associated in anemic, ill-developed children. Nervous and other 
habits that may be indications of continued irritation in other parts 
should also receive due attention. In the author's experience 
adult patients suffering from this affection have usually been those 
who smoked excessively, particularly cigarettes, who drank liquor 
freely, or depleted their systems through other habits of dissipa- 
tion, or who had disease of the kidneys, liver, and other organs, 
and particularly diseases of the blood, such as acute leukemia and 
pernicious anemia, of which it is usually one of the earliest symp- 
toms. Local causes in many of his cases were irritations and infec- 
tion from neglect of brushing the teeth or cleansing the mouth. 
More often, however, the insertion of bridges between teeth with- 
out due care for self-cleansing, and with disregard of occlusal 
conditions, not only favored the collection of debris under and 
around them, but in closure of the jaws the unusual stress of mal- 
occlusion kept up a chronic irritation and reduced the resistance 
of the tissues to bacteria. All irritating dental conditions, crowns, 176 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
bridges, plates, or whatever they may be, should be removed at 
once. Immediate reform with regard to smoking and other habits 
must be insisted upon. Urine for twenty-four hours saved and 
carefully analyzed and its indication followed in treatment. In 
serious or persistent cases a careful blood examination should be 
made. By reference to the case described under the heading 
Leukemic Stomatitis, p. 183, the importance of these examinations 
will be better understood. 
Gangrenous Stomatitis (Plate VI, Fig. 2), Cancrum Oris, Noma 
(Plate VI, Fig. 3).-Gangrenous stomatitis usually attacks the gums 
or cheeks, the slough extending until it involves a considerable 
portion of the face. 
Fig. 77.-Gangrenous stomatitis. Girl, aged five years. (Courtesy of Dr. R. 
C. Young.) 
Etiology.-This disease is undoubtedly of infectious origin. 
While attempts have been made to identify a specific germ, the 
results in this direction have not been such as to warrant general 
acceptance. The bacillus described by Lingard has been found 
in a small percentage of cases, but streptococci, staphylococci, 
leptothrix, and other microorganisms have been identified in 
these cases so frequently that there seems to be no doubt that 
the affection is polymicrobic. It frequently follows measles, 
whooping-cough, scarlet fever, and other infections. In these cases PLATE VI 
FIO i 
Aphthous Stomatitis. 
FIG 2 
Gangrenous Stomatitis. 
FIG. 3 
Noma. STOMATITIS 
177 
there appears to be some underlying systemic condition which 
predisposes to gangrene rather than to other manifestations of 
mouth infection. Although most commonly affecting ill-fed and 
uncared-for children and those debilitated from disease between 
the ages of two and twelve years, there is no actual age limit. 
With older persons it is almost invariably an expression of some 
pathological state of general character, such as pernicious anemia, 
leukemia, tuberculosis, diabetes. In one of the author's cases of 
noma affecting a girl nine years old the characteristic spirilla, and 
fusiform bacilli of Vincent's angina were found as illustrated and 
described in connection with that affection. Weaver and Tunnicliffe 
have previously called attention to these microorganisms in noma. 
Fig. 78.-Same child shown in Fig. 77, two and one-half days later. The rapid 
progress of the gangrene may be noted. 
Symptoms.-The following descriptions of examples from the 
author's practice are given as practical illustrations of the symp- 
toms of this disease. 
An unmarried man, aged twenty-two years, until recently in 
robust health, was referred by his physician, after about two 
weeks' treatment, suffering from the discharge of a dark fluid on 
the distal side of the left inferior third molar, a temperature of 
104°, not much swelling, practically no pain. A dark-colored spot 
formed on the buccal surface of the cheek, which quickly extended 
until it opened through the skin. At no time was there any evi- 
dence of pus. The black gangrenous masses formed so rapidly 178 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
that although cleansed from four to six times a day, the dead 
tissue could be wiped off with cotton swabs at each attempt. 
Germicides and other remedies seemed to have no effect whatever. 
It was useless to attempt to excise the dead tissue, because the 
gangrenous process began immediately at the border of the inci- 
sion. Bacterial examination showed staphylococcus infection. 
Notwithstanding the administration of stimulating remedies and 
suitable nourishment, the patient died about ten days after treat- 
ment was begun, and some two or three weeks after the onset of 
the first symptoms. Death occurred through extension of the 
gangrenous process to the lungs, black gangrenous masses being 
expectorated during the last twenty-four hours. 
Another case with symptoms of ulcerative stomatitis which 
quicklv extended until gangrene of the palate was established is 
described with reference to leukemia (page 183), as that proved 
to be the underlying cause. Large numbers of children, some of 
whose cases are described under the heading Necrosis, page 368, 
did not reach the author until sequestra of the maxillary bones 
required removal. Most of these gave histories of high tempera- 
ture and general symptoms which were frequently confused with 
typhoid and other fevets, wrong diagnoses being made until finally 
the condition of oral sepsis was so apparent that it could no longer 
be overlooked. Quite invariably cases of this type recovered 
quickly after removal of necrotic tissue, local disinfection, and 
proper general care (Plate VI, Fig. 2, and Figs. 77 and 78). 
Prognosis.-With adults, when leukemia, pernicious anemia, or 
similar blood disorders are the underlying causes, the prognosis 
is very grave and a fatal termination is likely to result through 
inability to overcome the first causes and the lack of resistance 
thus afforded in combating the toxic effect of the gangrenous 
processes. 
In other cases prognosis is favorable except with regard to cica- 
tricial contraction which sometimes results, and causes more or 
less serious deformity. 
Treatment.-Antiseptic dressings and the excision of gangrenous 
tissue must be supplemented by measures designed to overcome 
the underlying cause and to build up the general system. 
Antitoxic serum in this, as with other affections of similar char- 
acter, is deserving of due consideration, even though its therapeutic 
value in these cases is not fully established. 
Parasitic-mycotic Stomatitis or Thrush.-This is an affection 
which occurs most frequently in nursing children, though occa- STOMATITIS 
179 
sionally it is seen in adults after or during acute processes or 
chronic diseases.1 
Etiology.-It is a parasitic infection due to the thrush fungus, 
generally termed Oidium albicans. 
Symptoms.-The erosions are white, or creamy white in color, 
and usually begin upon the tongue or cheek and spread to the 
tonsils, palate, pharynx, esophagus, or lips. They may resemble 
flakes of curdled milk or may become brownish from the infiltra- 
tion of extravasated blood. It is distinguished from other forms 
of stomatitis by the presence of the fungus and marked dryness 
of the mouth instead of the reverse condition which usually accom- 
panies stomatitis, especially in infants and children. 
Treatment.-The parasite seldom infiltrates the epithelium of 
healthy individuals. It is therefore rarely seen except among 
ill-nourished or debilitated children. The first correction of hygienic 
and constitutional predisposing causes should therefore be by 
cleansing the alimentary tract with castor oil or small repeated 
doses of calomel, supplemented by bathing, fresh air, and strict 
attention to diet. If bottle-fed, as such infants usually are, the 
formula of the nourishment must be properly adjusted, bottles, 
nipples, and other accessories thoroughly sterilized, and the 
mouth swabbed with boric acid or other mildly antiseptic 
solution. 
Foot-and-mouth Disease.-Foot-and-mouth disease is a disease 
of the lower animals, most common among cattle, but believed to 
be infectious to man. 
Etiology.-Brush, after careful study of the review of the litera- 
ture of the subject, and an exceedingly painstaking investigation 
among dairymen and in communities supplied by herds having 
been affected by foot-and-mouth disease, concludes that "there is 
an aphthous condition of the young in both the bovine and human 
family which is not contagious, and there is an aphthous condition 
in both these species that is contagious." Proof of this is presented 
by reports of cases of children and older persons who were affected 
by aphthous ulcers and other more general symptoms of foot-and- 
mouth disease, after drinking milk of cows at the time suffering 
from the affection, and of dairymaids who contracted herpes on 
fingers and toes from milking cows having the herpetic' eruption 
of this disease. The disorder is assumed to be due to the patho- 
genic action- of an ultramicroscopic virus. 
1 Coplin: Manual of Pathology, p. 676. 180 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
Pathology.-Pathologically the disease is characterized by inflam- 
mation, with considerable thickening of the corium, and vesicles 
from the Malpighian layer which generally rupture, exfoliate, and 
cause ulcers. 
Symptoms.-There may be many simple erosions without vesicles, 
or the ulcers may become confluent and spread over considerable 
areas of the surface of the mouth. In animals there is often fever 
and a similar eruption upon the feet. Usually the disease in cattle 
runs its course in about ten days, and with humans in a somewhat 
shorter period, unless complications arise. Many instances are 
reported, however, in which calves have dropped dead immediately 
after sucking an affected mother. 
Treatment.-The treatment is to stop the milk by changing to 
that of healthy animals, or, if uncertain of this, to boil the milk. 
Give local treatment to relieve pain and other distressing symp- 
toms. Cleanse the intestinal tract and assist general support until 
the symptoms have run their course. 
Pseudomembranous Stomatitis.-Etiology.-This affection is 
most commonly caused by the Klebs-Loeffler bacillus, and under 
these conditions is diphtheria of the mouth. It is generally agreed, 
however, that pseudomembranous inflammation may be induced 
by certain kinds of irritation without bacteria, and also that it 
may result from infection by streptococci, staphylococci, and 
pneumococci as a complication of pneumonia. Other bacilli have 
sometimes been recognized as exciting causes. Notwithstanding 
this, however, it is commonly accepted as diphtheritic. Clini- 
cally this is much the safer ground to take and regulate treatment 
accordingly. 
Symptoms.-Marked hyperemia is followed by exudate in the 
submucosa, fluid exudates and leukocytes pass through the sur- 
face, and by necrosis form a grayish-yellow, dirty membrane 
which occasionally is quite dark. Ulcers may form as dead tissue 
is thrown off. The clearly defined outline indicative of the early 
stages becomes lost as the destructive process proceeds. 
Treatment.-Injections of antitoxin and good general care. 
Phlegmonous Stomatitis.-Phlegmonous stomatitis1 affects the 
lips more frequently than other portions of the mouth. 
Etiology.-Traumatic injuries with intense infection may be 
causes or it may be secondary to facial erysipelas or other cellular 
inflammation of the face. 
1 Stengel: A Text-book of Pathology, p. 544. STOMATITIS 
181 
Symptoms.-The lips and cheeks become swollen, with tendency 
to suppuration and the formation of abscesses which may rupture 
within the mouth. Hypertrophy of the deeper tissues of the lips 
sometimes follows a chronic form of this infection, especially of 
the upper lip in cases of long-standing coryza or eczema. 
Treatment.-Remove the cause if possible. Give general treat- 
ment if necessary to restore healthful bodily conditions and local 
treatment by the application of non-irritating, antiseptic, prefer- 
ably alkaline mouth washes, and upon the skin surfaces lano- 
line, vaseline, or other suitable salves or dusting powder as may 
be indicated. In addition to this, the surfaces of the ulcers within 
the mouth should be thoroughly cleansed with dioxogen. 
Tuberculosis.-Etiology.-Tuberculosis of the mouth may occur 
as a direct result of primary infection of the tissues by the Bacillus 
tuberculosis, or it may be secondary to tuberculosis of adjacent 
parts, or be an extension from lupus of the face. 
Symptoms.-Primary infection is usually evidenced by nodular 
masses in the form of papillary elevations with tendency to form 
tuberculous ulcers which become caseous and infiltrated by 
tubercles. 
Treatment.-See Tuberculosis, p. 113. 
Actinomycosis.-Actinomycosis (lumpy jaw) is also a disease 
common to cattle, horses, swine, sheep, the dog, and other animals, 
both domestic and wild. It affects the gums, alveolar and other 
tissues, the mucous membrane surfaces of the mouth, as well as 
the tongue and the maxillary bones. As these structures are 
usually jointly involved in this affection, its full consideration 
is taken up under Infectious Diseases, p. 142. 
Leukemic Stomatitis.-Leukemic stomatitis has already been 
referred to in describing gangrenous stomatitis, because in acute 
leukemia the gums become inflamed and the formation of ulcers 
quickly leads to necrosis and hemorrhagic inflammation. The 
affected tissues present much the same appearance as in other 
similar conditions. It is one of the symptoms of leukemia, a 
disease of the hemogenic organs characterized by increase in the 
number of leukocytes in the circulating blood, and by patho- 
logical changes in the bone marrow, spleen, and lymphatic glands. 
Detailed consideration of the nature and treatment of leukemia 
does not properly come within the province of this work, but in 
the diagnosis of the form of stomatitis, of which it is the under- 
lying cause, its importance is vital. Both the value of a blood count 
in recognizing the affection and the utter hopelessness of attempted 182 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
cure of the mouth lesions by local treatment are illustrated by 
the following description of one of the author's cases: 
Fig. 79.-Leukemia: Section showing necrosis of mucous membrane of the mouth. 
Fig. 80.-Leukemia: Section of the inner wall of the cecum, taken from the 
same individual as Fig. 79. STOMATITIS 
183 
A workman, aged fifty-four years, married, of good habits and 
family history, so far as could be learned, with several healthy 
Fig. 81.-Leukemia: Section of the same case as the previous numbers, cut through 
the muscular coat of the cecum, showing periarteritis and thrombus. 
Fig. 82. Leukemia: Section of spleen, from same case as Figs. 79 to 86 inclusive. 184 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
appearing children, gave a history of some months of ill health, 
but was until recently able to work. 
Fig. 83.-Leukemia: Section of liver, from same case as Figs. 79 to 86 inclusive. 
Fig. 84.-Leukemia: Section of kidney, from same case as Figs. 79 to 86 inclusive. STOMA TITIS 
185 
His anemic appearance was marked, but having formerly been 
of rugged constitution, he was able to get out of bed and go about 
Fig. 85.-Leukemia: Section of lung, in same case as Figs. 79 to 86 inclusive. 
Fig. 86.-Leukemia: Section of heart, from same case as Figs. 79 to 86 inclusive. 186 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
the house without assistance. Examination of his mouth disclosed 
interstitial gingivitis chiefly on the lingual side of the upper incisors, 
with gums and buccal mucous membrane in foul condition and 
tongue heavily coated. 
Every effort was made to build up the depleted system. Alcohol 
baths, beef peptonoids, bone marrow, and other nourishing agents 
were prescribed, and these supplemented with hypodermic adminis- 
tration of strychnin, normal salt solution per rectum and directly 
into the tissues, etc. 
The last blood count was as follows: 
Name. 
Normal. 
Present condition. 
Red corpuscles 
_ 5,000,000 
1,500,000 
Hemoglobin 
100 per cent. 
30 per cent. 
Corpuscle index . . . 
1 per cent. 
1.3 per cent. 
White cells 
. 7000 
105,000, Aug. 10 
Polymorphonuclear neutrophiles . 
70 per cent. 
8 per cent. 
Small lymphocytes .... 
8 per cent. 
26 per cent. 
Large lymphocytes .... 
20 per cent. 
60 per cent. 
Remnants of leukocytes . 
25 per cent. 
6 per cent. 
Megaloblasts 
f 1 to each 100 
leukocytes 
Normoblasts 
( 1 to each 100 
\ leukocytes 
Bacteriological examination of the lesion showed staphylococcic 
infection. Temperature ranged from 100° to 102°, with pulse 
indicative of increasing muscular weakness, both ranging higher 
toward the last. 
Mental faculties were clear until about forty-eight hours before 
death, which occurred about ten days after the author first saw him. 
Operation was attempted for the purpose of removing the 
necrotic tissue that rapidly increased toward the end. An open- 
ing was made through the hard palate into the nares, but the 
bone was found to be dead in every direction so far as it seemed 
advisable to remove it. Gangrene of the soft tissues was so rapid 
that black masses were removed at each dressing several times 
daily. 
The essentially interesting feature of this case is the lesson 
taught by the blood count, which indicates leukemia, the micro- 
scopic sections of the tissues of the mouth at the seat of the oral 
affection, and others of important visceral organs, each of which 
shows practically the same areas of inflammation (Figs. 79 to 86 
inclusive). 
Glanders.-Glanders is another disease of animals communi- 
cable to man, which sometimes affects the tissues of the mouth and 
the pharynx. (For further reference see p. 149.) STOMATITIS 
187 
Etiology.-Glanders infection is caused by the Bacillus mallei. 
W lien involving only the skin and adjacent glands it is called farcy. 
When the mucous membrane is affected, the condition is termed 
glanders. Usually it is communicated to man from the horse, 
although it affects a considerable variety of domestic and wild 
animals. The bacilli commonly gain entrance through some 
abraded or wounded surface in the skin or mucous membrane. 
Pathology.-It first appears in the form of a small nodule which 
contains the almost pure leukocytic infiltrate, a few giant cells, 
and the characteristic bacilli. This increases and produces an 
ulcer which usually results in a series of ulcers that may or may 
not become confluent. Extension through the lymphatic system 
sometimes leads to a chronic condition. In acute cases, multiple 
abscesses throughout the body sometimes cause death from exhaus- 
tion and toxemia. 
Diagnosis.-Mallein is prepared from the bacilli and used for 
diagnostic purposes in the same manner as tuberculin for tuber- 
culosis.1 
Leprosy.-In common with other diseases manifesting them- 
selves upon the skin surfaces, leprosy also affects the mucous 
membrane of the mouth. (See Leprosy, p. 155.) 
Ludwig's Angina or Diffuse Suppuration of the Floor of the 
Mouth.-Diffuse submaxillary cellulitis, or acute infectious sub- 
maxillary angina, is a septic condition affecting the tissues of the 
floor of the mouth. 
Etiology.-Infection usually occurs from ulcers, necrotic condi- 
tions of the mucous membrane of the mouth, injuries to the floor 
of the mouth or extension of disease from the pharynx, lungs, etc. 
The microorganisms usually found are streptococci, staphylococci, 
pneumococci, and other pyogenic bacteria. 
Symptoms.-Ulcers form under and around the tongue; occa- 
sionally there are abscesses. Induration of the tissue sometimes 
forces the tongue upward and backward until the swelling occupies 
the entire submaxillary space. It may extend downward into the 
neck or involve the pharynx, larynx, and tonsils (Fig. 87). 
Treatment.-The treatment comprises general disinfection of the 
mouth, direct treatment of the ulcers and relief of the abscesses 
if necessary, hot applications to control external swelling if this 
symptom be present in sufficient degree, thorough cleansing of 
the alimentary tract with cathartics, and treatment or removal 
1 Coplin: Manual of Pathology, p. 161. 188 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
of the primary cause, or of such irritating factors as may exist. 
In extreme cases tracheotomy is sometimes required to prevent 
Fig. 87.-Ludwig's angina: Section through jaw, showing the ulcerated condition of 
the floor of the mouth and other parts as indicated by the lines. (After Thomas.) 
suffocation when the affected parts are so swollen as to interfere 
with normal respiration. Nourishment per rectum is usually 
required for the same reason (Fig. 88). 
Fig. 88.-Ludwig's angina: Shows characteristic position of head in the effort of 
respiration. (Case of Dr. R. C. Young.) 
Vincent's Angina. (Diphtheroid Angina).-Vincent's angina is 
an inflammatory lesion usually appearing in the mouth as an acute STOMATITIS 
189 
stomatitis or pharyngitis, but most frequently as a tonsillitis. A 
pseudomembrane soon forms which resembles that caused by the 
Fig. 89.-Vincent's bacillus with accompanying spirochetes. 
Fig. 93.-Photomicrograph of smear from the cheek of a young girl with noma. 
Shows the characteristic spirilla and fusiform bacilli of Vincent's angina. (Prepared 
by Dr. V. A. Latham.) 
diphtheria bacillus. At a later stage ulcers form with well-defined 
borders not unlike syphilitic ulceration. It most commonly affects 
children. 190 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
Etiology.-It is believed to be caused by a spindle-shaped or fusi- 
form bacillus accompanying which is usually found a spirillum. 
(See Fig. 89.) 
Treatment.-Unless complicated by other conditions, as not 
infrequently occurs, these ulcers yield readily to mild cleansing 
antiseptic treatment. It sometimes is associated with diphtheria, 
and aggravates this affection quite seriously. When it complicates 
cases of specific fever Osler says it is very fatal. Weaver and 
Tunnicliffe have found the characteristic spirilla and fusiform 
bacilli in cases of noma. The author also found fusiform bacilli 
in a case of noma affecting a young girl about nine years old, with 
the typical opening through the cheek. This child died in spite of 
every effort to overcome the affection, but it was impossible to say 
whether the fusiform bacilli were the real factors in causation of the 
disease, or only incidental for streptococci (see Fig. 90) which were 
also present. 
Gonorrheal Ulceromembranous Stomatitis.-Infection by the 
gonococcus of Neisser occurs in adults and has also been observed 
in the newly born and at later periods of infancy. 
Etiology.-Menard1 claims that gonorrheal ulceromembranous 
stomatitis is always secondary to profound systematic infection, 
but this is opposed by many authorities and much clinical evi- 
dence, which leads to recognition of direct local infection by gono- 
cocci as the cause. 
Symptoms.-The symptoms are catarrhal or mucopurulent 
inflammation, particularly involving the mucosa of the gums and 
cheek. Sometimes a dirty gray coating, resembling a pseudo- 
membrane, is formed. 
S. M. Hyman2 reports the following case of a girl, aged eighteen 
years: "She first complained of terrible pain and burning in the 
cheeks and mouth. Intense pain caused by swallowing either 
liquid or solid food. The mouth felt parched; there was foul- 
smelling expectoration which contained traces of blood. Constant 
nausea was felt. Uvula, soft palate, and cheeks were covered with 
a milky white membrane with occasional bleeding spots. The 
membrane was non-adherent, and on removal showed a red in- 
flamed surface resembling the scarlatinal blush. The tongue was 
red, swollen, and painful, the patient being unable to protrude 
it completely. The gums were spongy, markedly retracted from 
the teeth, and bled freely on handling. The buccal temperature 
1 Practical Medicine Series, 1904, x. 
2 New York Med. Jour., January 25, 1907. PIGMENTATION 
191 
was 99.7° F. The pulse and respiration were normal. The pseudo- 
membrane consisted of mucous epithelial and pus cells, within and 
around which were groups of staphylococci and diplococci, the 
latter having all the characteristics of the gonococcus of Neisser." 
Treatment.-The treatment described by Hyman in the above 
case is a good example of what the treatment of such cases should 
be. Calomel in 10-grain doses at bedtime, daily applications of 
silver nitrate solution, 1 to 250, in the beginning, gradually increas- 
ing to 1 to 50 as the symptoms disappeared (about the sixth day), 
gargles of saturated solution of boric acid and alum, 1 to 1000, 
were used until the cure was complete. 
Pemphigus.-Pemphigus is an acute or chronic inflammatory 
disease of the skin, characterized by recurring eruptions of variously 
sized blebs, accompanied by systemic disturbance, and often ending 
fatally. The mouth and other mucous membranes may become 
involved. In the variety known as pemphigus vegetans, the 
mouth, vagina, or other mucous membranes are usually first 
affected. 
Etiology.-Pemphigus is a rare disease and its etiology is obscure. 
Toxins derived from various sources and acting on the nervous 
system offer the best explanation of its phenomena. 
Symptoms.-It may be confined to mucous membrane surfaces, 
or the skin may also be affected. Vesicles form upon the mucous 
membrane of the lips, cheeks, tongue, and palate. Bulla? may also 
form in the nasopharynx, esophagus, conjunctive, vagina, stomach, 
and throughout the intestinal tract. Chills, fevers, and other 
indications of toxic disturbances are evidenced under these con- 
ditions. Swelling of the tongue and painful difficulty in taking 
nourishment cause emaciation. 
Prognosis.-The prognosis in cases of this character is grave, 
because of the serious nature of the primary causes and rapid 
loss of bodily resistance occasioned by difficulty in taking food. 
PIGMENTATION. 
Etiology.-Stengel1 divides pigmentation into four groups, 
according to region and variety: (1) Those in which the pigments 
are derived from external sources; (2) those derived from the 
hemoglobin; (3) those derived from the bile; (4) those derived 
from the cellular activity within the organisms. 
1 Text-book of Pathology, p. 90. 192 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
Symptoms.-The manifestations may be local or general. Among 
the former are the pigmentations of nevi and moles, of pregnancy, 
and of the corpus luteum, freckles, some scars, and certain skin 
diseases, as chloasma and xanthelasma, of the lesions secondary 
to the more cutaneous parasites, etc. The special local type is 
that seen in tumors, notably in melanosarcomata. Lipomata 
and sarcomata (chloromata) may be analogously affected. Among 
general pigmentations are those of Addison's disease, certain severe 
anemias and cachexias, tuberculosis of the peritoneum, intestines, 
and retroperitoneal glands, and those of abdominal neoplasms and 
senility. The cases associated with abdominal lesions are held 
to be connected with disturbances of the adrenal bodies or of the 
splanchnic sympathetic system, which has been considered to have 
control of pigment formation.1 
The mucous membrane of the mouth may be affected in the 
following conditions: 
Pneumonokoniosis.-This is the result of inhalation of dust, 
from coal, iron, stone, and vegetable products. The fine particles 
are deposited along the bronchial walls, and carried by the phago- 
cytic cells into the submucosa or by the lymphatic circulation 
into the peribronchial, the mediastinal glands, and deeper tissues 
of the lungs, and in rare instances to other regions of the body. 
In some cases the mucous membrane of the lips and mouth becomes 
pigmented. 
Argyria.-The skin and the mucous membrane of the mouth, 
gastric and intestinal walls sometimes become pigmented as a 
result of excessive ingestion of soluble salts of silver. 
Hematogenous Pigmentation.-This form is due to the deposi- 
tion of pigments derived from the hemoglobin. In pernicious 
anemia, leukemia, malaria, severe cachexias, in occasional infec- 
tious and septic processes, and in various kinds of poisonings, 
hemoglobin is set free in the circulation and results in pigmenta- 
tion. In diabetes and cirrhosis of the liver and pancreas, a variety 
of hematogenous pigmentations occur. They vary in color from 
a rusty red to a dark black. Local pigmentations occur from 
thrombosis, interstitial gingivitis, and coagulation. 
Hepatogenous Pigmentation.-In jaundice the bilirubin and its 
exudation product, biliverdin, are deposited as pigments, either 
in solution of granular precipitations, or crystals in the liver, 
skin, mucous membrane, and other tissues. The color, at first 
1 Stengel: Text-book of Pathology, pp. 95 and 96. TRAUMA 
193 
yellow, gradually deepens to a deep olive, or may become brown 
or greenish. 
Metabolic Pigmentation.-Pigmentation derived from cellular 
activity. 
Treatment.-Upon skin surfaces, local pigmentation, such as 
nevi, moles, etc., require local treatment for their removal; but 
upon mucous membrane surfaces the treatment of all forms of 
pigmentation relates directly to efforts to overcome the primary 
cause or general condition. Locally considered, the symptoms are 
chiefly of diagnostic value as evidence of the progress of or recovery 
from general diseases. 
TRAUMA. 
Traumatic injuries to the surfaces of the mucous membrane 
of the lips, cheek, and tongue are of much more frequent occur- 
rence than is generally recognized, and are often of very great 
pathological importance. Nervous habits, favored by loss of teeth, 
improper interproximate spaces leading to the lodgment of particles 
of food between teeth, sharp borders of exposed surfaces of carious 
teeth or roots, malocclusion of teeth, malformed, ill-fitting, imper- 
fectly constructed tooth crowns, bridges, plates, and other dental 
work in the course of time are apt to cause habits of biting the 
cheek or lips or rubbing the tip or sides of the tongue against these 
roughened surfaces. The habit once acquired, such action is per- 
formed subconsciously, therefore the patient is conscious only of 
the fact that occasionally there are irritated or abraded surfaces 
upon the mucous membrane in these situations. Such chronic 
irritation occasionally leads to quite severe symptoms through 
infection and other contributing factors. More often, however, 
the danger lies in chronic thickening of the mucous membrane 
surfaces, which may make itself apparent in the form of ulcers, or 
the mucous membrane in that region may take on the appearance of 
leukoplakia; and under such conditions there is always likelihood 
of the occurrence of cancer in these situations. Nervous habits 
of the lips, jaws, and tongue are by far too little appreciated in their 
pathological importance. In the author's practice a number of 
cases of recurrent swelling of the cheek, some of them with histories 
extending over a period of several years, for which there appeared 
to be no known cause and which gave grave disturbance, were 
finally found to be the result of infections due to irritation induced 
by cheek biting. In another case the opportunity for infection by 
the tetanus bacillus was brought about in the same manner. Quite 194 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
frequently benign ulcers, diagnosticated as cancer, have been cured 
by removal of irritating tooth surfaces; on the other hand, many 
cases of cancer which have passed beyond surgical control before 
being properly diagnosticated, appeared to owe their first existence 
to chronic irritation of this character. 
Treatment.-Smooth rough tooth surfaces in the vicinity of the 
irritation, round sharp tooth borders, treat carious teeth, and 
correct such imperfect interproximate spaces or other dental 
imperfections as may be necessary to relieve the trouble; instruct 
the patient to endeavor to overcome the habit, apply tincture of 
iodin to the irritated surfaces until acute inflammatory symptoms 
have subsided, and then give repeated coating with glycerole of 
tannin to toughen and give temporary resistance to the exposed 
surfaces. 
BURNS AND SCALDS. 
Etiology and Symptoms.-Burns and scalds of the lips and mouth 
may occur from direct application of heat or flame, from solutions 
or drugs, the sun's rays, electricity, o'-rays, etc. They are classified 
as follows: First degree, erythema or congestion of skin surfaces; 
second degree, vesication; third degree, destruction of skin and 
deeper tissues. 
Burns of the mucous membrane of the mouth are most commonly 
due to liquids that are too hot, or drugs in sufficient strength to 
cauterize and destroy the tissues with which they come in contact. 
They may also be caused by the inhalation of flame or hot steam 
or fumes from burning chemicals. In these cases there is usually 
injury to the lungs and bronchi also. Quite frequently little or no 
painful sensation is experienced immediately following the inhala- 
tion of steam, and yet death follows soon thereafter as a result of 
pulmonary edema. A large number of the twenty-one persons 
injured in the accident to the Twentieth Century Limited train 
some years ago, who inhaled live steam from the burst pipes, 
were able to talk and give their places of residence shortly after- 
ward, their only complaint being a tickling sensation in the lungs 
and bronchi. Yet one by one they dropped dead in the course of 
a few minutes. The fumes of sulphuric and nitric acid in a fire at 
Milwaukee brought death within a very short period to a number 
of firemen who inhaled them. 
Treatment.-When lungs and bronchi are involved, little can be 
done, and this only by way of vapor and nebulized oil containing 
soothing alkaline properties. If the tissues of the mouth alone BURNS AND SCALDS 
195 
are involved, normal salt solution may be freely used. Carron oil, 
and paste of bicarbonate of soda and oil may be applied to the 
surfaces. Pain can to some extent be relieved by the use of a 2 
per cent, solution of cocain and normal salt. If the burn has 
occurred from carbolic acid in attempted suicide or accidental 
injury, the immediate use of alcohol to neutralize and stop the 
further destructive action of the acid is demanded. Milk, lime- 
water, and bicarbonate of soda are also useful in emergency. 
Saturated solution of carbonate of soda in oil, held in the mouth 
is a valuable agent. Upon the skin surfaces of the lips slight burns 
Fig. 91.-Boy, aged fourteen years, 
burned in the neck at the age of three 
years. Scar tissue has completely ar- 
rested growth in the mental region of 
his lower jaw. 
Fig. 92.-Same boy shown in Fig. 91 
after operation. Removal of scar tissue, 
skin grafting, and the formation of a 
chin from soft tissue has effected the 
change. 
may be coated with collodion, or dressed with saturated solutions 
of sodium carbonate or carron oil solution. Picric acid on dressing 
for five or six days, followed by vaseline and lint and later by a 
soothing ointment, gives good results in ordinary cases. Vesicles 
as they form must be opened, shreds of tissue removed, and slough- 
ing surfaces relieved by touching with swabs dipped in dioxogen 
followed by any non-irritating antiseptics, such as 2.5 per cent, 
solutions of carbolic acid, which is especially good for this purpose. 
With extensive burns of other portions of the body, the shock is 
usually profound. When they involve one-fourth or more of the 
cutaneous surface, death usually occurs. The extensive suppura- 196 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
tion which sometimes follows brings about extreme exhaustion 
and disease of the kidney, with quite frequent fatal result. In such 
cases the best treatment, by all means, is immersion of the body 
in a normal saline solution bath. Hypodermic injections of morphin 
are necessary to relieve the extreme pain. Stimulants and the appli- 
cation of heat to body surface, wet packs of normal salt or bicar- 
bonate of soda solution are also useful. Successes claimed for 
"ambrine" in the treatment for burns has led to the very general 
Fig. 93.-Man, aged twenty-one years, who was burned in the neck when three years 
old. Scar tissue caused unusual length and thickness of lower jaw. 
adoption of various paraffin mixtures in the treatment of wounds 
and burns. With this protecting agent anesthetic and antiseptic 
agents are sometimes used. The surface is dried with cotton 
pledgets dipped in ether; a coat of liquid petrolatum applied, and 
over this the warm paraffin. The effect is soothing and the repair 
of the wounds facilitated because the paraffin film does not adhere 
to the injured area and the granulations cannot penetrate as they 
do in the meshes of the dressing when gauze is applied directly. 
It is claimed that the resulting scar is less than by other methods. ERYTHEMA 
197 
Effect of Burns.-When contraction of scar tissue following 
extensive burns results in the destruction of the usefulness of 
the soft palate, a plastic operation, usually staphylorrhaphy, is 
necessary to restore speech function. The effect of burns in young 
children, involving the lower portion of the neck and face, may, 
by contraction of scar tissue, interfere with the growth of the 
jaw, mouth, and bones of the face, and cause marked deformity. 
In these cases much may be accomplished by surgical correction, 
and the possibilities for usefulness as well as the appearance of 
such individuals may be greatly improved by the restoration of 
Fig. 94.-Same man shown in Fig. 93 after operation. The lower jaw was excised 
from the bicuspid tooth forward and a mental process fashioned out of the thick 
jaw-bone that remained. 
the bony structures, at least approximately to normal form, and 
by plastic operations upon the soft tissues, supplemented by skin 
grafting. Two typical examples of this are shown in Figs. 91 
to 94, cases in the author's practice, which illustrate the effect 
of burns in early life, resulting in deformity and the benefit of 
operation. 
ERYTHEMA. 
Erythema is a hyperemic skin disorder, characterized by red- 
ness in diffused or circumscribed non-elevated patches. 
In common with other skin eruptions its several forms give more 198 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
or less manifestation upon the surfaces of the mucous membrane 
of the mouth, and the following types deserve special mention in 
this regard. 
Symptomatic Erythema. - Symptomatic erythema is a rash 
quite commonly affecting the mucous membrane as well as skin 
surfaces. 
Etiology.-It is caused by disturbances of the general system 
leading to morbid states. Drugs and certain foods thus affect 
individual cases. It may precede or be associated with variola, 
diphtheria, cholera, meningitis, vaccinia, etc. The chief importance 
of all these classes of erythemata lies in their resemblance to 
exanthematous fevers. 
Treatment.-Treatment is chiefly directed to correction of the 
underlying general cause, local use of soothing washes, and general 
oral cleanliness. 
Erythema Multiforme.-Erythema multiforme is an acute dis- 
ease characterized by purplish-red macules, papules, and tubercles 
becoming vesicular or bullous. These usually affect the backs of 
the hands and feet, although they appear also upon the other 
portions of the body and the mucous membrane. 
Etiology.-Systematic disarrangement leading to digestive dis- 
turbances and the absorption of toxic elements of the general 
system are the chief etiological factors. Erythema zris and erythema 
nodosum, as well as other forms in which the eruption is some- 
what similar, it is generally agreed should properly be grouped 
together in this class. 
Symptoms.-In many cases the disease is preceded or accom- 
panied by rheumatoid pains, malaise, sore throat, and fever. The 
eruption develops rapidly, and may consist of macules, papules, 
tubercles, vesicles, blebs, or hemorrhagic lesions, with one or other 
type of lesion predominating. Although usually most pronounced 
on the extensive surfaces of the extremities, any part of the body 
may be involved, and at times the mucous surfaces of the mouth, 
eyelids, nose, and throat are affected. The lesions are of charac- 
teristic bluish-red color. 
Treatment.-General treatment in all such affections includes 
free administration of cathartics, stimulation of diuresis if neces- 
sary, and the administration of suitable tonics. Locally, soothing 
washes and lotions should be applied, and when nodules exist, 
especially lead lotions. 
Erythema Endemicum, Erythema Pellagrosum, or Pellagra.- 
Pellagra is an endemic trophoneurotic disease of toxic origin URTICARIA 
199 
affecting the nervous and digestive systems and producing char- 
acteristic changes of this kind. 
Etiology.-The disease is supposed to be due to the eating of 
diseased maize. 
It is chiefly found in the countries of southern Europe, but 
within recent years has been very frequent in the United States, 
especially in the South. 
Symptoms.-Diarrhea, dementia, and dermatitis are the cardinal 
symptoms. Recurrent attacks of gastro-intestinal disturbance, 
accompanied generally by various nervous symptoms, result in 
progressive physical and mental debility. The cutaneous symp- 
toms may be a marked feature of the disease, and consist of erythe- 
matous eruption on the backs of the hands and fingers, forearms, 
face, neck, upper chest, and dorsum of the feet, resembling "sun- 
burn." This is succeeded by a stage of thickening and pigmenta- 
tion, and still later atrophy of the skin occurs. In most cases 
some degree of stomatitis is found which may be sufficiently intense 
to resemble an advanced stage of mercurial stomatitis. The entire 
buccal mucosa is then bright red and denuded of epithelium, the 
gums are swollen and show aphthous ulcers, while the tongue is 
brightened with enlarged papillse. 
Pellagra pursues a variable course and may recur annually 
for several years. Its mortality is high, the final stage being one 
of marasmus. 
Treatment.-Good hygiene and nutritious food are important. 
Lombroso recommends arsenic internally. Salvarsan has been 
tried without success. Transfusion has recently given some favor- 
able results. 
URTICARIA. 
Urticaria is an affection characterized by the development of 
wheals which are accompanied by burning and itching sensations. 
Etiology.-The general causes are gastro-intestinal derange- 
ments, quite frequently due to a great variety of foods or idiosyn- 
crasy with regard to special food, drugs, intestinal worms, malaria, 
affections of the generative organs, chronic disorders of the stomach, 
bowels, and kidneys, or of the brain and spinal cord. 
Local irritations, such as insect bites, coarse underwear, etc., 
may be exciting factors. 
Symptoms.-There may be only a few, or large numbers of 
wheals may appear suddenly and remain for a few minutes or 
several hours, then disappear in the same abrupt manner. The 200 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
skin is usually affected, but mucous membrane surfaces, the mouth, 
pharynx, respiratory tract, and stomach may also be implicated. 
In acute cases there are only one or two outbreaks; in the chronic 
form successive attacks may occur during an indefinite period. 
Treatment.-Treatment should be directed to elimination of 
disturbing food, correction of stomach or other disorders, general 
cleansing of intestinal tract.1 Ice held in the mouth and soothing 
washes are beneficial. 
HERPES SIMPLEX. 
Herpes facialis is commonly called fever blisters. 
Etiology.-It is associated with febrile disorders, though it may 
result from gastro-intestinal disturbance or local irritation. 
Recurring forms are frequently seen in syphilitic patients, and 
may be confounded with relapsing mucous patches. 
Symptoms.-This form of the affection usually appears upon 
the lips, angle of the mouth, and lower part of the face. It also 
quite commonly affects the mucous membrane of the mouth. 
Treatment.-Flexible collodion or other non-irritating coating 
to protect from irritation and rupture is useful. Attention should 
be paid to the underlying general condition. 
LICHEN PLANUS. 
A disease of the skin characterized by red or bluish-red, angular, 
flat, shining umbilicated papules, usually affecting the anterior sur- 
faces of the forearm, and on subsidence leaving pigmentation. 
This eruption develops gradually, the lesions tend to group, 
and large areas of skin may be affected. It is not unusual to find 
the disease upon the mucous membrane. In these cases it occurs 
most often in the mouth, the frequency of affection of the anus, 
urethra, and larynx decreasing in the order given. 
Etiology.-Lichen planus is nearly always of neurotic origin, 
although digestive disturbances seem causative in some cases. 
Symptoms.-Lieberthal gives the following description of lichen 
planus as it appears in the oral cavity: 
"On the cheeks, lichen planus, as a rule, affects that part which 
is just opposite the interdental space and presents papules, oval 
or circular plaques, and most frequently streaks or linear pro- 
jections with intervening furrows. These projections are arranged 
1 Hare: System of Practical Therapeutics, pp. 56 and 57. PLATE Vil 
FIG. 1 
Lichen Planus. 
FIG. 2 
Leukoplakia. LICHEN PLANUS 
201 
in different ways, parallel to each other, convergent or divergent, 
passing each other in different directions and forming networks 
or stellar or brush-like formations. They all show the character of 
the elementary papules, are opaline, sharply defined, and painless. 
"The lesions of the tongue differ somewhat. On the back they 
present irregular, oval, or circular plaques, while on the upper 
and lower surfaces of the margins solitary papules are found, or, 
Fig. 95.-Lichen planus. (After Schamberg.) 
more frequently, irregular or band and stripe-like plaques. All 
these differ from the lesions of the cheeks. They are, as a rule, 
not sharply defined, are smooth, less hard, not raised above the 
level of the normal surface, not glossy, but dull and grayish white. 
On the mucous membrane of the lips, the papules form irregular 
plaques, and on the vermilion border groups of irregular plaques. 
"On the soft and hard palates, and on the gums, solitary and 
aggregated papules are more frequent than plaques or networks. 202 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
On the tonsils the more solitary lesion prevails. As mentioned, 
the older the process upon the mucous membranes, the more do 
the papules coalesce and lose their distinct outlines, until the ele- 
mentary lesions cannot be recognized as such. The plaques and 
streaks lose to a great extent their roughness and hardness, and 
at last they become so flat that there is no elevation present, but 
only the shiny white discoloration resembling mucosa touched with 
silver nitrate. These lesions show no tendency to degenerative 
changes; no erosion or ulceration occurs. The anatomy is similar 
to that of the lesions of the skin" (Fig. 95). (Plate VII, Fig. 1.) 
The mucous membrane lesions of lichen planus are often only 
with difficulty distinguished from those of syphilis, and inasmuch 
as lichen planus is also favorably influenced by mercury the thera- 
peutic test is of no value. 
Treatment.-Arsenous acid in steadily increasing doses and regu- 
lation of diet are suggested. Local applications are not required. 
Salicylate of soda is sometimes efficient in cases where arsenic 
does not give favorable results. Protiodide of mercury is of distinct 
value in many cases. 
LEUKOPLAKIA. 
Leukoplakia Buccalis, Leukokeratosis Buccalis, Leukoma, Leuko- 
plasis.-This is a disease of the mucous membrane of the mouth. 
It may appear upon the surface of the palate, gums, cheeks, but 
occurs most frequently upon the lips and tongue, and is character- 
ized by white or bluish-white plaques or patches (Plate VII, Fig. 2, 
and Plate VIII, Fig. 1). 
Etiology and Pathology.-Syphilis has been held to be a frequent 
etiological factor, and of this form the plaques, opaline or milky- 
white patches, have been held to be pathognomonic (Plate VIII, 
Fig. 2). Recent writers, however, incline to the belief that syphilis 
is not frequently a direct cause. Since it affects males almost exclu- 
sively and after the age of thirty, and because excessive use of 
tobacco has been found to be an almost constantly associated con- 
dition in such cases, this and local irritations, coincident with the 
use of strong spirituous liquors, hot fluids, and hot or highly spiced 
foods, together with digestive disturbances and conditions of the 
gastro-intestinal tract, due to faulty metabolism and the effect of 
hypo- or hyperacid conditions of the body, are the chief causes. 
Local irritation from abrasion by rough, carious, or otherwise 
improperly cared for teeth; ill-fitting crowns, plates, or dental PLATE VIII 
FIG. 1 
Leukoplakia. 
FIG. 2 
Mucous Patch. LEUKOPLAKIA 
203 
bridge-work, have also been recognized as of etiological importance. 
But in the opinion of the author, by far the most important factor 
may be included under the general description "nervous mouth 
habits." (See page 193.) All of the factors enumerated would 
predispose to nervous conditions- of the jaw. Constant pressure 
or rubbing of the tongue upon roughened or uneven surfaces in 
the mouth, the biting of the cheeks or lips, and various other 
habits of like character are subconsciously indulged in, in one form 
or another, by large numbers of people and undoubtedly account 
for irritation by roughened surfaces in this affection, even as they 
do for other local manifestations of disease. The marked tendency 
to carcinoma, which has been so frequently noted in such cases, 
has led to the association of leukoplaques with true leukoma 
which is distinctly carcinomatous in character. 
Symptoms.-Usually the affection is not recognized until the 
white appearance is more or less fully developed, although in its 
initial stage the patches are slightly red. The circumscribed areas 
later become white or bluish white, radiating or oval, and by 
coalescence tend to become large. At this stage the surface is 
glistening and raised above the surrounding membrane, and though 
large surfaces may be covered, they quite frequently pass unno- 
ticed, on account of the fact that they are not sensitive at this 
stage. With progress of the disease the surfaces become hardened, 
discolored, dry, rough, and by thickening of the epithelial cover- 
ing more or less raised. This roughened or cornified layer, as the 
thickening progresses, becomes loosened at the edge. Upon acci- 
dental or other removal of this thickened epithelium, the under 
or interlying surface is exposed and found to be smooth, red, and 
highly sensitive. Occasionally there is tendency to bleed. At this 
time there may be acute sensitiveness to irritation, with a burning, 
dry sensation. Marked fissures and furrows may develop upon 
the tongue. 
Hypertrophy of the papillae sometimes gives a warty appear- 
ance, ulcers ultimately form, and from this usually cancer of the 
tongue originates. 
Prognosis.-The prognosis is serious only insofar as there is 
danger of carcinoma developing, as it so frequently does on leuko- 
plakic surfaces. 
Treatment.-The treatment consists in removal of local causes 
of irritation, including, if possible, correction of nervous habits 
by which such irritation is provoked. Attention should be paid 
to improvement of both local and general hygienic conditions. 204 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
Abstinence from or at least marked limitation in the indulgence in 
alcohol, tobacco, or other forms of dissipation are recommended. 
Cauterization and the use of escharotic drugs by direct appli- 
cation should be avoided on the ground that they tend to increase 
rather than diminish the trouble. 
Surgical removal of the mucous membrane over the affected 
area is sometimes required. 
ECZEMA. 
Eczema is an inflammatory disease of the skin, with diffuse 
redness and exudation, or with papules, vesicles, or pustules, fol- 
lowed by weeping or scaling, and usually accompanied by much 
itching.1 
This affection according to Schamberg,2 constitutes about 30 
per cent, of all of the skin diseases, and is met with at all ages 
and conditions of life. One of its many forms, eczema labialis, 
touches the field of our present consideration. 
Eczema Labialis.-Eczema labialis is a small pustular form 
of eczema which affects the lips (Plate IX, Fig. 2). 
Etiology.-Its causes are local irritations, and constitutional 
influences due to alimentary disorders, auto-intoxication, gouty 
and rheumatic diathesis, functional disorders, and affections of 
the nervous system. 
Treatment.-Schamberg states that eczema of the vermilion 
border of the lips often runs an obstinate course, and advises the 
use of lotions of resorcin, boric acid, or ointment of salicylic and 
boric acids in cold cream. In chronic cases, weak solutions of 
nitrate of silver and caustic potash. General treatment and 
hygienic measures should be adopted for correction of the consti- 
tutional causes. The following formula is recommended: 
-Resorcini, 
Acidi borici aa 3j 
Olein amygdal. dulcis . . . fgij 
A qua; calcis f§iv 
Pulv. zinci oxidi giv-M. 
PURPURA. 
Purpura is manifested by red or purple hemorrhagic patches 
upon the skin which do not disappear upon pressure. These are 
1 National Medical Dictionary, p. 49. 
2 Diseases of the Skin and Eruptive Fevers. PLATE IX 
FIG. 1 
FIG. 2 
Seborrheic Eczema. 
FIG. 3 
Herpes Labialis. PURPURA 
205 
usually symptoms of an infectious eruptive disease, such as small- 
pox, scarlet fever, measles, cerebrospinal meningitis, malaria, diph- 
theria, and similar affections. Under such conditions there is 
usually a more or less characteristic and somewhat similar affec- 
tion of the mucous membrane of the mouth. It may also appear 
without the association of infectious diseases. Of its several forms, 
purpura hemorrhagica is of special importance to our subject. 
Purpura Hemorrhagica. - Etiology. - It is caused by many 
different kinds of toxic influences acting through the circulation 
or upon the vessel walls. These are not alone those incident to 
infectious diseases, but the poisons of many different kinds of 
drugs, either by reason of individual susceptibility or otherwise, 
may also produce similar eruptions, as do also the autotoxins and 
imperfect metabolism. It is sometimes an evidence of organic disease. 
Symptoms.-There is usually languor, headache, and fever. 
Hemorrhagic spots of varying size appear upon the skin, and 
petechise on mucous membrane surfaces with tendency to hemor- 
rhage of the mouth, nose, and other parts covered by mucous 
membrane. The period of its duration is uncertain, but in the 
fulminating form, when due to intense septic or toxic influence, 
rapid death results. 
Prognosis.-In purpura hemorrhagica the prognosis is more 
uncertain than in other forms, because of the possibility of its being 
an indication of some grave underlying disease and the likelihood 
of fatality resulting through internal hemorrhage. 
Treatment.-Support and stimulate the patient to assist natural 
resistance. Give easily digested, highly nourishing diet, good 
hygienic care, alcohol baths. Keep patient in bed. Give rest and 
quiet. Use astringent mouth washes. Coat the gums and other 
affected surfaces of the mucous membrane of the mouth with 
tincture of iodin. When hemorrhage of internal parts is so per- 
sistent as to become a menace and refuses to yield to adminis- 
tration of ergot and remedies of similar character, it is the belief 
of the author that the transfusion of blood from a normal indi- 
vidual is the most efficient way to prevent fatal termination (see 
p. 43). 
Scorbutus, Scurvy, Sometimes Called Purpura Nautica.-Scor- 
butus is a disease affecting the blood and general system, and is 
due to the absence of certain articles of diet. It has been recog- 
nized from the very earliest ages by frequent historical reference. 
Modern methods have made possible the preservation of vegetable 
foods, and for this reason it is now rarely met with. 206 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
Symptoms.-Mental depression, marked and progressive emacia- 
tion, hemorrhagic spots on the skin, and tendency to hemorrhage 
of the nasal, buccal, and pharyngeal mucous membrane surfaces, 
with spongy and bleeding gums, indicative of interstitial gingivitis, 
are among the symptoms. There is usually chronic diarrhea 
with pain in the joints and also neuralgic affections. 
Diagnosis.-On account of the similarity of symptoms it is 
sometimes necessary to make careful differential diagnosis between 
purpura hemorrhagica and scorbutus. This has been summed 
up by Schamberg in the following form: 
SCORBUTUS. 
1. Occurs in those subject to lack of vege- 
table food and to bad hygiene. 
2. Definite antecedent symptoms: weak- 
ness, impaired circulation, etc. 
3. Onset slow. 
4. Gums spongy, swollen, and bleeding; 
teeth loose. 
5. Severe muscular pain. 
6. Brawny infiltration of lower extremities. 
7. Hemorrhages from mucous membranes, 
not, as a rule, profuse. 
PURPURA HEMORRHAGICA. 
1. No such etiological relationship. 
2. Antecedent signs slight or absent. 
3. Onset sudden. 
4. Gums often bleeding, but not 
swollen. 
5. Less marked. 
6. Not present. 
7. Hemorrhages from mucous mem- 
brane may be so severe as to 
prove fatal. 
Treatment.-Its treatment should be preventive, by proper 
regulation of the diet whenever conditions are such as to favor 
its occurrence. Cure may be effected by dietetic correction, through 
the addition to the dietary of potatoes, pickles, lime juice, vinegar, 
citric acid, etc. Rubbing the body and particularly stiffened joints 
with olive oil is also beneficial. Local treatment consists of thorough 
cleansing of the teeth, particularly their necks and exposed root 
surfaces and the application of tincture of iodin. 
Infantile Scorbutus. - This disease is sometimes also called 
Barlow's disease, and some writers, notably Schubert,1 make an 
effort to distinguish between the two diseases. It is a form of 
scurvy affecting infants. Because of its resemblance to other 
infantile affections it has only been generally recognized during 
comparatively recent years. 
Morse2 states that when of mild form it is overlooked and mis- 
taken for difficult dentition. Among the thirty infants he exam- 
ined the trouble had been diagnosticated as rickets, Pott's disease, 
hip disease, periostitis, gout, syphilis of the cord, acute nephritis, 
uric acid diathesis, and arsenic poison. 
1 Deutsch. Arch. f. klin. Med., December 13, 1905. 
2 Med. Rec., October 19, 1907. PURPURA 
207 
N. Jacobson1 believes infantile scurvy to be more frequently 
overlooked than any other pathological condition of childhood. 
Cases have been reported in which this affection has been mistaken 
for periostitis, osteomyelitis, and osteosarcoma, and because of 
erroneous diagnosis operations have been undertaken for the 
removal of conditions which did not exist. 
Among the early valuable contributions to this subject we find 
an article "Two Cases of Infantile Scorbutus," by Dr. Edward 
C. Kirk, of Philadelphia, published in the Dental Cosmos of June, 
1895. Kirk recognized the true cause of this affection through 
his study of faulty metabolism, and his interest was excited by a 
case of Dr. J. W. White's that came under his observation, which 
he reports in connection with one of his own patients. Both these 
cases and others presented by more recent writers are described 
in detail below to give a proper basis for comparison of symptoms. 
Etiology.-The disease is generally recognized as a form of mal- 
nutrition due to either excess or insufficiency of certain food ele- 
ments, producing changes in the blood in infants similar to those 
long recognized as indications of scurvy in adults. Authors, 
however, differ as to the exact nature of the exciting causes. 
Stoles2 attributes it "to the distribution of the ferments in the 
milk," and Cohns to disturbance in absorption of calcium. Certain 
authors see no connection between the disease and sterility of the 
food, but regard it as a manifestation of auto-intoxication in 
chronic dyspepsia. It is generally agreed that an important factor 
is the use of proprietary foods in feeding infants. 
Kirk says: "There is, however, an important side to this matter 
of infant nutrition, not by any means so clearly manifest, but 
which careful investigation will, I think, prove to be a definite 
outgrowth of the pernicious custom of depending altogether upon 
proprietary and chemical laboratory food products for the nourish- 
ment of infants. I refer to the systemic nutritional disorders 
so often produced by this custom. Disorders of the digestive 
tract, with their sequelse, are sufficiently familiar; they do not 
only give rise to a number of acute and chronic pathological con- 
ditions, but indirectly bring about impairment of nutrition through 
the inability to properly prepare and assimilate food. This train 
of evils can be shown to be more closely connected with the indis- 
criminate use of artificially prepared foods in many instances 
than the properties of the preparations would be willing to admit. 
1 New York Med. Jour., December 11, 1909. 
2 Practical Medicine Series, Pediatrics, 1908, vii. 208 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
But a special feature which constitutes an important objection 
to the habitual use of these preparations is one which directly 
affects the nutritional process, viz., their inadequacy to supply all 
the elements necessary for the normal nutrition of the individual. 
Two closely allied conditions directly due to imperfect nutrition, 
from lack of essential food elements, are rickets and scorbutus." 
Schubert states, "the latter (Barlow's disease) affecting infants, 
has been attributed to the use of sterilized cow's milk." Griffith 
has seen cases which occurred in infants nursed by their mothers, 
and which recovered by the use of sterilized cow's milk. 
The author has known infants to die of inanition who nursed 
the breasts of mothers with an abundance of milk which evidently 
did not contain all of the necessary food elements in proper dis- 
tribution. 
This seems to be the essential point. While artificial foods and 
even modified milk products are, as a matter of necessity, less 
perfect, and bottle infants therefore more prone to all forms of 
digestive nutritional affections, the disease may, nevertheless, 
occur in individual cases when the mother's milk is insufficient. 
Symptoms.-The onset of scurvy is slow. There is a general 
appearance of malnutrition, such as anemic emaciated appearance, 
with restlessness and evidence of irritability. The gums over 
unerupted teeth and around those that are already erupted become 
spongy, swollen, dark in color, with marked tendency to bleed. 
Teeth become loosened and are sometimes lost. As the disease 
progresses the maxillary bones become involved, causing necrosis 
as with other forms of scurvy. There is a noticeable tenderness, 
especially of the legs, which gradually increases until the use of 
the legs is lost. Subperiosteal hemorrhages sometimes occur 
and also circumscribed hemorrhage, in which separation of the 
epiphysis causes severe pain. Hemorrhagic swelling of the eyelid 
with or without exophthalmos is sometimes an important symptom. 
Hemorrhages may occur over the bones of the skull, giving the 
face an expression of abject terror, and also in the skin and roof 
of the mouth as well as the eyelids and intestinal walls. Usually 
there is no fever, but cases have been reported with temperatures 
as high as 105° F. 
Description of Cases.-Since recognition of the symptoms is 
the element of vital consequence, especially to dentists and oral 
surgeons, because of important indications appearing in the mouth, 
the author gives full descriptions of cases to facilitate comparison 
and to impress the important features. PURPURA 
209 
Edward C. Kirk's Cases.-"About six years ago I was asked by 
the late Dr. J. W. White to see a case under his care which pre- 
sented a remarkable and unusual condition of the gums. The 
patient was an infant girl of about ten months, the child of well- 
to-do parents, surrounded by all the conveniences and comforts 
of living that ample means and intelligence could procure. The 
child had been weaned at about two months, owing to some imper- 
fection in the quality of the mother's milk, and had been artificially 
fed with great care under intelligent medical direction from that 
period. A short time before I saw the case, about two or three 
weeks as I now recollect it, the child had shown symptoms of ill 
health, becoming pale, somewhat emaciated, restless and irritable, 
especially at night, with a tendency to cry out in its sleep, which 
was more or less broken and fitful. Later, the mother noticed a 
marked loss of power in the lower limbs, which at first the attending 
physicians were inclined to regard as a mere fancy on the part of 
the anxious mother, but the observation was later confirmed, when 
almost total paralysis of the lower limbs ensued; there was, however, 
apparently no loss of sensation. There were no pathological 
manifestations upon the skin, swellings or ecchymoses upon any 
part of the body, so far as I could learn. An examination of the 
mouth revealed a most distressing state of affairs. The incisors 
of both jaws were fully erupted, and were apparently standing in 
their alveoli without the least particle of attachment of gum to 
them. The gingival border had receded from the teeth for at least 
a line in distance, and presented a thickened necrotic edge, highly 
vascular, and bleeding at the slightest touch. Over the position of 
each of the first molars was a vascular tumor, the size of a half- 
cherry, and it in fact closely resembled one of the small and dark- 
colored cherries in appearance. Upon passing a bistoury into these 
vascular tumors a considerable flow of dark, apparently disorganized 
blood took place, and the erupting molar could be felt, and later 
seen at the bottom of the spongy vascular mass which surrounded 
it. The bone of the alveolar border surrounding the incisors was 
denuded so that it could be distinctly seen and felt with an instru- 
ment. The teeth were so loose that it seemed almost certain that 
they would soon be thrown out of their sockets from loss of their 
attachment. The case had been examined by a number of the most 
experienced and reliable physicians of Philadelphia, without having 
arrived at a satisfactory diagnosis, and the treatment was largely 
upon the expectant plan, with the endeavor to combat the several 
pathological manifestations as they arose. One specialist had 210 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
diagnosticated the case as purpura, another as of metallic poisoning. 
The former diagnosis was found to be erroneous, because none of 
the general symptoms of the disease subsequently developed, while 
the mouth conditions grew gradually worse." Change of air and 
diet resulted in the complete recovery of the case. 
Dr. Kirk describes another one of his cases as follows: "The 
onset of the attack on the incisor region was sudden. There 
appeared in less than two days a large, pendulous, dark red, vascular 
tumor from the palatal gingival border of the superior incisors, 
which hung down below their cutting edges, and interfered with 
closure of the jaws. A corresponding mass developed in relation 
to the lower incisors. It was noticeable in this case that areas of 
ecchymosis of varying size, dark red in color, very much like what 
we commonly know as blood blister, excepting that they were 
only slightly elevated above the surrounding gum tissue, appeared 
at the points not connected with the erupting or erupted teeth. 
I mention this point because nearly all writers state that the 
sponginess and vascularity of the gum tissue occurs only in con- 
nection with teeth, and is not seen in edentulous mouths. 
"This patient was given local treatment, similar in therapeutic 
principle to the former one. I suggested to the mother to give the 
child orange juice in liberal quantities. The family physician, 
Dr. John H. Musser, added to this the direction to give the child 
the pulp of sound, ripe white grapes. In addition to this, beef 
juice, rare meat shredded, milk, potato, etc. The change was 
rapid and wonderful. The mouth trouble subsided quickly, and 
the whole systemic condition became normal. The child had been 
fed almost exclusively on proprietary foods."1 
Other Cases.-Morse2 divides the symptoms of his cases into three 
groups: "One was characterized by tenderness noticeable when 
the child was handled, and especially on the legs, and it gradually 
increased until the child ceased to use its legs. The thigh was 
flexed on the abdomen and the leg on the thigh. The natural 
mistake was to regard this as rheumatism or paralysis. The gums 
swelled sometimes before the appearance of the teeth, sometimes 
after eruption. In some instances hematuria persisted for weeks 
or months and led to the diagnosis of acute nephritis, tumor of the 
bladder, uric acid diathesis, etc. Unless treatment was given 
there appeared swellings in the extremities due to subperiosteal 
hemorrhages in the diathesis. These occurred most frequently 
1 From the Dental Cosmos, June, 1895. 
2 Med. Rec., October 19, 1908. PURPURA 
211 
ill the lower portion of the femur, less often in the upper part of 
the tibia, and still less often in the lower part of the humerus. 
Such severe cases were mistaken for osteomyelitis and acute 
superficial edema." 
Interesting cases have also been reported by Irving Snow1 and 
Coots.2 George Dock3 reports a case of infantile scurvy which 
for two months had been treated as neuritis and anterior polio- 
myelitis. "The child, aged two months, was admitted to the 
hospital October 23, 1904. The mother had been able to nurse 
her for only three weeks, and then gave her equal parts of milk 
and water, sterilized by boiling for one hour. After that barley 
gruel and milk-sugar were added to the milk, and later a prepara- 
tion of Mellin's Food, which had been heated about ten minutes 
was tried. 
"Toward the end of August the stools contained bright red 
blood and then for two or three weeks they were almost black. 
The baby screamed when her feet and back were touched, and soon 
ceased to use her legs or arms or to sit up; the upper gum swelled 
and looked like a blood blister, and then the lower one did the 
same thing. A little later the upper right eyelid suddenly swelled, 
but the swelling subsided leaving a bluish-red discoloration, then 
the left upper eyelid became involved. 
"The baby now weighs fifteen pounds. Both eyes are prominent 
and seem to look down. The upper eyelids are slightly swollen, 
and the right shows a pale blue oval discoloration at the upper 
margin. The gum around the lower central incisors is slightly 
swollen, reddish purple, especially close to the teeth. The upper 
incisors cannot be seen, the gum over them is so swollen and ulcer- 
ated. The left arm lies extended, the right thumb is in the mouth 
and cannot be moved without causing pain. The wrists and lower 
fourths of the forearms are swollen; there is a firm swelling appar- 
ently beneath the deeper fascia. The legs and feet are extended 
and no effort is made to move them. The lower thirds of the legs 
and ankles are swollen; the swelling is firm and the skin over it 
glossy, bluish yellow, and pitted like orange peel. When the arms 
are touched the child cries. 
"Orange juice and a cream and milk mixture were given as soon 
as the baby was admitted to the hospital and later mutton broth 
cooked with potato and carrot. Improvement was immediately 
noted." 
1 Arch. Pediat., August, 1905. 2 St. Louis Med. Review, March 24, 1906. 
3 Jour. Am. Med. Assn., January 27, 1906; Practical Medicine Series, 1908, vii. 212 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
Diagnosis.-Infantile scurvy is differentiated from rheumatism 
because the latter affection never occurs at this early age, and the 
swellings are over the joints and not over the epiphysis. Rheuma- 
tism is never accompanied by bleeding gums or hematuria. It is 
distinguished from periostitis and osteomyelitis, because in those 
affections the tenderness and swelling are limited in extent and 
accompanied by signs of acute inflammation, also because of its 
bleeding gums; from infantile paralysis, because of the sudden 
onset of that affection; from difficult dentition, by difference in 
the appearance of the gums; from traumatism and hip disease, 
because of the general symptoms that accompany scurvy. The 
final test, however, is the improvement of the patient upon adminis- 
tration of orange or lemon juice and other changes in diet. 
Prognosis.-The prognosis is good if the disease is recognized 
early and corrective measures are temporarily instituted. 
'Treatment.-As already indicated, orange or lemon juice, about 
two tablespoonfuls daily, fresh beef juice in such quantities as 
may be administered without disturbance of the child's digestion, 
plenty of fresh air and good general care with careful readjustment 
of the food formula. Soothing, mildly astringent, antiseptic mouth 
washes are required for the treatment of the mouth and gums. 
Immobilization of the limbs is sometimes necessary to relieve pain 
and tenderness. 
BLASTOMYCOSIS CUTIS. 
Blastomycosis is a chronic infectious inflammatory disease 
caused by a pathogenic fungus. 
Etiology.-Blastomycetes gain entrance to the tissues often 
through some external wound. When these have a pathogenic 
tendency, their budding leads to the formation of miliary abscesses 
which frequently require microscopic and cultural examination 
to differentiate from tuberculosis. 
Symptoms.-The papule which marks the beginning of the 
disease becomes covered with crust, enlarges, and assumes a warty 
appearance. The papules enlarge until they sometimes cover 
quite considerable surfaces which are elevated, have sharply 
defined borders, and as they become older lose the appearance 
of dryness and become more or less softened with pus at the base. 
The skin surrounding these is filled with tiny abscesses, so small 
as to be barely visible to the naked eye. The pus that exudes 
when they are punctured contains the yeast organism. It quite ERYSIPELAS 
213 
frequently affects the face, and may therefore be found upon the 
lips. Its resemblance to syphilis is often marked. 
Prognosis.-Its chief danger of fatal termination lies in the 
development of pyemia or some form of septicemic complication. 
Treatment.-The treatment consists in excision, the application 
of jc-rays, administration of large doses of potassium iodide, and 
copper sulphate applied locally. 
ERYSIPELAS. 
Erysipelas is an acute specific inflammation of the skin and sub- 
cutaneous tissues characterized by pronounced general symptoms. 
Etiology.-Its cause is generally admitted to be the Strepto- 
coccus erysipelatis of Fehleisen, although other organisms are 
often present. Wounds and even slight abrasions or imperfections 
in the skin and mucous membrane surfaces give opportunity for 
entrance of the germs. Uncleanliness, alcoholism, general debility, 
diseases of the kidney and of other vital organs may be predis- 
posing causes. 
Symptoms.-Its symptoms are usually ushered in by a distinct 
chill followed by fever (usually 103° or 104° F.), headache, and 
sometimes nausea. The degree of fever, as with other infections, 
is usually an indication of the character of the disease. Its first 
appearance is usually in the neighborhood of the infection. Other- 
wise the mucocutaneous junctions, such as the nostrils, angles of 
the mouth, eyelids, and ear, are the points of onset. It begins 
with a rose-red spot, which spreads peripherally and sometimes 
very rapidly until considerable surfaces may be covered, when 
the blush-like appearance may change to various hues of yellow, 
brown, or darker shades. 
The skin surface is hot, tender, and glazed, with tendency to 
become indurated and rough to the touch. The swelling may be 
slight, or if in the neighborhood of the eyelids or other loose skin 
surfaces, is sometimes a very marked symptom. As the disease 
progresses, there usually is formation of vesicles and blebs which 
may be filled with clear serum, be purulent or in severe cases 
hemorrhagic. The lymphatic ganglia sometimes show marked 
effect of infection. The subjective symptoms are burning, itching, 
local tension, and tenderness to pressure. Usually such attacks 
run their course in less than two weeks, but unfavorable conditions 
may cause their prolongation for a much longer period. 
A form of this disease which disappears from one region of the 214 
DISEASES OF MUCOUS MEMBRANE OF MOUTH 
body and reappears in another is called erysipelas migrans or 
ambulans. 
Mucous Membrane Surfaces.-Although chiefly affecting the 
skin surface, erysipelas may spread to the mucous membrane 
surfaces of the nose, pharynx, throat, and other parts. When the 
pharynx is affected there is usually marked swelling of the sub- 
maxillary and cervical glands, a burning sensation in the throat, 
accompanied by intense dryness and difficult breathing. Edema 
in these cases is a serious complication. Marshall1 reports a 
patient dying from suffocation in this condition when associated 
with dento-alveolar abscess. The mucous membrane of the mouth, 
as well as the throat, assumes a dark red color, vesicles appear 
upon its surface with general swelling. Glossitis is frequently a 
marked symptom. Erysipelas neonatorum is a form of the disease 
affecting newly born children. It is quite commonly fatal and 
undoubtedly due to infection. Its first manifestations appear in 
the region of the umbilical cord. The symptoms are marked, 
progress rapidly, and usually terminate in collapse and death in 
the course of a few days. 
Diagnosis.-Facial erysipelas is distinguished from erythematous 
eczema, although in the latter there may be great swelling and 
closure of the eyes, by the absence of fever and constitutional 
symptoms. In erysipelas the border is more sharply defined. 
Prognosis.-The prognosis is good unless abscesses or gangrene 
develop, or when age, habits of life, or constitutional conditions 
are unfavorable. In such cases there may be fatal termination. 
Treatment.-Remove predisposing condition by disinfection of 
wound surfaces and building up the general health. Give light, 
easily assimilated, nourishing diet. 
Local application of ichthyol ointment, such as- 
P-Ichthyol 5j_ij 
Lanolin, 
Adipis benzoat aa 3iv 
Sig.-Apply to affected surface. (Schamberg.) 
or lead water and laudanum may be grateful in relief of local 
irritations. Local applications of a hot saturated solution of 
magnesium sulphate are of decided value. 
1 Surgery of the Face, Mouth and Jaws, p. 127. CHAPTER V. 
DISEASES OF THE NERVOUS SYSTEM AFFECTING 
THE BUCCAL REGION. 
Because of the wide distribution of such affections it is difficult 
to take up the consideration of all nervous diseases that may be 
directly or indirectly manifested in this field, but it is essential 
that at least a measure of consideration be given to neuroses 
which through direct connection w'ith the parts in this anatomical 
situation, or because of oral symptoms that may be of diagnostic 
value, should be understood by those whose practice favors their 
observation during early stages, even though the actual seat of the 
disease may be in some other division of the body. 
Injuries of Nerves.1-Nerves are frequently injured, being exposed 
in their long course. The pathological effects of such injury and 
the symptoms produced are somewhat different from those of 
neuritis, hence they require a separate consideration. 
Present knowledge is chiefly based upon experimental division of 
nerves in animals, but notwithstanding controversial opinion, it is 
assumed that the process in man is much the same as' in animals. 
The cut end of a divided nerve becomes swollen into a bulbar 
extremity by growth of connective tissue and by the development 
of fine nerve fibers in process of regeneration. This forms a very 
sensitive scar. Whether a true union of the divided ends ever 
occurs is still a matter of dispute. 
The Process of Regeneration.-Ranvier and his followers 
affirm that the new nerve is wholly a product of the central end 
of the injured nerve, growing out from it and making its way 
along the track of the peripheral end, which takes no active part 
in the process. This rule has recently received confirmation by 
the studies of Harrison and Mayer, and more recently Ballance 
and Stewart have affirmed to the contrary that the regeneration 
goes on in the peripheral end of the cut nerve, segment by segment 
being formed successively or simultaneously, the new nerve being 
built up by the union of each distal segment with one lying cen- 
1 Starr, Nervous Diseases, Organic and Functional, Part II, pp. 155 to 162. 216 
NERVOUS SYSTEM AND THE BUCCAL REGION 
trally to it, until tbe process is complete. All surgeons believe 
that function may be rapidly resumed after suture of freshly 
divided nerves with rapid restoration of sensation. 
NEURITIS. 
Classification.-The forms of neuritis may be described as: 
Localized, when the nerve is inflamed in the short portion of its 
course; Disseminated, when affected at many different parts; 
General, when diseased in its entire length; Ascending or Descend- 
ing, according to the direction in which disease makes progress, 
and Migratory, with tendency to appear in different parts of nerve 
distribution. 
Multiple neuritis, polyneuritis, or peripheral neuritis is a general 
disseminated inflammation upon both sides of the body and gen- 
erally affecting all the nerves of the limbs, particularly in their 
terminal branches. The affection rarely, if ever, extends as high 
as the nerve plexuses. 
Etiology.-Neuritis may occur secondarily to inflammatory 
changes in other parts, as with periostitis or abscesses. Syphilitic 
deposits in the nerves, tubercles in the nerves, cancer or other 
neoplasms along the nerves, may cause a proliferation of the 
connective-tissue elements or a true diffuse inflammation. 
It may result from traumatic or other injury to the nerve. 
Among other underlying causes are constitutional diseases, blood 
disorders, inflammatory changes in other parts, as from periostitis, 
abscess, etc., septic infection, auto-intoxication, and other toxic 
effects, from lead, alcohol, and other poisons. 
Multiple neuritis is due to general constitutional states. La 
grippe is a frequent cause. It is more common in males than in 
females, and may affect all ages. The diphtheritic type is more 
commonly seen in children. Heredity appears to play little or 
no part in the causation, excepting insofar as the general tenden- 
cies to gout, rheumatism, diabetes, carcinoma, arterial sclerosis 
and tuberculosis may be said to be hereditary. 
Pathology.-An inflamed nerve is red and swollen, lacking in 
its natural surface luster, and no longer firm and smooth to the 
touch. Its vessels are congested, and there may be hemorrhage 
within its sheath. If the process has been in progress for some 
time there may be bulbous swellings on the nerve resulting from 
connective-tissue infiltration, or the nerve may be markedly 
atrophied. A section of the nerve as viewed by the microscope NEURITIS 
217 
shows a distention of the vessels, an infiltration of the endoneu- 
rium with small cells, and a thickening of the connective-tissue 
elements. Pathological distinctions are marked by the following 
forms of the disease. 
Parenchymatous Neuritis.-At the outset the myelin sheath 
appears slightly swollen or else homogeneous, and from a differ- 
ence of refractive power is less translucent. 
Interstitial Neuritis.-Interstitial neuritis shows the nerve to 
be congested, swollen, thicker than normal, and lacking in luster, 
or to be yellow and irregular and swollen by the accumulation of 
pus and serum and reduced to a nerve connective-tissue strand. 
Segmental Periaxillary Neuritis.-A toxic neuritis from lead or 
alcohol poisoning in which the degenerative process is not uniform 
throughout the entire length of the nerve fiber. 
Symptoms.-The symptoms of neuritis are pain and tenderness 
along the course of the nerve. The latter is its distinguishing 
feature. 
Severe attacks of neuralgia accompany or follow la grippe in 
about 15 per cent, of the cases, and are an evidence of direct action 
of the poison upon the nerve trunks. Thus trigeminal neuralgia, 
occipital neuralgia, intercostal neuralgia, and sciatica frequently 
develop and some run a very severe and long course. They are 
occasionally bilateral and symmetrical, which is rare under other 
conditions. 
Many cases of local neuritis appearing simultaneously in one 
or in several nerves in the body have been observed after la grippe. 
Any of the cranial or spinal nerves may be involved. 
Prognosis.1-The prognosis in neuritis, as a rule, is good. There 
is a spontaneous tendency to regeneration in a nerve that is 
injured or that has been affected by inflammation, and while 
this progress toward recovery is usually slow, yet eventually it 
becomes complete and all functions of the nerve are restored. 
Recovery is impossible if a union between the severed ends of 
the nerve is prevented by the interposition of a callus, or inter- 
vening connective-tissue scar; but after such obstructions are 
remedied by surgical treatment, regeneration takes place, even 
though the obstruction may have persisted for many months. 
Spontaneous recovery, unless the nerve is put in normal condition 
by being freed from scar tissue, may not occur. 
Bruns2 has recently called attention to the ultimate results in 
1 Starr: Nervous Diseases, Organic and Functional, p. 167. 
2 Neurol. Cent., November, 1902. 218 
NERVOUS SYSTEM AND THE BUCCAL REGION 
injuries of the nerves and of the plexuses, and has shown that 
while two-thirds of his cases of nerve injury recovered, only about 
one-quarter of the cases of injuries of the plexuses were cured.1 
Treatment.-In the treatment of injuries and wounds of nerves 
or in spontaneous neuritis the first and most important object 
is to secure the possibility of regeneration by establishing the 
continuity of the injured nerve. Clean-cut ends of the nerve may 
be brought together and carefully united, as in Fig. 96, or if lacera- 
tion has taken place with loss of continuity, a flap may be made 
from both ends and these elongated nerves then united (Fig. 9.7). 
Fig. 96.-Methods of nerve suturing: A, B, sutures passing through sheath and 
part of nerve; C, sutures through sheath, reinforced by relaxation suture through 
entire nerve. (After Brewer.) 
Fig. 97.-Nerve suturing, with lengthening. (After Brewer.) 
Inserting the ends within a tube of decalcified bone or a non- 
absorbable celloidin tube as advocated by Sweet, may serve to 
direct the regenerating fibers outward toward the distal end and 
prevent the regenerating nerve from becoming entangled in an 
obstructing mass of connective tissue. Ochsner has secured good 
results with catgut extensions to promote union, even when a 
distance of half an inch or more was to be bridged. 
In cases of spontaneous neuritis from cold, etc., it is only neces- 
sary to maintain the parts in a perfectly quiet position, and, if 
possible, to reduce congestion in the inflamed nerve. This may 
be done by the use of a counter-irritant, of which the actual cautery 
1 Kennedy: British Med. Jour., February 7, 1903. TUMORS OF THE NERVES 
219 
is probably the best. Light touching with a Paquelin cautery 
along the course of the inflamed nerve will often relieve intense 
pain and reduce the congestion which attends spontaneous neuritis. 
Small mustard plasters are also of service. 
Local applications of heat are often very grateful in painful 
conditions of neuritis, and usually more agreeable than cold; 
poultices or packing the affected limb in cotton-wool covered with 
oiled silk may be of service. In more severe cases, with intense 
pain which prevents rest at night, it may be necessary to use 
analgesics. Antipyrine, 10 grains; acetanilid, 3 grains; exalgin, 
3 grains; or salophen, 10 grains, may be used every two or three 
hours; or a combination of these with a small amount of codein if 
the pain is very persistent. The following formula is generally used: 
K-Phenacetin . . . gr. vj 
Acetanilid gr. iij 
Codein gr. 1 
Caffein gr. ij 
Sacch. lactis ........... gr. v 
Mix and triturate. 
Sig.-One such powder every three hours. 
TUMORS OF THE NERVES. 
Neuroma.-Any form of tumor (fibroma, angioma, sarcoma, etc.) 
may develop within a nerve sheath or upon it and thus produce 
an apparent tumor of the nerve. In such cases the nerve fibers 
may pass through the tumor or may be dissected apart by it and 
pass around it. . Such tumors have been termed false neuromata, 
for they are not composed of nerve cells or fibers. But the fibers 
may become compressed by the newgrowth and undergo. degen- 
eration. The symptoms and course of the case under such con- 
ditions will be expressed according to the character of the affected 
nerve. 
Starr1 gives the following description: 
"Neuromata, or tumors consisting of nerve fibers, first described 
by Virchow, are a rare form of tumor. The fibers of which they 
consist may be medullated or non-medullated; nerve cells are not 
found in such tumors; connective tissue exists in greater or lesser 
degree, so that some tumors are neurofibromata. There appears 
to be a tendency for such tumors to be multiple, and in the large 
majority of recorded cases hundreds of minute tumors have devel- 
oped. Occasionally the tumors have been large, but usually 
they are the size of a pea. When they appear on the sensory 
nerves of the skin they are easily felt and are usually tender. 
1 Nervous Diseases, Organic and Functional, p. 191. 220 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Under these circumstances they have been called 'tubercula dolo- 
rosa.' I have seen a patient with more than a hundred such 
tumors distributed over the entire body. Hoggan has shown that 
some tumors of this description were adenomata of the sweat 
glands. That some congenital tendency to the multiplication of 
nerve fibers is at the basis of this affection is proved by the fact 
that many of the cases reported have been in children. Thus in 
the so-called plexiform neuroma of the fifth nerve the disease is 
usually congenital and other nerves have been affected later in 
life. The tumors obtain a certain size, and then, as a rule, cease 
to grow; the condition remains permanent until death from some 
other cause. 
"In the majority of cases no symptoms are caused by neuro- 
mata, as the nerves on which the tumors develop are not affected 
by the growth. The tumors may be felt and may be tender to 
pressure. They are not subject to treatment and cannot safely 
be removed, as they are so numerous, and as the nerves may be 
cut. Occasionally pain, hyperesthesia, and numbness are caused 
by neuromata. 
"There is one form of neuroma which, however, requires special 
mention. It is the neuroma which develops on the cut end of a 
divided nerve, either after an amputation or after an injury with- 
out union. Such a neuroma may be extremely painful to the 
peripheral termination of the nerve, and also cause spasms in the 
muscles related to these terminations. In such cases excision is 
imperative, but recurrence is not infrequent. 
"In one patient under my observation who suffered from great 
pain referred to the toes for many years after an amputation of 
the leg above the knee, excision of the neuroma on the sciatic 
failed to give relief. A portion of the sciatic nerve in the thigh 
was then excised, but this also failed to stop the pain. In this 
case it seemed probable that atrophic changes had occurred in 
the spinal cord, such as are known to follow amputations, and 
that these had involved not only the anterior horns, but also the 
sensory columns." 
DISEASES OF THE SPINAL CORD, ETIOLOGICALLY, SYMP- 
TOMATICALLY, OR OTHERWISE RELATED TO THE 
REGION OF THE MOUTH, FACE AND JAWS. 
The following diseases deserve the special consideration of all 
who undertake the treatment of buccal affections, because (1) the DISEASES OF THE SPINAL CORD 
221 
face and mouth so frequently evidence developmental imperfec- 
tions which are indicative of neurotic tendencies that predispose 
to spinal diseases. (2) Direct and reflex irritations from develop- 
ing teeth and other causes sometimes give rise to disturbance 
through trigeminal irritation, which may increase susceptibility to 
other nerve affections. (3) In many of the spinal diseases the 
etiological character of which is not fully understood, it will be 
noted that infection and disturbance of the digestive tract are 
among the constantly recognized important factors, therefore the 
causal relation of pyogenic microorganisms of the mouth and 
diseased conditions directly or indirectly connected therewith, 
including malnutrition, must receive due consideration. (4) 
Symptoms affecting the facial, buccal, and lingual regions are 
of vital interest because they indicate the upward progression of 
spinal diseases that by giving rise to bulbar paralysis point the 
way to hopeless prognosis, without due recognition of which the 
true disease might be confused with affections of the cranial nerves 
or brain of vastly different character. (5) There is a significant 
developmental relation between atrophic and hypertrophic ten- 
dencies commonly associated with spinal affections and deformities, 
as noted in the teeth, palate, jaws, and bones of the face, that 
deserves much greater attention than it has yet received with 
reference to both diagnosis and treatment of oral and facial 
deformities. 
Syringomyelia or Glossis Spinalis.-This is a central myelitis 
and is marked by the formation in the spinal cord of a fissure or 
canal which is usually posterior to the central canal and preceded 
by hyperplasia, degeneration, and softening of the neuroglia. 
Etiology.-Without exact knowledge of a true cause, the com- 
monly accepted factors pertaining to the etiology of this affection 
are based chiefly upon pathological manifestations. These indi- 
cate that it may be due (a) to congenital defects of development, 
(6) disintegration of the spinal cord from inflammatory causes, 
(c) retrograde metamorphosis caused by impairment of tissue nutri- 
tion by obstruction to the circulation, (d) destruction of the cord 
by hemorrhage. 
Bacterial infection is quite generally recognized as an important 
etiological factor. 
Symptoms.-Analgesia.-There is a loss of the sensation of pain 
and temperature with preservation of the tactile sense in the 
analgesic area. The affected part of the body will necessarily 
depend upon the extent of the lesion of the cord. Usually the 222 
NERVOUS SYSTEM AND THE BUCCAL REGION 
hands are first affected because the cervical portion of the cord 
is most commonly the point of origin. By reason of the fact that 
the sense of touch is seldom influenced, patients are frequently 
unconscious of the anesthetic condition of the affected parts until 
it is demonstrated that there is no pain felt from pricking, cutting 
or burning. Sometimes the sensation of cold is recognized and 
that of heat much impaired, or vice versa. 
Trophic Disturbance.-Trophic disturbances occur through 
injury to which there is a predisposition on account of the insen- 
sibility to pain of the affected area of the body and because of the 
impairment of nutrition through affection of the trophic centers 
of the spinal cord. Abnormalities of the skin are noted in these 
cases, varying from slight surface changes, to ulcers, gangrene, 
and graver conditions of this character. The extremities and 
joints are also frequently affected, particularly the shoulder, elbow, 
and wrist, in contradistinction to tabes, which more often affects 
the lower extremities. 
Muscular atroi^hy attended by paralysis affects many of these 
patients. Extension of the disease to the medulla may cause any 
of the cranial nerves to become affected. The involvement of 
the motor portion of the fifth and glossopharyngeal nerves, as in 
syringobulbia or the lower portion of the nucleus of the seventh 
nerve, sometimes gives rise to intense atrophy of the tongue, 
disturbance of speech, facial paralysis, and other symptoms in 
the area of distribution of these nerves. 
Diagnosis.-Recognition of the three characteristic symptoms 
of this disease, when all are sufficiently developed, serves to dis- 
tinguish it from other affections causing bulbar paralysis, locomotor 
ataxia, general myelitis, tumors of the cord, and other spinal 
diseases. 
Treatment.-There is no method of treatment which may be 
relied upon to check the progress of this disease. The x-rays, 
radium, electricity, and similar measures are recommended. Relief 
of symptoms is about all that can be done with benefit in a thera- 
peutic or surgical way. 
Anterior Poliomyelitis; Acute Anterior Poliomyelitis; Infantile 
Paralysis; Acute Atrophic Spinal Paralysis, or Retrogressive 
Paralysis.-Poliomyelitis is an acute disease characterized by 
sudden, complete loss of power in one or more limbs, usually in 
the legs, followed by rapid atrophy of the paralyzed muscles and 
imperfect growth of the limb, with slight pain and no permanent 
sensory disorder. It occurs chiefly among children, and may DISEASES OF THE SPINAL CORD 
223 
occasionally affect older persons. It may be of sporadic or epi- 
demic form. E. Farquhar Buzzard1 suggests the use of the term 
acute poliomyelitis instead of acute anterior poliomyelitis, because 
the latter term is misleading, "since it describes the limitation 
that is at times incorrect." The word infantile is also objected 
to because the disease is not within any of the first four decades of 
life. 
Etiology.-At the time of the epidemic appearance of poliomye- 
litis in Norway in 1903 to 1906, F. Harbitz and Osheel, of the 
Pathological Institute of the University of Christiania, stated that 
it seemed to be an infectious disease with living virus, possibly 
diplococcus. Epidemics in New York and other localities in 1907 
seemed to corroborate this conclusion. It has long been known, as 
stated by Buzzard, that "its essential lesion is an inflammation of 
the interstitial tissue of the central nervous system due to the 
presence of microorganisms or other toxins, probably in the blood 
(but possibly in the lymph) circulating within the system." 
In 1910 the United States Public Health and Marine Hospital 
Service Report stated that it had been proved " by work at various 
laboratories, notably the Rockefeller Institute for Medical Research, 
that anterior poliomyelitis is transmissible to monkeys; that the 
causative organism is a 'filterable virus;' that not only the central 
nervous system, but also the secretions of the nose and mouth are 
infective, and that the most probable avenues of infection are the 
respiratory and digestive tracts. A distinct immunity has been 
demonstrated in recovered animals, holding out the hope, as yet 
far from realization, of a possible specific therapy."2 
In 1913 Flexner and Noguchi reported the finding of a micro- 
organism which they described under the term globoid bodies. 
During the epidemic of 1916 in the United States, George Mathers 
and Ruth Tunnicliffe, Nuzum and Herzog, and Rosenow, Towne, 
and Wheeler, isolated a coccus, which according to their researches 
caused experimental poliomyelitis. Rosenow and Towne hold that 
the small globoid microorganisms which Flexner and his followers 
believe to be the cause of poliomyelitis were, as a matter of fact, 
the result of the breaking down of large diplococci which have been 
isolated from the central nervous tissues of each monkey affected 
with poliomyelitis. 
Simmons sums up the situation by stating that "the fact remains 
1 Practical Medicine Series, 1907, x, 143; Lancet, March 16, 23, and 30, 1907. 
2 Annual Reports United States Public Health and Marine Hospital Service, 1910, 
p. 33. 224 
NERVOUS SYSTEM AND THE BUCCAL REGION 
that a very interesting coccus has been found in the brain and spinal 
cord of patients who have died of poliomyelitis, but its relation to 
the disease is not yet determined." 
Symptoms.-Sporadic Cases.-Fever may rise rapidly to 102° or 
103° F., or .remain at about 101° for several days and then sink to 
normal in the course of about six or seven days. There may be 
convulsions and delirium, vomiting, diarrhea, and general malaise, 
with considerable pain in the back, body, and limbs. The onset 
of the paralysis may be sudden or appear after several days. 
Rigidity of the spine and neck may occur as in meningitis. When 
the other symptoms subside the paralysis remains. The para- 
lyzed muscles undergo atrophy with marked change in the size of 
the limb. In some cases the febrile symptoms do not appear, 
the paralysis occurring while the child is apparently in good health. 
When the cranial nerve nuclei are invaded the symptoms which 
ordinarily appear in the extremities are evidenced in facial palsy, 
paralysis of the larynx and tongue, strabismus, etc. Deformities 
of the bones and joints occur as sequelae of the disease. 
Epidemic Cases.-The symptoms in this form of acute polio- 
myelitis are similar to those occurring in infectious diseases. There 
is an initial chill, high fever, vomiting, malaise, severe pains in 
the back and limbs, with occasional rigidity of the spine and retrac- 
tion of the head as in meningitis. The fever usually lasts from five 
to ten days, and about the third or fourth day the paralysis is 
suddenly manifested. The paralysis may extend to the neck, 
throat, face, and eyes, and present all the symptoms of bulbar 
palsy. 
Diagnosis.-There is usually little difficulty in recognizing the 
disease with evidence of the paralysis and history of the initial 
symptoms. 
Prognosis.-The prognosis is always grave. Death sometimes 
occurs during the acute onset. This rarely happens, but the 
resulting paralysis is quite permanent. In the epidemic cases 
fatal results are more frequent and usually occur from paralysis 
of the respiratory muscles. 
Treatment.-In the acute stage the child must be kept in bed 
and counter-irritation should be applied along the spine. The 
febrile condition must be allayed by sponging with tepid water 
and alcohol, light nourishing diet is required, and laxatives, such 
as castor oil, are given to assist elimination of gastro-intestinal 
poisons that may be present. Ergot in 10-minim doses of the 
fluidextract for a child, aged two years, is recommended to be DISEASES OF THE SPINAL CORD 
225 
given every four hours, with 2 minims more for each additional 
year. Iodide of potassium, 1-grain doses, salicylate of strontium 
and urotropin, 1 grain every six hours during the first ten days, 
are all recommended. 
The intraspinal injection of human serum from recovered and 
convalescent cases of the disease seems to offer the best promise of 
success in treatment. . 
Amoss, Chesney, and Draper1 report and recommend its use. 
Antipoliomyelitis horse serum is reported to have protective 
and curative properties against the virus of poliomyelitis.2 
C. W. Wells recommends the intravenous injections of immune 
serum in doses of 50 to 100 c.c. or more, daily, and following intra- 
venous or intramuscular injections of serum, spinal fluid should be 
withdrawn. He advocates an early diagnosis of the disease and an 
early administration of the serum. 
After the acute symptoms have subsided the paralysis and 
atrophy require such treatment as massage, hydrotherapy, and 
electricity, and as the disease progresses, the use of mechanical 
appliances for support of the deformed parts. Operations upon 
the muscles, tendons, and nerves, especially nerve grafting, give 
promise of overcoming, to some extent at least, the effects of the 
paralysis. Much progress' is now being made in the direction of 
the restoration to usefulness of children deformed by this affliction. 
Neutralization of Virus of Poliomyelitis.-The results of fifty-six 
experiments by Amoss and Taylor showed that washings of the 
nasal and pharyngeal mucosa possess definite power to inactivate 
or neutralize the active virus of poliomyelitis. This power is not 
absolutely fixed, but is subject to fluctuation in a given person. 
Apparently inflammatory conditions of the upper air passages 
tend to remove or diminish the power of neutralization. Mouth 
disinfection should therefore be recommended in all growing 
children as a prophylactic measure and rigidly maintained during 
the treatment of such cases. 
Chronic Anterior Poliomyelitis; Chronic Atrophic Paralysis; 
Progressive Muscular Atrophy.-This is a condition of paralysis 
with atrophy. 
Etiology.-The etiological factors of this affection appear to be 
closely allied to those already enumerated for acute anterior polio- 
myelitis. Injury, overwork, exposure to cold, and infectious 
diseases are the causes most frequently reported. Notwithstand- 
1 Jour. Am. Med. Assn., May 12, 1917, p. 1436. 
2 Neustaedter andBanzhaf: Jour. Am. Med. Assn., May 26, 1917, p. 1531. 226 
NERVOUS SYSTEM AND THE BUCCAL REGION 
ing this, it is not yet fully established whether the disease is inflam- 
matory or degenerative in character. 
Pathology.-There is a slowly advancing atrophy in the primary 
motor neurons of the cord, the cell bodies, dentrites, and axons 
degenerating together. These cells lie in groups in the anterior 
horns and in the central gray matter, and the lesion affects these 
groups in different degrees. 
Symptoms.-The symptoms are those characteristic of affec- 
tions of the spinal cord, advancing paralysis affecting one leg, 
then the other, the feet, hands, etc. In the last stage, as the 
disease extends, bulbar palsy ensues with paralysis and atrophy. 
The muscles of the face, tongue, and throat become paralyzed and 
atrophied with difficulty of speech, swelling, etc. 
Prognosis.-Death usually results from respiratory or bulbar 
paralysis and the prognosis depends upon the possibility of its 
arrest before these symptoms ensue. Rapid course and recurrence 
are both unfavorable. 
Treatment.-Good hygienic care and food, moderate exercise, 
avoidance of fatigue, the correction of any associated disease or 
etiological factor that may exist. Massage and electricity are 
sometimes recommended, especially mechanical massage; strychnin 
and similar remedies are occasionally administered to advantage. 
Amyotrophic Lateral Sclerosis.-This disease is a chronic pro- 
gressive form of spinal paralysis characterized by the symptoms 
of progressive muscular atrophy. It was formerly believed to 
affect almost exclusively the arms and legs, but is now known to 
include all the motor elements of the nervous system. 
Etiology.-The causes are not definitely known. Presumably 
congenital weakness of the motor elements of the nervous system 
renders such individuals particularly susceptible to cold, over- 
exertion, various forms of poisoning, such as alcohol, arsenic, 
lead, mercury, the toxins of infectious diseases, auto-intoxication, 
rheumatism, gout, diabetes, etc. 
Symptoms.-Stiffness of the muscles, with increased reflex 
excitability, followed by atrophy and paralysis of the extremities, 
is sometimes associated with bulbar symptoms. Occasionally the 
affection begins with bulbar palsy, and in these cases there is dis- 
turbance of speech due to paralysis of the muscles of the tongue, 
lips, mouth, and palate. Among other symptoms are fibrillary 
twitchings of the tongue, which sometimes protrudes from the 
mouth, difficulty in swallowing, attacks of choking, with return 
of fluids through the nose on account of paralysis of the soft palate, DISEASES OF THE SPINAL CORD 
227 
paralysis of the facial muscles, saliva flowing from the corner of 
the mouth, etc. There is increased muscular irritability, so that 
percussion of the masseter and other muscles of the jaw will produce 
a sudden spasmodic contraction. 
Starr1 describes the following case, which gives a good clinical 
picture of the disease. "I. D., aged forty-two years, had been 
much exposed to wet, to extreme heat, and to cold in his occupa- 
tion, and had suffered from muscular rheumatism for years. In 
February, 1889, he noticed double vision, due to a lesion of the 
left external rectus muscle, and ptosis, which first affected the 
left eye and then the right eye. The ptosis gradually subsided, 
but the strabismus remained. In March, 1889, his speech became 
thick, and in April he began to have difficulty in swallowing, 
fluid food coming out of his nose. In May he noticed difficulty 
in chewing, and his friends saw a change in his facial expression 
due to a weakness of the facial muscles. During all this time he 
felt an increasing weakness in all his movements. His neck had 
become stiff and his head tended to fall forward and was held with 
chin projecting beyond the line of the body. On several occasions 
after March, 1889, he had fainting attacks, in which he became 
pulseless and pale. In June, when I saw him, he was thin and pale, 
clear in his mind, but feeble in all movements. His eyes wrere 
both turned in a little and his left eye looked up. He had corre- 
sponding double images, but no nystagmus, and his pupils were 
normal. His optic nerves were normal, but the muscles of masti- 
cation were atrophied, did not react for faradism, and were so 
weak that chewing was impossible. He moved his jaw with his 
hand and gave it constant support. His face was expressionless; 
he could not whistle, food collected in his cheeks, but all his facial 
muscles could be slightly moved, and reacted to faradism. His 
palate was paralyzed, and it was to this cause that his defect of 
speech was due, as the tongue was not paralyzed or atrophied. 
His neck muscles were weak. There was an atrophic condition 
of the thenar muscles of the forearm. The deltoids and muscles 
of the arms were in good condition. His gait was slow and feeble, 
but not spastic; but his knee-jerks were exaggerated and ankle- 
clonus was obtained. He controlled his sphincters well. During 
the following year his paralysis increased in his arms and legs, 
his inability to talk became more apparent, and in August, 1890, 
he choked to death." 
1 Nervous Diseases, Organic and Functional, p. 296. 228 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Diagnosis.-The symptoms in some respects are almost self- 
evident, because* in muscular dystrophy there are no muscular 
symptoms or fibrillary twitchings. Bulbar paralysis alone does 
not have .spinal symptoms. Absence of sensory disturbances or 
trophic affections distinguishes it from syringomyelia. Tumors of 
the spinal cord have sensory symptoms as well as paralysis and 
muscular atrophy, as does also myelitis. 
The effect of this disease upon muscular action in the various 
anatomical regions is quite similar to that of progressive muscular 
atrophy. Although positive and radical lines of symptomatic 
distinction do not seem to be fully warranted, the following dis- 
tinguishing characteristics are in a general way conclusive according 
to some writers, notably Williamson i1 
AMYOTROPHIC LATERAL 
SCLEROSIS. 
1. In favor of amyotrophic lateral 
sclerosis would be a spastic condition of 
the legs, spastic gait, scraping of the 
toes in walking, rigidity of the legs on 
passive movements, increased knee- 
jerks, ankle-clonus, and the extensive 
type of plantar reflex, Babinski's reflex. 
2. Symptoms of bulbar paralysis 
would be in favor of amyotrophic lateral 
sclerosis. 
3. Runs more rapid course. Usually 
terminates fatally in from one to four 
years. 
4. Paresis may occur without mus- 
cular atrophy. 
PROGRESSIVE MUSCULAR 
ATROPHY. 
1. These symptoms not so marked. 
2. These symptoms not so marked. 
3. Tendency to become chronic, may 
continue for ten, fifteen, or twenty 
years. 
4. Muscular atrophy primary symp- 
tom. 
Prognosis.-The prognosis is exceedingly doubtful. Cases of 
recovery have been reported, but are rare. 
Treatment.-Therapeutic aid must rely upon efforts to build 
up the general tone of the system, massage, electricity, good 
hygienic care, rest. 
Muscular Dystrophies.'-These forms of paralysis appear in 
early life, and are regarded as due to muscular and not nervous 
disease. 
Etiology.-The disease is recognized as one of development, 
presumably an inherent tendency toward weakness of certain 
muscles indicating insufficient developmental vigor in these parts, 
or the trophic influences to which they are subject. Many cases 
have been reported in which the family history showed other 
1 Edinburgh Med. Jour., April, 1907. DISEASES OF THE SPINAL CORD 
229 
members of the family having tendency to muscular dystrophy. 
On the other hand, there have been sufficient cases in which no 
hereditary influence could be recognized to eliminate it as a con- 
stant factor. Occasionally infectious diseases, unusual muscular 
effort, traumatism, exposure to cold and similar agents, have 
appeared to be influential. 
Symptoms.-The symptoms appear in early life, become arrested 
in the course of its progress with tendency toward improvement, 
or to continue until there is complete muscular destruction. 
The different forms of these affections bear the names of their 
first observers, as Duchenne type, pseudohypertrophy, and appar- 
ent disproportionate increase in the size of muscles usually begin- 
ning with the calves of the legs, which is rarely an increase of fat 
cells with atrophy of muscular fibers. The Erb type of juvenile 
dystrophy, usually beginning between the ages of twelve and six- 
teen, affecting primarily the muscles of the shoulder, which become 
hypertrophied but.weakened, and by gradual progress affecting the 
muscles of the body. Landouzy-Dejerine dystrophy, also usually 
developed in early childhood, but occasionally appears in adults. 
Its principal feature is muscular atrophy of the face, which begins 
with the orbicularis oris, extends to the risorii, to the levator menti, 
and to the other muscles of the face associated with the mouth. 
In consequence the lips cannot be firmly closed, the mouth is 
habitually open with the lips projecting forward, the so-called 
"tapir mouth." Quite naturally there is more or less difficulty 
in speech, control of saliva, drinking, and other acts which depend 
upon the lips. There are no fibrillary twitchings, no disturbance 
of sensibility, and there is gradual decrease of mechanical muscular 
excitability. 
Prognosis.-The prognosis in muscular dystrophy is generally 
regarded as unfavorable, and it is expected that in some forms of 
the disease there will be a continued although not rapid progress, 
which by extension from muscle to muscle will ultimately bring 
about a condition of complete paralysis. The hopeful feature 
lies in the fact that this does not always occur, and that after a 
time the progress of the disease ceases. Death usually occurs 
through the development of some complicating condition or par- 
alysis of the respiratory apparatus. 
Treatment.-The treatment advised is in the nature of general 
measures to improve health and nutrition, fresh air, well-selected, 
nourishing food, exercise, massage, with avoidance of unusual 
fatigue. 230 
NERVOUS SYSTEM AND THE BUCCAL REGION 
The author Jias deemed it important to include muscular dys- 
trophy among the affections which bear an important relation to 
the oral and facial regions, because in a large number of cases 
under his care and observation irregular dental arches, high, 
narrow palatal vaults, and the nasal defects which are usually 
associated in individuals so affected have been coincident with 
asymmetrical muscular development in other parts of the body. 
Whether these cases should have been properly classified under 
any of the several forms of muscular dystrophy is perhaps to 
some extent questionable on account of incomplete history and 
diagnosis. But there can be no doubt of the fact that the factors 
leading to irregular or imperfect development in other divisions of 
the body, can be in like degree influential in making for irregu- 
lar development of the jaws and face. Again, it is equally true, 
and fully demonstrable from innumerable cases in practice, that 
with proper expansion of the palatal arches by separation of the 
upper maxillae at the median suture, and the widening of the nares 
invariably following this procedure, the first result is an improve- 
ment in nasal respiration and increased healthfulness of intranasal 
tissues, with attendant marked general improvement of health, 
nervous and other governing influences. When supplemented by 
proper form of the dental arches and correct occlusion of the teeth, 
it gives at least reasonably good promise for the betterment of 
developmental influences. We have, therefore, in the region of 
the mouth and jaws not only an index of individual tendency to 
imperfect or asymmetrical growth, but a promising opportunity for 
directly benefiting predisposing conditions, and this is certainly 
worthy of consideration in every instance. 
Without doubt many cases which dentists treat for the correc- 
tion of dental irregularities are merely expressions of some more 
general affection. Although the regulation of the teeth does have 
a wider beneficial influence than is usually contemplated when 
such procedures are undertaken, a more general examination of 
the developmental conditions of such patients would undoubt- 
edly lead to detection of many diseases at an early stage when 
curative treatment could be successfully applied and the influence 
of mouth treatment be much extended in its beneficial aspect. 
Just where the line of demarcation should be drawn in every 
instance between muscular atrophy, which notes the beginning of a 
progressive condition that may be expected to lead on to paralysis, 
and one of such character that its progress will be arrested in 
natural course without necessarily causing a state of helplessness DISEASES OF THE SPINAL CORD 
231 
and endangering life, is often difficult to decide. It must also 
be more or less a matter of speculation, when the progress of the 
disease has ceased during treatment with apparent restoration or 
increased usefulness of the affected parts, to determine just how 
much or how little the actual remedial measures may have accom- 
plished. While the author fully appreciates these facts, he believes 
(1) that the centers governing trophic changes, especially when 
these show pathological alterations in the region of tbe face and 
jaws, may be directly benefited by maxillary separation, which, 
as already stated, relieves nerve tension and compression in the 
region of the jaws and teeth, widens the nares, and thus makes 
possible better respiration; (2) that in young persons it is only 
reasonable to expect the effect of expansion in the lower regions 
of the face to favor also greater freedom of growth in the higher 
structures at the base of the skull in which are situated tbe larger 
foramina through which the cranial nerves and their important 
accompanying vessels emerge, compression of any one of which 
would be capable of causing both local and general disturbances 
of far-reaching character; (3) that it is not impossible for this 
influence to extend still higher until it could affect the form of the 
sella turcica in which the pituitary body is situated and thus reach 
the hypophysis which is now recognized as an influential factor 
in aberrations of growth; and (4) that in this way the vegetative 
nervous ganglia of the nose and respiratory tract are stimulated 
as the nares become enlarged, and nasal respiration secured. In 
due course the ciliary otic, and sphenopalatine ganglia are affected, 
and through these the .balance of control between the sympathetic 
and the vagus systems is regulated in such manner as to establish 
a widely beneficial result. Thus the endocrin (so-called ductless 
gland) organs become included with other corrective influences on 
nervous, circulatory, digestive and glandular physiological activi- 
ties. Without desire, to urge unduly what in our present state 
of knowledge must be admitted to be largely theoretical, the 
author presents brief descriptions of two of his cases (Figs. 98, 
99, 100 and 101). It will be seen that they bear indications of 
dental and facial irregularity of development of not uncommon 
type, yet further study of their histories and symptoms reveals the 
fact that they undoubtedly belong to the class of muscular dys- 
trophy, while the results of treatment are apparent in both general 
and local improvement. 
Analysis of Two Cases.-Case I (Fig. 98).-The patient was a girl, 
aged sixteen years. History.-Three operations had previously 232 
NERVOUS SYSTEM AND THE BUCCAL REGION 
been performed for the removal of nasopharyngeal adenoids, with 
apparent recurrence after each operation. On account of general 
ill health, nervousness, and frequent colds, attended by evidences 
of both local and general arrest of development, the patient had 
for some time been unable to attend school continuously and 
suffered frequent illness. 
Symptoms and General Appearance.-Height, 5 feet 2 inches; 
weight 92| pounds. More or less other indication of insufficient 
development. Marked inequality of development in the region of 
the shoulder-blades, closely approximating if not identical with 
the Erb type of juvenile dystrophy. This was so evident, her 
mother said, that the dressmakers had considerable difficulty in 
Fig. 98.-Girl, aged sixteen years, with symptoms of the Erb type of juvenile 
dystrophy, associated with nasal and maxillary defects, who was greatly benefited 
by maxillary extension. (Described as Case I in text.) 
fitting her dresses. Marked nasal obstruction, arrested develop- 
ment of the lower part of the face, receding chin, and contracted 
upper and lower dental arches. Two superior bicuspids had been 
removed (one on each side) by some dentist, with the mistaken 
idea of correcting dental irregularity. When she was about nine 
years old the spaces thus caused were almost completely closed 
by contraction of the upper dental arch. One lower bicuspid on 
the right side had been extracted about the same time with the 
same effect. 
Treatment.--The upper maxillae were readjusted by maxillary 
expansion and the lower arch made to correspond. Both arches 
were increased in an anteroposterior direction sufficiently to regain DISEASES OF THE SPINAL CORD 
233 
insofar as possible the space lost through extraction of the teeth, 
after which a dentist, Dr. P. B. Wright, of Milwaukee, inserted 
bridge-work to retain the full size of the jaws thus secured. 
Result of Treatment.-As a result of this treatment, which was 
begun in October, 1906, there was improvement in facial sym- 
metry and widening of the nares, which made better respiration 
possible. Coincident with this there was marked decrease of 
nervous symptoms, so much so that the patient was able to go 
on with her studies, and in due course graduated with honors 
from the high school. Growth in height and increase in weight 
began almost immediately. September 2, 1910, her weight was 
107J pounds and her height 5 feet 3 inches. Her mother reported 
that they no longer had difficulty in fitting her dresses, because 
the maldevelopment of her shoulders had disappeared. 
Conclusions.-The author is aware that in consideration of 
the prognosis as generally understood with regard to the Erb 
type of muscular dystrophy, and in view of the later improve- 
ment of the muscular deformity, there may be question as to this 
being a true case of this affection. But without desire to claim too 
much, the fact that this young woman had for a time during the 
course of treatment a facial paralysis of short duration, and taking 
into account all the other symptoms, there is at least sufficient 
evidence to warrant the belief that her condition was one at least 
closely akin to muscular dystrophy, and that through the restora- 
tion of general health and improvement by renewal of constructive 
trophic changes continued degenerative progress was averted. 
Case II (Figs. 99, 100 and 101).-History.-The patient in this 
case was a boy, aged ten years. He had been a mouth-breather 
for a long time, had scarlet fever one year ago, a sequela of which 
was evidenced by neuritis "extending around his head," and he 
had for a long time enlarged glands upon both sides of the neck. 
Bodily growth for a time seemed to be normal, but for some time 
past had not been progressing as expected. He was unable to 
attend school continuously when treatment was begun. 
Symptoms.-Both upper and lower arches were markedly con- 
tracted. Arrested development of the lower part of the face, 
particularly in the region of the lower jaw, caused marked recession 
of the chin. The nose was slightly to the right of the central 
facial line. There was an appearance of depression on the left 
side of the nose, including the malar region, with corresponding 
appearance of hypertrophic development of the same regions on 
the opposite side of the face. The thumb and palm of the left 234 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Fig. 99.-Boy, aged ten years, described in the text as Case II. With unequal 
facial development, indicating tendency to hemiatrophy, tapir mouth, and other 
symptoms of the Landouzy-Dejerine type of muscular dystrophy. Dystrophy of 
the muscles of the shoulders and back, indicative of Erb's juvenile form of muscular 
dystrophy. Thumbs, palms, and hands and feet affected, as in progressive muscular 
dystrophy, but without fibrillary twitching. In this case tendency to normal growth 
was apparent immediately after separation of the maxillae by expansion of his dental 
arches. 
Figs. 100 and 101.-The palms of both hands of the boy shown in Fig. 99. Waste 
of the thenar eminences. The altered position, form and size of the thumb may be 
noted in Fig. 100. 
Fig. 100 
Fig. 101 DISEASES OF THE SPINAL CORD 
235 
hand (Figs. 100 and 101) showed marked asymmetry of develop- 
ment. The thumb was believed to have been injured in infancy. 
The lips hung loose, the mouth was habitually open, with appear- 
ance much resembling the "tapir mouth'' of the Landouzy-Dejerine 
type of muscular dystrophy. 
Fig. 102.-Boy, aged eight years, described in text as Case III. His face shows 
unequal facial development, nose insufficiently developed, maxillae contracted; 
dental arches irregular; mouth-breather; one side of the mouth lower than the other, 
affection of the risorii muscles and characteristic appearance of chest and shoulders. 
Treatment.-The treatment consisted in expansion of both upper 
and lower dental arches with separation of the .maxillae, and in this 
way widening the nares. 
Result.-This treatment promptly improved his nasal breathing 
and has overcome to some extent at this date, eighteen months 
after treatment was begun, the relaxed condition of the lips, for 
the mouth no longer hangs open as it formerly did, and there is 236 
NERVOUS SYSTEM AND THE BUCCAL REGION 
apparently going on a normal growth which is overcoming the 
asymmetrical appearance of the face, quite outside of alterations 
in facial appearance that might be expected from regulation of 
the dental arches alone. Nervousness has almost entirely dis- 
appeared, and general health is also much improved. He has 
for some time been regularly pursuing his studies, and appears in 
Fig. 103.-Presents the back view of the same boy shown in Fig. 102. The typical 
difference in the shoulder-blades and the spinal curvature may be noted. 
all respects to be quite normal. (Later report.) In an eastern pre- 
paratory school this lad has led his class in both scholarship and 
athletics for two or more years. 
Case III.-The boy illustrated in Figs. 102 and 103 is another 
of the author's patients whose back, nose, and palate attest a 
tendency to muscular atrophy. OTHER SPINAL DISEASES 
237 
In this case also there was marked improvement in growth and 
general health as soon as the upper maxillge were separated and 
nasal conditions thus improved. 
Conclusions.-In these cases, as in the one previously described, 
the author presents the facts with suggestions of diagnosis rather 
than a desire to assume a dogmatic position. But with the great 
mass of other examples that might be cited to enhance the impor- 
tance of the clinical evidences of these cases, the author unhesi- 
tatingly urges the great possibilities of furthering constructive 
development in all respects and assisting to check progressive 
degenerative conditions, whether purely muscular or of nervous 
origin, by treatment such as described in these and other cases, 
as discussed more in detail on pages 621 and 630. 
OTHER SPINAL DISEASES IN WHICH SYMPTOMS SOMETIMES 
EXTEND TO THE FACE, MOUTH AND JAWS. 
Acute Progressive Paralysis; Landry's Paralysis.-This is an 
acute, rapidly progressing, ascending paralysis, usually fatal, but 
in rare instances recovery has been reported. 
Etiology.-Its symptoms and frequent association with infectious 
diseases, in the absence of definite knowledge to the contrary, 
led to the belief that it is simply an evidence of acute infection. 
Autopsies have repeatedly demonstrated changes in the viscera, 
liver, kidneys, and lymph glands. 
Pathology.-Changes.in the spinal cord have been noted which 
include acute myelitis, perivascular and inflammatory conditions, 
acute degenerative processes, and sometimes pathogenic micro- 
organisms, but no special germ. Also lesions of the nerves and in 
the neuron bodies, as well as in the pons and in the cerebral axis. 
Symptoms.-Beginning with the lower extremities, the paralysis 
usually is accompanied by numbness, and rarely with pain without 
tremor, muscular contraction, or spasm, and progresses rapidly 
until the bulbar region is reached. The muscles of deglutition, 
speech, and of the face become totally paralyzed, as do the other 
portions of the body. There may or may not be sensory disturb- 
ance, but consciousness remains clear. 
Prognosis.-Prognosis is grave. Death usually results in from a 
few days to two weeks. 
Treatment.-Treatment is practically unavailing, but such as may 
be attempted must be directed to relief of the primary infection and 
the distressing symptoms, as well as to give prompt general support. 238 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Locomotor Ataxia.-This is a chronic disease of the sensory 
portion of the nervous system. 
Etiology.-Its most common cause is syphilis, although exposure 
to cold, overexertion, traumatism, excessive use of alcohol, and 
other factors are undoubtedly influential in this relation. 
Pathology.-The posterior spinal ganglia and ganglia of the cranial 
nerves are first affected. The sympathetic ganglia are sometimes 
included. The axons of the neuron bodies of these ganglia undergo 
various forms of degeneration. 
Symptoms.-The physical manifestations of this affection are 
numerous and varied. There is a first stage of pain or paresthesia, 
a second stage of ataxia or imperfect coordination of muscular 
action, and a third stage of paralysis. Among the rare symptoms 
we find bulbar paralysis resulting from continued progress of 
the disease, with the usual facial, lingual, and other symptoms in 
this region, also blindness and other indications of affections of 
the cranial nerves. Hemiatrophy of the tongue sometimes occurs, 
or there may be muscular atrophy affecting facial, buccal, lingual, 
and palatal muscles or other muscles of the body. 
Diagnosis.--While the general aspect of the disease recpiires 
differentiation from multiple neuritis, neurasthenia, diseases of 
the cerebellum, general paresis, and other similar affections, the 
somewhat rare cases having manifestations in the mouth and face 
would by reason of their history be readily distinguished. 
Treatment.-Treatment is practically unavailable from a curative 
point of view. Such therapeutic measures as may assist in arrest- 
ing progress of the disease are indicated as: Change of climate, 
regulation of diet, suitable exercise, massage, baths, counter- 
irritation, electricity, etc. When syphilis is known to be the cause, 
antisyphilitic treatment. (See Syphilis, page 117.) 
Friedreich's Ataxia.-A disease appearing in childhood, charac- 
terized by development of the spinal cord with affections of the 
neuroglia tissue which supplants the defective or degenerative 
fibers.1 First described by Friedreich, in Heidelberg, in 1863 and 
1876. Schultz, in 1877, showed that the disease is not related in 
any way to locomotor ataxia, but due to a defective development 
of the spinal cord. 
Etiology.-Heredity seems to have an influence, since it occa- 
sionally happens that members of the same family are affected. 
Infectious diseases of childhood are at least predisposing factors. 
1 Starr: Nervous Diseases, Organic and Functional, p. 388. OTHER SPINAL DISEASES 
239 
Alcoholism and syphilis in the parents are a parental heritage or 
active influence. 
Pathology.-The spinal cord in these cases appears thin and 
small, with thinning of the pia mater. There is thinning of tissue 
in the posterior and lateral columns of the spinal cord, with exten- 
sive degeneration of the nerve fibers and changes in the gray matter 
of the cord. 
Symptoms.-The affection may be congenital, or symptoms may 
develop gradually about the sixth or eighth year. In congenital 
cases the children learn to walk with difficulty, if at all, are unsteady 
upon their feet, fall easily, and have tendency to stagger. Feet are 
far apart, steps short and unsteady, with difficulty in preserving 
balance. The speech is slow, difficult, and indistinct. 
In the author's practice a considerable number of hare-lip and 
cleft-palate infants have given evidence of arrested development 
of the spinal cord in association with the defective development 
which caused hare-lip and cleft-palate. In these cases some of the 
children failed to learn to walk at all until three or four years old, 
and even the gait presented the characteristic uncertainty. There 
was the usual speech difficulty which always accompanies cleft- 
palate, but even after the palates were closed there remained the 
slowness of speech, difficulty in learning to use the tongue, and, 
above all, a disinclination to make speech effort. In contradis- 
tinction to the usual description of such patients it was found that 
some of these children appeared to be unusually bright. Others 
had the stupid appearance of the weak-minded. 
Diagnosis.-This is usually not difficult. The appearance of the 
characteristic symptoms before five or six years of age in most 
cases, or even later than sixteen years, is important. 
Children are seldom ever affected by locomotor ataxia. Mul- 
tiple neuritis is readily excluded by history of the case. Ataxia 
from cerebellar disease occurs later in life. 
Prognosis.-In Friedreich's ataxia, as generally understood, the 
prognosis is unfavorable, and a gradually progressive increase of 
symptoms may be expected until the child is quite crippled from 
paralysis, and although the affection itself is not fatal, suscepti- 
bility to other disease often brings early death. 
The author has observed a considerable number of defective 
infants and children with symptoms quite similar to those of 
Friedreich's ataxia, and he believes that other forms of affections 
of this character which signify less serious conditions should be 
recognized. Otherwise it does not necessarily follow that degenera- 240 
NERVOUS SYSTEM AND THE BUCCAL REGION 
tive processes must steadily continue, for with correction of the 
external defects and proper general care many of these patients 
seem to show a tendency to outgrow the deficiency to some extent, 
and do learn to use the affected muscles in speech and movement 
with decided improvement. 
Treatment.-No regular treatment can be depended upon. If 
the cases be of such character as those already described, patient 
upbuilding of general health and the steady cultivation of the 
affected muscles may do much, and is at least worth an effort. 
Myelitis.-Hyperemia, anemia, and myelitis of the cord are 
affections that relate to conditions of the blood and to infection 
which by reason of this fact are necessarily more or less closely 
associated with diseases of the mouth. 
Symptoms.-The degenerative conditions of the cord in acute 
and chronic myelitis cover a wide range. They include paralysis 
of the parts of the body supplied by the spinal nerves, trophic 
changes, and finally affections of speech, facial paralysis, and other 
indications that the disease has extended to the bulbar region. 
Prognosis.-The prognosis is unfavorable. Usually such patients 
become chronic invalids. 
Treatment.-Treatment is to support the general health, give 
the patient such comfort as may be possible, and to guard against 
complicating disease which may hasten death. Other measures 
which are recommended for spinal diseases are to some extent 
applicable in these cases. 
Pachymeningitis Cervicalis Hypertrophica.-This is a disease 
of rapid progress, presenting the symptoms of myelitis of the 
cervical region. 
Pathology.-Compression of the cord results from fibrous thicken- 
ing of the dura mater, which also affects the nerve roots in their 
passages through the dura. 
Symptoms.-This affection is of particular importance to our 
subject because its early symptoms may easily be mistaken for 
evidences of other diseases. In the first stage there is pain in the 
back of the neck and head, with stiffness of the neck, but the fact 
that pain is also felt in the hands and arms serves to distinguish 
this from other causes of pain in the back of the head and neck. 
In the second stage there are muscular contractions, and in the 
third stage paralysis. 
Prognosis.-The prognosis is fairly good if the disease be diag- 
nosticated in its early stage. The responsibility of the oral surgeon 
for prompt reference of such cases for immediate proper treatment 
is therefore important. DISEASES OF THE BRAIN 
241 
Treatment.-Treatment consists of mercury and iodide of potash 
in large doses, since the cause of the affection is presumed to be 
syphilis. The actual cautery is also applied to the back of the 
neck, and remedies are given for the relief of pain. 
Spinal Meningitis. - Etiology. - This is an acute meningitis, 
limited to the spinal cord, which develops after various forms of 
disease of the spinal column or dura mater. It follows spinal 
injuries and other diseases of the spinal cord, but its most frequent 
causes are infectious diseases ranging from comparatively simple 
infections through pneumonia, typhoid, septicemia, etc. Its forms 
are acute or chronic. 
Symptoms.-Acute meningitis develops suddenly with fever, 
chill, malaise, nausea, and other symptoms of acute infection. 
Pains in the head, back, and limbs are followed by stiffness of the 
back and neck and rigidity of the body. Hyperesthesia of the skin 
surface, muscular spasms, and twitchings are followed by anesthesia 
and paralysis as the degeneration progresses. Vasomotor disturb- 
/ances, trophic changes, etc. 
Chronic cases quite closely resemble the acute except that the 
onset is less marked and symptoms due to changes occurring through 
longer continuance of a somewhat wider range. 
Diagnosis.-Diagnosis is best accomplished by lumbar puncture. 
Usually the spinal fluid contains leukocytes and bacteria of various 
kinds which are representative of the character of infection. 
Prognosis.-The prognosis depends largely upon the character 
and influence of its septic cause. 
Treatment.-Treatment consists in rest in bed, relief of the 
symptoms, applications of heat, plasters, or actual cautery along 
the spine. Sedative and general treatment should be appropriate 
to the infection. 
Its chief interest to our subject lies in the possibility of the 
influence of mouth infection and recognition of its symptoms in 
differential diagnosis. 
DISEASES OF THE BRAIN. 
Cerebral Diseases. - Cerebral Hemorrhage, Cerebral Embolism, 
and Cerebral Thrombosis.-These are chiefly important to the oral 
surgeon from a symptomatological point of view, because among 
the symptoms headache is one of the most common premonitory 
evidences of these affections, particularly with endarteritis. 
Plethoric individuals with much redness of the face and distention 242 
NERVOUS SYSTEM AND THE BUCCAL REGION 
of the veins may be the subjects; in other cases they are pale, 
ill-nourished persons, the sufferers of existing diseases, weak hearts, 
and similar conditions. Headache of this character commonly 
affects the frontal or occipital regions. It is usually bilateral and 
varying in intensity, and must needs be distinguished from headache 
due to other causes. When hemorrhage, embolism, or thrombosis 
is followed by paralysis, the tongue, face, and palate are included 
in the hemiplegia, the muscles about the eye that close the lids 
being the only ones which are not involved, thus distinguishing this 
form of facial paralysis from that due to affections of the facial 
nucleus in the pons or of the facial nerve. 
Intracranial Pressure.1-Symptoms.-When the contents of the 
skull are slowly increased by a small tumor or by a small clot, the 
displacement of cerebrospinal fluid and the narrowing of the veins 
prevent tangible effects. But when a large clot suddenly forms, the 
pressure causes venous stasis and a slowing of capillary circulation. 
Nature in attempting correction raises the arterial tension, and thus 
maintains the nutrition of the medullary centers necessary to life. 
If the pressure is increased beyond the power of adjustment of the 
heart, then a weak, rapid heart action, a relaxed arterial tension, 
and an irregular respiration are followed by collapse and death.2 
Arterial tension therefore indicates the degree of intracranial 
pressure. A tension of 220 mm. developed suddenly is dangerous 
and a tension of 280 is fatal. 
Treatment.-Decompression is the only means of relieving intra- 
cranial pressure when the arterial tension rises to the danger point.3 
Hemiplegia.--Hemiplegia may be defined as paralysis of motion 
of one side of the body, usually due to cerebral diseases and occa- 
sionally due to injury or disease of the spinal cord. 
Cerebral Spastic Paralysis.-Etiology.-This disorder results from 
maldevelopment. Atrophy or injury to the brain from any cause 
may give rise to symptoms of hemiplegia. 
Symptoms.-Cerebral spastic paralysis may develop in infancy 
and be attended by high fever (temperature 102° to 105° F.), 
nausea, vomiting, headache, and delirium; in the case of older 
persons it may be associated with feeble-mindedness, imbecility, 
idiocy, blindness, deaf-mutism, and epilepsy. The paralysis may 
affect the face and jaws in common with other anatomical regions, 
or there may be spastic rigidity or athetosis (inability to retain the 
1 Starr: Nervous Diseases, Organic and Functional, p. 466. 
2 Kocher Hirndruck, Nothnagel's spec. Path, und Ther., ix, 32. 
3 Cushing: Am. Jour. Med. Sc., September, 1902, and June, 1903. DISEASES OF THE BRAIN 
243 
fingers in any spastic position in which they are placed, the constant 
state of slow movement of fingers and toes, flexion, extension, etc.). 
In these cases the athetoid movements may affect the face and 
tongue, causing constant grimaces and interfering with speech, or 
there may be choreic movements more violent than athetosis. 
Starr1 describes a case with total paralysis of the tongue and right 
hemiplegia. This child at the age of twelve years was still unable 
to articulate, and food was pushed into the throat by the finger 
and then swallowed. 
Treatment.-An attempted description of the treatment of these 
cases would be quite outside the purpose of this volume. This 
reference is included because the symptoms which affect the face 
and jaws sometimes require to be differentiated from other patho- 
logical states causing similar paralysis. Moreover, a field is develop- 
ing which promises useful results in the differential diagnosis of 
mental defects. This applies particularly to the distinction between 
aphasia (partial or complete loss of the use of language by the tongue 
or pen), a common associate of right hemiplegia, and the inability 
to pronounce certain words and other evidences of defective brain- 
cell development due primarily to arrested development of the jaws 
or disproportion between the size of the tongue and its maxillary and 
palatal enclosures. In the latter case the large size of the tongue, 
in comparison with the jaws in embryo, makes its proper use in word- 
forming exceedingly difficult, or impossible if later growth of the 
jaws be arrested. Children, therefore, with large tongues and narrow 
or otherwise deformed palatal vaults can only learn to speak certain 
words with great difficulty if at all. Undoubtedly this disadvantage 
causes disinclination to make the attempt, thus the necessary 
brain centers are not properly stimulated to activity. As a result 
an individual in the course of time becomes really defective, 
although in the beginning imperfect form of the parts and organs 
concerned in speech, which could have been readily corrected if 
properly diagnosticated, was chiefly responsible for the ill-developed 
brain which later became evident. It must, of course, be under- 
stood that these stigmata of degeneracy, as Talbot2 has so lucidly 
explained, quite commonly go hand in hand. The mouths of 
idiots, epileptics, and other children are characteristically con- 
tracted and ill-formed because the irregular cell development 
affects these and other parts as well as the brain. Nevertheless 
it is a matter of utmost importance that no factor be allowed to 
1 Nervous Diseases, Organic and Functional, p. 521. 
2 Stigmata of Degeneracy, Etiology of Osseous Deformities. 244 
NERVOUS SYSTEM AND THE BUCCAL REGION 
interfere with brain growth, and every impediment to proper 
mental training be removed. To this end recognition and dis- 
tinction between affections which might by any possibility act 
as predisposing or exciting causes should be emphasized. Proper 
expansion of the dental arches, which widens also the almost 
invariably associated contracted nares, and the surgical correction, 
if necessary, of any defectively formed parts, should receive due 
consideration and become a matter of routine procedure. 
Encephalitis; Cephalitis.-By this term is meant inflammation 
of the brain in contradistinction to that of the membrane of the 
brain. 
Etiology. The general opinion seems to be that it is an acute 
infectious disease. There is some question as to whether or not 
it could be caused by an injury to the head without fracture or 
meningitis, as it is usually only after the invasion of bacteria that 
bruises in the soft tissues of the brain are followed by inflammation. 
The pathological conditions with which it is etiologically associated 
are scarlet fever, influenza, pneumonia, erysipelas, whooping- 
cough, mumps, diphtheria, ulcerative endocarditis, otitis media, 
and septicemia. Ptomain poisoning, alcoholism, syphilis, and 
similar causes also bear an important relation. Infection from 
diseased conditions of the mouth, whether carried directly through 
circulatory or lymphatic channels or by extension of disease through 
associated sinuses, is a matter of important consideration, par- 
ticularly as this disease occurs most often in children and young 
people, and, as is well known, the mouths of most children, except 
under unusually rare conditions, almost always contain diseased 
teeth or gums, or both, to predispose to such infection. 
Pathology.-The changes in brain structure may be of the char- 
acter of an acute hyperemia, with extension of the bloodvessels, 
rupture of the walls, and other characteristic effects, or they may 
be attended by degeneration of the neurons with entire destruction 
of the cell and nerve elements. 
Symptoms.-General.-The general symptoms are malaise, ver- 
tigo, headache, sudden chill, followed by temperature that may 
be as high as 104° F., or somewhat less, with vomiting, convulsions, 
and, as the disease progresses, stupor or coma. The pulse is rapid 
but regular, and the respiration usually normal. If death does 
not follow coma and there is gradual recovery, there may be delirium 
or actual maniacal excitement. 
Local.-Since lesions of this character may affect different parts 
of the brain, the symptoms are in accordance with the affected DISEASES OE THE BRAIN 
245 
area, and if the facial and lingual muscles be paralyzed, as in acute 
bulbar palsy, there will necessarily be defective speed), difficulty in 
swallowing, and change in facial expression, just as there might 
be imbecility from involvement of the frontal lobe, strabismus, 
or paralysis of ocular movement, if the oculomotor nuclei were 
affected and decrease of coordination from involvement of the 
cerebellum or characteristic symptoms from the spinal cord. 
Prognosis.-The prognosis is bad. The severity of the convulsions, 
depth of the coma, degree of temperature, pulse, respiration, and 
physical condition of the individual are determining factors in 
deciding between a fatal result or gradual recovery. 
Treatment.-Treatment includes complete removal and disin- 
fection or correction of any known cause whenever such treatment 
may be possible. Obviously there should be careful consideration 
of even remote sources of local irritation. General care should 
be in the nature of purgatives, ice applied to the head, antipyretics, 
hot mustard baths or hot foot baths, and similar expedients to 
stimulate flow of the blood to the extremities. 
Cerebral Meningitis. - Etiological Classification.-The several 
forms of this affection are as follows: 
Primary Meningitis.-(1) Epidemic cerebrospinal meningitis 
(spotted fever), due to the Diplococcus intracellularis. (2) Endemic 
meningitis of infants, due to infection by various microorganisms. 
(3) Septic meningitis occurs with wounds, fractures, and operations, 
and sometimes follows otitis media, and is due to streptococcic or 
staphylococcic infection. 
Secondary Meningitis.-This may result from pneumonia, 
ulcerative endocarditis, empyema, typhoid and typhus fever, 
influenza, the eruptive fevers of childhood, erysipelas, and other 
forms of disease due to microorganisms. The most important 
forms are: (4) Tubercular meningitis. (5) Syphilitic meningitis. 
Meningitis in infants is of particular interest to those whose 
practice is limited to the operative field under consideration, and 
who do not practise general medicine, since it may be due to septic 
infection following disease of the mouth, nose, and ear, all of which 
are closely associated or may be secondary to operations in the 
region of the mouth, throat, and sinuses, because of the conditions 
which are favorable to more direct infection from these regions. 
The syphilitic forms bear a considerable measure of diagnostic 
importance which relates to all fields of practice. 
Pathology.-Cerebral meningitis is marked by hyperemia and 
congestion of the pia followed by exudation of serum, lymph, 246 
NERVOUS SYSTEM AND THE BUCCAL REGION 
fibrin, and pus. As the disease extends, the cortex, ventricles, and 
cranial nerves become affected, as does the cerebrospinal fluid, 
examination of which by lumbar puncture makes diagnosis possible. 
In the tubercular and syphilitic forms, characteristic evidences 
may be noted. 
Fig. 104.-Patient with septic meningitis, subsequently fatal; relaxed; comatose. 
(''Brudzinski's sign," after Northrup.) 
Symptoms.-The cranial symptoms of all forms of meningitis 
may be summarized as follows: Initial chill followed by high 
temperature, usually about 104° to 106° F., rapid pulse, headache, 
delirium, stupor, insomnia, rigidity and pain of the back and neck, 
hypersensitiveness to sound, strabismus, and disturbance of vision. 
Sometimes deafness is a noticeable symptom and facial paralysis 
Fig. 105.-Method of eliciting the identical reflex, or neck sign, by flexing head on 
chest. ("Brudzinski's sign," after Northrup.) 
very commonly occurs, as may also general convulsions. Marked 
restlessness, screaming, and other evidences of irritability are some- 
times accompanied by champing movements of the lower jaws, 
lips, and tongue. Bulging of the fontanelle or hydrocephalus may be 
apparent in the long-continued cases (Figs. 104 to 107). DISEASES OF THE BRAIN 
247 
Treatment.-In the cerebrospinal form the antiserum of Flexner, 
to be obtained at the Rockefeller Institute in New York, seems 
to offer the only hopeful means of combating the disease. By 
lumbar puncture 15 to 30 c.c. of cerebrospinal fluid is withdrawn 
and the same amount of antiserum is injected directly into the 
Fig. 106.-Method of eliciting the identical reflex, or neck sign, by reflexing head on 
chest. ("Brudzinski's sign," after Northrup.) 
spinal canal slowly and carefully, in order to avoid the production 
of symptoms of increased pressure. This is repeated at intervals of 
three or four days. The septic forms require the correction of 
the sources of infection wherever possible, and with infants the 
greatest possible care should be taken to diagnosticate definitely 
the pathological condition which has acted as a predisposing or 
Fig. 107.-Producing contralateral reflex, or leg sign, by passive flexion of one leg, 
causing a reflex flexion of the other leg. ("Brudzinski's sign," after Northrup.) 
exciting cause. Tuberculosis and syphilis require treatment for 
those affections. General treatment for relief of the symptoms and 
to assist nature in combating the ill effects of the disease is in 
the nature of stimulating and supporting measures to conserve and 
build up strength with nourishing food and the judicious use of 248 
NERVOUS SYSTEM AND THE BUCCAL REGION 
stimulants. Ice-packs to the head and spine, and cool sponge 
baths, supplemented by the use of sedatives, such as the bromides, 
codein, or morphin, if necessary in small, frequently repeated 
doses, may be employed. 
Multiple Sclerosis.-This disease affects both brain and spinal 
cord in varying degree, and is characterized by small plaques or 
eyelets of sclerotic tissue scattered irregularly through the central 
nerve system. 
Etiology.-It sometimes affects infants, but is more common 
between the tenth and thirtieth year, very rarely affecting older 
persons. It is generally recognized as due to infection from any 
of the various diseases caused by microorganisms. 
Pathology.-The sclerotic patches vary from a millimeter to 
several centimeters in diameter. There may be hundreds of these 
plaques in the white matter and other portions of the brain and 
spinal cord. There is production of a neuroglia structure and 
disappearance of the myelin sheath of nerve fibers. 
Symptoms.-Its symptoms are those that might be expected 
from lesions which involve the brain axis and spinal cord. In 
addition to the disturbance or loss of muscular action of various 
portions of the body, there is marked defect in speech, charac- 
terized by slow, jerky utterance of words, pauses between words 
or syllables, and forced effort to pronounce. There may also be 
tremor of the face and tongue, with jerky movements of the head. 
In one type the bulbar symptoms appear first. 
Prognosis.-It is claimed that some patients gradually recover, 
others die within two years, while others still live for many years. 
Treatment.-Stimulating and supporting treatment, and that 
which relieves the symptoms, is about all that can be done except 
the application of electricity, which is of questionable usefulness. 
Its importance to our subject lies in its recognition in diagnosis. 
Abscess of the Brain.-Etiology.-Injury of the head with or 
without fracture and particularly septic infection from compound 
fractures, foreign bodies forced through the skull, or other infection 
of any kind that may reach the brain structures, are among the 
causes. Abscesses and necrosis of the jaws, septic disease of the 
sinuses and middle ear, which are so frequently associated in disease, 
by reason of their direct avenues for conveying specific and other 
infections, have an important diagnostic as well as etiological 
relation. 
Pathology.-Infection by any of the pathogenic microorganisms 
may lead to a purulent encephalitis with small localized softened DISEASES OF THE BRAIN 
249 
conditions of the brain tissue or larger collections of pus as with 
other abscesses. 
Symptoms.-The general symptoms of cerebral abscesses are, in 
the order of their importance: (1) Headache, general but some- 
times located over the seat of the abscess. (2) A change in mental 
characteristics of the nature of irritability, alternating with dul- 
ness, imperfect attention, slowness of thought, and defects of 
memory, a semicomatose condition and appearance of illness out of 
proportion to the other symptoms. (3) Abnormal temperature. (4) 
Changes in the blood. (5) Tenderness of the head to percussion 
with change in the percussion note over the site of the abscess. 
(6) Facial palsy of the peripheral type upon the side affected. 
(7) Optic neuritis. (8) General febrile symptoms with occasional 
chills. 
The development of these symptoms in a patient who has had 
an injury of the head, or is the subject of chronic otitis media, 
or who has been exposed to any of the causes already mentioned, 
should awaken grave anxiety.1 
Diagnosis.-The diagnosis depends upon the history of the 
injury or discovery of the possible source of infection and differ- 
entiation from meningitis, thrombosis of the lateral sinuses, and 
acute encephalitis. 
Prognosis. --The prognosis necessarily depends upon the possi- 
bility of successfully draining the abscess. 
Treatment.-Surgical opening of the abscess cavity and evacua- 
tion of the pus. 
Thrombosis of the Venous Sinuses.-Thrombi usually form 
in the lateral or transverse sinuses, but may occur in any of the 
cranial venous sinuses. 
Etiology.-This disease is caused by phlebitis of the wall of the 
sinus due to inflammatory extension. The source is usually some 
septic process from the dura mater or from otitis media, or chronic 
nasal, orbital, or oral diseases. It may result secondarily from 
carbuncles and abscesses of other portions of the body. 
Pathology.-The thrombosis is usually a soft clot or clots adhering 
to the wall of the sinus. These may become hard or organized, 
or are purulent with any of the evidences of pus formation. 
Symptoms.-The general constitutional symptoms are cpiite 
similar to those of brain abscesses. There is choked disk in over 
one-half the cases within the first week, especially with thrombus 
1 Starr: Nervous Diseases, Organic and Functional, p. 549. 250 
NERVOUS SYSTEM AND THE BUCAL REGION 
of the lateral sinus, which is the most frequent through its close 
connection with the ear. Edema and swelling with venous con- 
gestion of the face and about the eye, with other eye symptoms, 
occur in thrombus of the cavernous sinus from nasal and orbital 
disease. 
Prognosis.-Absolutely fatal, except when thrombosis of the 
lateral sinus enables operation to be performed. 
Treatment.-Surgical opening of the sinus, cleansing of the clot, 
and curettement. 
Tumors of the Brain.-Brain tumors in common with other 
brain affections bear a certain symptomatological relation to our 
subject, chiefly useful in preventing errors of diagnosis which by 
causing delay might lead to serious results. Early differentiation 
is therefore of the first importance. 
Pathology.-Nearly all varieties of tumors have been found 
within the brain, some frequently, others more rarely. Tubercular 
tumors are by far the most common. (See Tumors, page 486). 
Symptoms.-The general symptoms due to the existence of a 
new growth in the brain irrespective of its position are headache, 
general convulsions, choked disk, and optic atrophy, changes of 
disposition and mental power, vomiting, vertigo, insomnia, changes 
in the pulse-rate, attacks of syncope, polyuria, and progressive 
malnutrition. 
Focal symptoms of the disease in the cortex of the brain or 
beneath the cortex in the projection tracts which join the cortex 
to the various subcortical centers, are unilateral spasms, mono- 
plegia or hemiplegia, paresthesia or anesthesia in one or more 
limbs, hemianopsia, and the various forms of aphasia. Affections 
of the cranial nerves and basal parts of the brain occur with tumors 
in the basal ganglia and cerebral axis, or external to .the brain 
upon the base. Symptoms affecting the twelve cranial nerves 
necessarily cover a wide range. 
Diagnosis.-The presence of any of the foregoing symptoms, 
unless otherwise accounted for, with reasonable certainty, should 
at once demand consultation or reference to a neurologist or sur- 
geon of sufficient experience in brain surgery to prevent the likeli- 
hood of delay, which might prove serious. 
Complete Report of Case of Brain Tumor.-The following complete 
report of a case of brain tumor received through the courtesy of 
Dr. Charles H. Frazier is included as a valuable illustration of 
symptoms such as might be noted in treatment of pathological 
conditions of the mouth, jaws, and surrounding parts which would DISEASES OF THE BRAIN 
251 
require distinction from similar indications of local diseases. Their 
prompt recognition and early reference of the patient to a brain 
surgeon would certainly tend to increase the likelihood of avoiding 
a fatal result: 
Amos Kump (25), 
Littletown, Pennsylvania. 
University Hospital. 
No. 2223 
Service of Dr. Frazier. Referred by Dr. Harry S. Crouse. 
Admitted March 3, 1907. Discharged April 12, 1907 (death). 
Diagnosis. Brain tumor. Not found. 
Operation. Bilateral decompression, April 11, 1907. 
Result. Death. 
Chief Complaint. 
Blindness, intense headache, vomiting. 
Social History. 
Patient is a bricklayer and stonemason. He is unmarried. He uses beer and whisky 
sometimes to excess. He chews tobacco rather freely. He had specific urethritis 
about a year ago, but has no history of specific infection. 
Family History. 
Father and mother both living. Father has had St. Vitus' dance for over forty 
years. He is about seventy years of age. Two brothers and three sisters living and 
well. One sister died of eclampsia. The patient says the members of his family are 
all more or less "nervous." No family history is obtained of tuberculosis, or malig- 
nant, cardiac, or renal disturbances. 
Previous Medical History. 
Negative, except that he has had a number of attacks of tonsillitis. 
History of Present Condition. 
The patient is in an advanced stage of mental hebetude, probably as a result of 
bromism, and his statements are vague and unsatisfactory. He says that last winter 
he began to have weakness and soreness about the articulation of his jaw. The sore- 
ness afterward spreading to his head, where it has persisted ever since. About two 
months ago blindness developed in right eye, and this was followed about two weeks 
later by blindness in the left eye. During this same period he has vomited a number 
of times. He is not able to walk about unless someone leads him. He believes his 
inability to walk is caused by his blindness. His general health he believes has not 
suffered much. Headache of late has been very severe. 
Physical Examination. 
A rather poorly developed and emaciated male subject, looking considerably older 
than his given age of twenty-five years. Skin is covered with a profuse deeply 
colored red eruption, probably the result of bromides. No noteworthy glandular 
enlargements. Pulse is regular, volume fair. Chest poorly developed. Expansion 
fair and equal on both sides. Heart and lungs negative. Abdomen soft and symmet- 
rical. Abdominal organs negative. 
Examination by Dr. Spiller, March 6,1907. 
The left pupil is much larger than the right. Both are immobile to light; slight 
contraction is obtained in each pupil in attempt at convergence. He says he sees 
light with each eye separately. He wrinkles the forehead well, closes the eyelids, 
shows teeth, and draws up each corner of mouth well; therefore he has no involve- 
ment of either facial nerve. Tactile sensation is completely lost in the entire distribu- 
tion of the right fifth nerve. Provided no pressure is produced. Sensation of pain 
is lost in same distribution. Sensation is preserved along the border of the lower 
jaw in the distribution of the cervical nerves. Conjunctiva and corner of right eye 
are anesthetic, not so of the left eye. A piece of paper put far up the right nostril 
is not felt unless pressure is produced aiid causes no lacrimal reflex. The jaw is 252 
NERVOUS SYSTEM AND THE BUCCAL REGION 
swollen and uvula is-absent. Sensation of left nostril is normal. He is distinctly 
deaf to voice in both ears. The soft palate moves very imperfectly on the right side. 
The sense of smell is greatly impaired on each side. The tongue is protruded straight. 
Grasp of each hand is fair. Upper limbs move freely in all parts, biceps and triceps 
tendon reflexes not distinct on either side. Sensation of touch and pain are normal 
in each upper limb. Movements of lower limbs are free in all parts. Patellar tendon 
reflexes and Achilles tendon reflexes are lost on each side. Brudzinski reflex is not 
obtained; toes are not moved distinctly in either direction. Sensation of touch 
and pain are normal in each limb. Gait and station are very ataxic; he has marked 
sway with his feet close together. His body is covered with eruption, probably 
from bromides. Taste for salt and sugar probably lost on front and anterior part of 
tongue. 
Eye Examination by Dr. de Schweinitz. 
Palpebral fissures are about equal width, left eye slightly divergent. Left external 
rectus movement is preserved. Movement of interims superior and inferior rectus 
is markedly limited. 
Right Eye. 
There is loss of movement of external rectus and marked limitations of movements 
of superior and inferior recti, with almost lost internal rectus movement. There is 
extensive double optic neuritis with large retinal hemorrhages on the right side. 
April 11, 1907. Last night the patient became unconscious; for the last few days 
he has not seemed to be quite well. He was transferred to Dr. Frazier's service for 
operation. A lumbar puncture was made, and the cerebrospinal pressure was found 
to be equal to 27 mm. of mercury (351 mm. of water) and about 5 mm. of mercury 
(65 mm. of water). 
April 12, 1907. A decompressive operation was done on each side of the head, just 
above the ear, in order to relieve intracranial pressure. The brain bulged much on 
the right side. The patient died April 12, about 2 p.m. 
April 13, 1907. Autopsy today disclosed large tumor of the left lingual lobe, 
densely adherent throughout the entire tight middle fossa of the skull, and extending 
over the petrous portion of the temporal into the posterior fossa. The growth 
appeared to extend across the inferior surface of the pons and medulla, involving 
many of the cranial nerves. The brain tissue of the temporal lobe was very much 
softer than usual, and could not be removed from the skull without being badly 
broken up. 
Description of Operation by Dr. Frazier. 
Bilateral decompressive operation. Horseshoe cutaneous flap, long incision in 
temporal muscle and fascia. Crucial incision in dura-not nearly as much tension 
on right as on left side. There was great bulging on left side (which proved to be the 
site of tumor). 
Diseases of the Pituitary Body.-Diseases affecting this body, 
particularly tumor formations, have been so frequently observed in 
acromegaly and the pituitary extract administered internally has 
in some cases appeared to have such a marked effect in checking 
the progress of this affection that lesions of the hypophysis are now 
regarded as definitely affecting development. Notwithstanding 
this, Coplin reports twenty-five tumors of the hypophysis as being- 
on record without acromegaly. Tuberculosis and the gummata of 
syphilis and adenomata are its most common affections. Other 
tumors have been reported, but are somewhat rare. 
Treatment.-As already stated, the administration of pituitary 
extract is sometimes beneficial in arresting abnormal growth. 
Removal of the gland is required in cases of tumor growth. DISEASES OF THE CEREBRAL AXIS 
253 
DISEASES OF THE CEREBRAL AXIS. 
Bulbar Palsy.-This form of progressive paralysis affects the 
lips, tongue, and larynx. 
Etiology.-The claims of authors who have brought forward 
certain specific causes have not been fully accepted. It is safe to 
assume, however, that it may result from any factors contributing 
to nerve-cell degeneration which may affect the motor cells of the 
medulla oblongata and pons varolii, such as the various intoxications, 
syphilis, etc. 
Pathology.-There is a gradual atrophy and degeneration of the 
motor nuclei and nerves of the medulla oblongata and pons, which 
may or may not be accompanied by degeneration of the pyramidal 
tracts. There is usually marked degeneration of the nerves involved 
which are the hypoglossal, facial, pneumogastric, glossopharyngeal, 
vago-accessorial, and motor trigeminal. 
Symptoms.-When the disease affects the bulb either primarily 
or as an extension from the cervical region of the spinal cord the 
clinical picture is often described as "syringobulbia." Atrophy 
of the tongue and unilateral or bilateral paralysis of one or both 
vocal cords are among common symptoms. 
Defective speech is first noticeable in an effort to pronounce 
such letters as d, g, k, I, r, s, t. Its tendency is to progress until 
speech is completely lost. The constant flow of saliva from the 
mouth is exceedingly annoying. Difficulty in swallowing is made 
doubly so by fluid passing into the nose or larynx. The lips cannot 
be contracted, the voice also is affected by paralysis of the soft 
palate and larynx, as is evidenced by loss in volume and change in 
tone. Mastication is difficult, due to the loss of the use of the 
tongue. There may or may not be stiffness or weakness of the 
muscles of mastication. Usually marked atrophy of the lips and 
tongue is noticeable, so much so, that it is impossible to protrude 
the tongue beyond the lips and its tremor is markedly noticeable. 
Diagnosis.-Its distinguishing feature is the fact that in addition 
to the symptoms previously described, the upper part of the face 
and the branches of the facial nerves which supply the upper part 
of the face are apparently normal, and the affected portion is limited 
to muscles of the mouth and chin, the upper part of the face being 
quite free. It is sometimes necessary to distinguish it from pseudo- 
bulbar palsy, in which there is absence of atrophy and vibratory 
tremors. Other brain and nervous affections causing paralysis are 
more easily excluded (Figs. 108 and 109). 254 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Prognosis.-The termination is necessarily fatal and may come 
in the course of a number of days or years, according to the rapidity 
of the action of destructive process. 
Treatment.-Treatment is at best only palliative, since nothing 
can cure the disease, and it is doubtful if efforts to check its progress 
are effective. To the oral surgeon its interest in this regard comes 
by reason of the fact that he will usually be called in such cases in 
the hope that he may be able to relieve the exceedingly distressing 
salivary symptoms, and while the administration of tonics and 
spraying the mouth with astringent remedies may give a measure 
of temporary comfort, they cannot be permanently effective. 
Fig. 108.-Patient suffering from bulbar 
paralysis. Double ptosis, slight external 
strabismus, facial paralysis, with lack of facial 
expression and inability to close the lips are 
to be seen. The effort to open the eyes causes 
a wrinkling of the forehead. (After Starr.) 
Fig. 109.-Bulbar paralysis 
Double ptosis, with external 
strabismus, flattening of the face, 
inability to close the mouth, and 
atrophy of the right half of the 
tongue are to be seen. (Icon, de la 
Salpetriere.) (After Starr.) 
Iii considering affections of the nerves no attempt will be made 
to include all of the pathological conditions which affect each of 
the twelve cranial nerves. Since, however, the primary centers 
of cranial nerve nuclei are so closely joined by associated fibers, 
and combined action is such a necessary part of reflex action con- 
cerned in all such an infinite number of movements and sensations 
intimately connected therewith, and because involvement of the 
higher centers makes up the complement of coordination as affecting 
DISEASES OF THE CRANIAL NERVES LESIONS OF THE FIRST OR OLFACTORY NERVE 
255 
the basal ganglia through which provision is made for automatic 
acts, it is evident that there must necessarily be more or less wide 
distribution in symptoms resulting from cranial nerve disease, even 
though the actual pathological changes may be evidenced in only one 
nerve or in a distinct region of nerve distribution. It therefore 
becomes necessary for us to consider each nerve through which 
pathological states may be evidenced that may affect nerve dis- 
tribution in the region of the mouth, face, and jaws, or in which 
connection therewith may be more indirectly evidenced. Beyond 
this, however, an attempted detailed distribution of more remote 
affections would not only be inadvisable, but impracticable in this 
relation. 
LESIONS OF THE FIRST OR OLFACTORY NERVE. 
The first or olfactory nerve governs the sense of smell through 
the specially endowed primary neurons and finer filaments dis- 
tributed through the Schneiderian membrane of the nose. It is 
particularly sensitive to any disease which may be inflammatory 
or to other destructive processes affecting the mucous membrane 
of the nose and the nerve filaments it contains. 
Anosmia (Loss of smell; perversion of smell).-Etiology.-Loss 
or perversion of smell, which is the direct result of such disease, 
may be brought about by nasal catarrh, arrest of nasal secretion 
when due to disease of the fifth nerve, tumors of the nose or polypi, 
ethmoiditis or disease of the bones and cells in this region, as well 
as meningitis, brain tumors, if located in the anterior fossa, and 
any disease which may destroy or disarrange the functional activity 
of the olfactory bulb or tract. Occasionally the activity of this 
center is an evidence of hysteria. 
Diagnosis.-Since catarrhal affections of the nose are so closely 
associated with disease and deformities of the mouth and allied 
affections, as are also pathological conditions of the maxillary sinus, 
through which the sphenoidal, frontal, and ethmoidal sinuses are 
so constantly involved by extension of the disease from one to the 
other, it is self-evident that due consideration must be given dis- 
orders of the oral cavity in considering both the etiology and treat- 
ment of these cases. The loss of sense of smell is sometimes a 
valuable test, inasmuch as it is seldom an evidence of unilateral 
disease. 
Treatment.-The treatment concerns the oral surgeon only in- 
sofar as the correction of the oral disease may be involved, and for 256 
NERVOUS SYSTEM AND THE BUCCAL REGION 
differentiation in the defect of such etiological influences as may 
require treatment at the hands of rhinologists, neurologists, or 
those who follow other divisions of practice. 
LESIONS OF THE SECOND (OPTIC) NERVE. 
Hyperemia and Anemia.-Hyperemia and anemia of the optie 
nerve are associated with similar conditions of the brain. Throm- 
bosis of the retinal artery may be caused by arterial disease or 
malarial and other poisons. Blindness may result from either. 
Each is usually associated with headache. Both are therefore 
matters of consideration in differential diagnosis when pain in the 
distribution of the fifth nerve is a marked symptom. 
Edema of the Optic Nerve, "Choked Disk," "Papilledema."- 
Etiology.-Edema occurs from obstruction of the circulation in the 
eye or increased intracranial pressure, and is a common symptom 
of tumors, and occasionally of abscesses of the brain. It may cause 
impaired vision or blindness, is usually bilateral, but may for a 
time affect one eye. Its diagnostic value in cases of brain tumor, 
brain abscess, and intracranial pressure of any kind is of the first 
importance, and being associated so often with trigeminal pain 
should always be sought for by proper examination wherever there 
is suspicion of the existence of such disease. 
Optic Neuritis.-Etiology.-Optic neuritis may be the expression 
of known heredity or result from any of the blood poisons which are 
recognized as of etiological importance in other forms of neuritis 
such as alcoholism, leukocythemia, diabetes, and syphilis, or even 
rheumatism and gout. Direct infection from brain disease, pressure 
of brain tumors upon the nerve and other evidences of intracranial 
disease may be direct causes. 
Symptoms.-Among the more prominent symptoms are failure 
of sight, objects become blurred, sensitiveness to light, decrease 
and disarrangement of the vision field. The additional symptoms 
of headache, vertigo, digestive disturbances, nausea, vomiting, 
loss of strength, which are common to so many different affections, 
confuse the question of diagnosis and not infrequently require 
differentiation. 
Optic Nerve Atrophy.-Etiology.-Atrophy may result from any 
of the diseases or indirectly from all of the causes recognized as 
affecting brain and nerve lesions. 
Symptoms.-The symptoms of gradually increasing blindness 
and loss of the field of vision may be associated with pain in the 
eyes and discomfort after their use or exposure to light. LESIONS OF THE SECOND {OPTIC} NERVE 
257 
Diagnosis.-All the diseases directly affecting the optic nerve and 
all other affections of the eye, whether due to visual defects, muscular 
weakness, overuse, or any other cause in which the symptom of 
pain is a marked feature, and conjunctival affections which by any 
possibility could be confused with or induced by buccal diseases, 
should be referred to a competent oculist. All attempts at descrip- 
tion of symptoms which could by any possibility lead operators in 
other fields to attempt eye examination for the purpose of differen- 
tiation between the various pathological optic states have been 
excluded because the author is very firmly of the belief that such 
attempts in practice are in the highest degree pernicious. That 
there is a rapidly developing field for useful consultation and cooper- 
ation between the dentist, the oral surgeon, rhinologist, and the 
ophthalmologist is undoubtedly true. In the author's practice the 
valuable assistance of competent examination has many times led 
to the avoidance of great error in diagnosis and treatment. On the 
other hand, gratifying results have sometimes been brought about 
by the correction of causes of reflex disturbances from dental irri- 
tation which were evidenced by pain in the eye or eyes or other 
optic disturbances which might otherwise have been confused with 
the result of eyestrain. 
Treatment.-In the correction of chronic conjunctivitis due to 
nasal disease proper maxillary expansion frequently may be 
depended upon to open avenues for proper exit of secretions and 
by improvement in their character effectually to restrain certain 
forms of this affection. It is confidently believed that better 
understanding of the inter-relation in development between the 
bones of the head and face as influenced by development of the 
jaws, may in the future,-by earlier widening of the palate for cor- 
rection of contracted maxillae, lead to more symmetrical develop- 
ment of the orbits in common with other parts, and in this way 
reduce to some extent the frequency of myopia and presbyopia. 
In one case referred by the patient's oculist, believed to be marked 
strabismus due to unusual nervous and weak muscular inequality, 
markedly increased by general causes, spreading of the maxillae 
and oral treatment appear to be giving valuable assistance at 
the present time in the direction of aiding a girl, aged ten years, 
to overcome this defect without other operative assistance. 
Such treatment is at least helpful and beneficial in a general 
way, even though not entirely curative. 258 
NERVOUS SYSTEM AND THE BUCCAL REGION 
LESIONS OF THE THIRD, FOURTH AND SIXTH NERVES.. 
Paralysis or other disorders affecting the movement of the muscles 
of the eye and eyelid bear a considerable measure of diagnostic 
importance in the distinguishment of nervous disorders affecting the 
mouth or other portions of the face and jaws, for the reason that 
factors which are responsible for the causation of diseases of oral 
nerves are identical with those which lead to other brain and nerve 
affections. Because the sympathetic fibers of the third nerve, which 
leave the spinal cord in the first dorsal nerve root, pass to the 
superior cervical ganglion and from the cavernous plexus to the 
Gasserian ganglion of the fifth nerve, and with the first branch of 
the fifth to the iris; there is also much in common between these 
nerves as evidencing pathological influences upon either or both. 
Quite frequently the presence or absence of loss of motion in the 
region of the eye serves to point the way to differentiation between 
central and peripheral locations of first causes in nerve disease. 
Therefore symptoms of ptosis, or falling of the upper eyelid, dila- 
tation of the pupil and loss of reflex action to light and accommoda- 
tion, turning of the eyeball outward and slightly upward, which are 
indications of third nerve paralysis, may call for careful oral examina- 
tion in at least a supplementary way or be of value in preventing 
attempted local care of central disease. 
Patheticus Paralysis.-Patheticus paralysis is a rare affection 
due to paralysis of the fourth nerve. It causes double images. 
When isolated, paralysis of the fourth nerve exists without affec- 
tion of the third or sixth nerves. It is an important symptom of 
tumor of the cerebellum. 
Paralysis of the Sixth Nerve.-Abducens Paralysis.-Paralysis 
of the sixth nerve is a frequent evidence of intracranial disease. 
Its characteristic symptom is internal strabismus, or turning of 
the eye inward, with inability to turn the eye outward, due to 
paralysis of the external rectus muscles. This nerve supplies the 
unopposed contraction of the internal rectus. It is accompanied 
by double vision and may also be associated with various forms 
of ocular palsy. The cranial course of the sixth nerve is so long 
that it is likely to be affected by disease at any part at the base of 
the brain. Its symptoms therefore require due consideration 
in the diagnosis of many pathological conditions pertaining to 
both fifth and seventh nerves as well as affections of the third or 
sixth and in cases of brain tumors. LESIONS OF THE THIRD, FOURTH AND SIXTH NERVES 
259 
Symptoms.-Acute ophthalmoplegia, a disease of the nuclei of 
the nerves that supply the muscles of the eyeball and causes their 
paralysis, usually begins suddenly with severe cerebral symptoms, 
vertigo, vomiting, headache, and sometimes delirium and coma, 
accompanied by paralysis affecting the action of the pupil or of 
motion of the eyeballs when the levator palpebrse are affected. 
(Ophthalmoplegia externa, Fig. 110.) 
Fig. 110.-Patient suffering from chronic ophthalmoplegia externa. The wrinkling 
of the forehead in the effort to open the eyes is noticeable. The external strabismus 
can be seen. (After Starr.) 
Prognosis.-In all forms of paralysis of the eye muscles when 
symptoms of bulbar paralysis develop the result is usually fatal. 
Otherwise there may be relief in the course of one or two weeks, 
or a chronic, slightly improving paralysis extending over a period 
of years. In the chronic form there may be gradual development 
of bulbar palsy, or extension of paralysis to other regions, or recovery 
in the large majority of cases if the ophthalmoplegia is only 
partial. 
Treatment.-The treatment of lesions of the third, fourth, and 
sixth nerves properly belong with other fields of practice, except 
insofar as the oral surgeon may be able to contribute to general 
healthfulness or to the relief of local irritations which may tend 
to aggravate the condition. 260 
NERVOUS SYSTEM AND THE BUCCAL REGION 
DISEASES OF THE FIFTH OR TRIGEMINAL NERVE. 
General Consideration.-In order to facilitate better understanding 
of each of the many diseases of this nerve, those affecting its principal 
divisions are separately described, but it must be remembered that 
since both motor and sensory portions of the nerve are so commonly 
involved, especially when the Gasserian ganglion is affected, an 
exact division of pathological evidences of disease is impossible. 
Quite commonly spasmodic contraction of the muscles is associated 
with pain. In like manner, trophic disturbances may be evidence 
of disease affecting either or both divisions. The same is true of 
irritations, such as herpes, acne, or eczema, flushing or paling of the 
skin, alteration of temperature and appearance of the skin surface, 
unusual activity of the sweat glands, atrophy, or altered develop- 
ment. Consideration of the causes and treatment of these affections 
is necessarily a part of the description of the diseased conditions 
with which they are associated (Fig. 111). 
Degeneration.-Degeneration takes place in this as in other 
nerves and nerve structures, and the same general or local causes 
come into consideration. As a result of injury there may be com- 
pression without rupture of the sheath of Schwan, which drives 
the myelin away from the point of pressure and causes degeneration 
of the axis-cylinder, or with the sheath of Schwan ruptured, exuda- 
tion of the myelin occurs with consequent degeneration of the 
axis-cylinder. Following these changes there is an increase of 
nuclei and connective-tissue fibrils, with tendency to transforma- 
tion of the nerve into connective tissue. At the point of division 
a bulbous growth of connective tissue forms a sensitive scar. 
Nerve Regeneration.-Nerve regeneration is important in its 
bearing upon the continuance of relief from operations for tic 
douloureux, and the possibility of surgical anastomosis or spon- 
taneous correction of results from disease or injury. Clinically, 
it is well known that some sort of regenerative process does take 
place when nerves are severed. Whether it is by a continued 
growth and extension of the nerve fibers from the central portion, 
as claimed by Ranvier and others, or because protoplasm with 
specific developmental properties forms and unites the elements 
of the new fiber to the old one, as claimed by Neumann, may be 
a matter of question. Bowlby,1 however, found regenerating nerves 
in the peripheral portion in three cases some months after opera- 
1 Starr: Nervous Diseases, Organic and Functional, p. 161; Injury of Nerves, p. 25; DISEASES OF THE FIFTH OR TRIGEMINAL NERVE 
261 
Fig. 111.-Scheme of the neurons making up the fifth or trigeminal nerve. (Edinger, 
after Starr.) 262 
NERVOUS SYSTEM AND THE BUCCAL REGION 
ation, and the quite common practice of surgical anastomosis of 
nerves with strands of catgut, with favorable results, demonstrates 
the clinical possibilities of regenerative processes. 
AFFECTIONS OF THE MOTOR PORTION OF THE FIFTH OR 
TRIGEMINAL NERVE. 
Paralysis.-Injury or disease of the motor portion of the trigem- 
inal nerve is evidenced by paralysis of the muscles of mastication. 
The lower jaw falls open and the acts of swallowing or speech 
become difficult or impossible. Unless, however, both sides are 
affected, there will be sufficient activity of the muscles upon the 
opposite side to prevent complete loss of action. 
Fig. 112.-Hemiatrophy of the face. 
The condition had developed in two 
years. (After Starr.) 
Fig. 113.-Hemiatrophy of the face. 
The condition developed slowly during 
five years, and then came to a stand-still 
at the point shown. (After Starr.) 
Deafness and tinnitus aurium (page 338)* may result when the 
small branch of the motor portion which passes to the tensor tympani 
from the otic ganglion is paralyzed, because tightening of the 
ear-drum is thus prevented. Paralysis of the sphenostapedius 
muscle may cause a slight difficulty in swallowing, with deviation 
of the uvula toward the paralyzed side, due to paralysis of the 
muscles about the hard palate, through paralysis of this muscle, 
which is connected with the motor branch of the trigeminal nerve. 
These symptoms follow division of the motor branch when this 
occurs in operation for trigeminal neuralgia (page 291), and as a AFFECTIONS OF THE FIFTH OR TRIGEMINAL NERVE 
263 
matter of course the motor branch should be avoided if possible 
(Fig. 114). 
Fig. 114.-Showing the distribution of the fifth, seventh and eleventh cranial 
nerves and the cervical and brachial plexuses; also the area of the middle meningeal 
artery in the inner table of the skull, injury to which is sometimes the cause of hemi- 
plegia; also the course of the bloodvessels in the neck and face. (Arnold's Atlas.) 
Hemiatrophy of the Face.-Paralysis of the muscles which 
depend upon this nerve for motor activity sometimes leads to a 264 
NERVOUS SYSTEM AND THE BUCCAL REGION 
gradual facial atrophy, and through the effect of muscle degenera- 
tion causes gradual sinking in of the facial features upon the affected 
side. This is differentiated from true facial hemiatrophy, because 
in the latter the muscles are not paralyzed and there is no marked 
loss of sensation, although there is a slowly progressive atrophy 
which affects all of the tissues, including skin, fat, muscles, and 
bones. This affection is rare, and its pathology practically unknown. 
It usually appears before the age of ten years, and rarely after 
twenty. The general effect is asymmetry of the face, which gradu- 
ally becomes more and more evident until in natural course its 
progress ceases. A fatal termination does not result, and it there- 
fore is distinguishable from muscular dystrophy, which has a 
tendency to fatal termination, and because there is no associated 
muscular paralysis. It seems reasonable, however, to suppose 
that there is some analogy between the etiological factors which 
act as predisposing or exciting causes in the several forms of facial 
atrophy (Figs. 112 and 113). 
HABIT AND OTHER SPASMODIC AFFECTIONS OF THE 
MUSCLES SUPPLIED BY THE MOTOR DIVISION 
OF THE FIFTH NERVE. 
Spasm of Muscles of Mastication.-Trismus, or tonic spasm 
of the muscles of mastication, is usually associated with general 
convulsions or tetanus (page 97), and in these cases is not properly 
a local disease of the motor branch of the fifth nerve. Spasmodic 
affections of the muscles of mastication which occur in connection 
with facial or other spasms are also to be excluded for the same 
reason (page 349). 
Etiology.-Direct irritation of the trigeminal nerve from im- 
pacted third molars and other teeth is quite a common cause of 
tonic spasm of the masseters. These and other causes, such as 
long-continued dental operations, irritation from inflammatory 
conditions, results of paralysis, hysteria, etc., are treated more 
at length (page 349). Clonic spasm of the muscles of mastication 
occurs in many different forms in greatly varying degrees and from 
widely different causes. It may be evidenced by chattering of 
the teeth during chills or fear, or be a symptom of paralysis agitans. 
Grinding the teeth, particularly at night, is a well-known symptom 
of many affections of childhood, which directly or indirectly disturb 
the nervous system, such as intestinal irritations from worms, 
indigestion or similar affections, adenoids and enlarged tonsils, AFFECTIONS OF THE FIFTH NERVE 
265 
irritating conditions of the eye or ear, or of the genitals, or any 
similar form of reflex irritation, and particularly pathological 
dentition (page 63). It is sometimes a sign of irritation at the base 
of the brain, and notes the beginning of tubercular meningitis. 
Tumors at the base of the brain or any of a variety of diseases may 
be so slight as to be safely outgrown or lead on to serious or fatal 
termination. In adults the habit of tooth grinding is an important 
factor from both causative and complicating aspects in many 
nervous affections (page 316). It is also important when concerned 
in habits of biting the cheeks or lips as leading to possible degenera- 
tive changes in the tissues subject to these chronic irritations. 
Herpes Zoster.-Herpes zoster upon the face is sometimes 
associated with congenital paralysis of the trigeminal, and may 
result from diseased conditions of the Gasserian ganglion, injury of 
the fifth nerve, or pressure upon the base of the brain by tumors. 
Syphilitic or tubercular exudation in the meninges may be asso- 
ciated with symptoms of the bulbar paralysis of syringomyelia, as 
described on page 222. 
Treatment.-The treatment of the foregoing diseases affecting 
the motor branch of the fifth nerve, insofar as they may be amen- 
able to therapeutic measures, depends chiefly upon a diagnosis which 
will lead to discovery of the cause and to correction. Aside from 
the general upbuilding which all such patients require, remedial 
efforts must be directed to relief of the causative factor, and such 
hope of improvement as there may be necessarily depends upon the 
possibility of successful accomplishment in this direction. General 
treatment must be givenfor causative or complicating constitutional 
pathological states, and this supplemented by hygienic care, elec- 
tricity, massage, or other efforts to bring about improvement of 
nervous conditions. Chief dependence must be placed upon 
diagnosis and the treatment of local affections which may cause 
peripheral irritation in the distribution of the nerve. These are 
identical with those which cause other forms of disturbance, and 
are grouped and considered on pages 316 to 326. 
AFFECTIONS OF THE SENSORY PORTION OF THE FIFTH OR 
TRIGEMINAL NERVE. 
Hyperesthesia-Hyperesthesia consists in excessive sensibility 
or impressibility. Hyperesthetic areas of skin surface, exceedingly 
painful to touch, are quite frequently associated with trigeminal 
neuralgia. Among the author's patients, persons of otherwise 266 
NERVOUS SYSTEM AND THE BUCCAL REGION 
cleanly habits have been unable to wash their faces for weeks or 
months because of the painful sensation this excited. 
Paresthesia.-Paresthesia is characterized by a tingling and 
numbness of the skin and mucous membrane felt in the distribution 
of the sensory filaments of the nerve. Such sensations are usually 
felt in the extremities, but are not infrequent in certain portions of 
the mouth, particularly along the side of the tongue. 
Etiology.-Numbness of this character in the extremities, as, 
for example, when the foot or hand is said to be asleep, is caused 
by pressure upon the nerves during sleep or otherwise, and may be 
a first symptom of the onset of some more serious affection. In 
the distribution of the fifth nerve the cause is frequently irritation 
from dental pulps or pericemental inflammation due to malocclusion, 
jaw-biting habits, and similar affections. 
Pathology.-There is slight impairment of nutrition in the nerve 
caused by venous congestion. 
Symptoms.-The numbness may be of transitory nature, may 
last for short periods but recur frequently, or may be almost con- 
tinuous and in time lead on to true neuritis. 
Treatment.-The treatment consists in relief of the local irrita- 
tion whenever such cause may be discovered. The author believes 
paresthesia to be a much more important symptom in the fifth 
nerve distribution than is usually understood. In a considerable 
number of his cases it has been found to be a first indication of 
reflex irritation from dental pulp disease, or tooth-crowns that have 
been inserted injudiciously or unskilfully without due regard for 
occlusion. For example, a young woman, aged about thirty years, 
a seamstress, was so troubled by numbness along the side of her 
tongue that it began to prey upon her mind until it became a 
very important irritating factor in connection with a condition of 
general nervous debility with symptoms of neurasthenia. Exami- 
nation disclosed a piece of bridge-work that had been inserted 
by a dentist some months before, upon which were bright worn 
spots upon the occlusal surfaces, such as in gold crowns, bridges, 
and fillings always indicate malocclusion and the results of tooth- 
grinding. The removal of this bridge-work and treatment of the 
pulp of a'molar tooth that had been crowned by one of the gold 
caps gave relief from the distressing symptoms, and this, supple- 
mented by tonics and good general care, brought about a restored 
condition of health with marked increase in weight. After a period 
of rest an attempt was made to restore the bridge-work in the 
belief that it might then be safely tolerated in the mouth, but a AFFECTIONS OF THE FIFTH NERVE 
267 
prompt recurrence of the numb sensation in the tongue made 
removal necessary. 
Anesthesia.-Paralysis of the sensory portion of the fifth or 
trigeminal nerve. 
Etiology.-It may be due to any pathological condition involving 
the Gasserian ganglion or one or more branches of the nerve, 
operations upon the Gasserian ganglion and resections and other 
operative procedures upon the nerve, traumatic injury to the 
nerve structures, laceration incident to the removal of impacted 
third molars or other teeth, resections of the jaws, removal of large 
sequestra of necrosed bone containing more or less important 
branches of the nerve and similar conditions. 
Symptoms.-The symptoms include numbness and anesthesia of 
the parts supplied by the nerve, including mucous membrane 
surfaces. This numbness is sometimes accompanied by a prickling 
sensation which is occasionally very distressing to the patient. Food 
collects between the teeth and cheeks. The facial muscles are 
affected in their normal activity through loss of muscle-sense by 
reason of the lack of normal sensory stimulation and the guidance 
which sensation gives. Occasionally this is so great as to simulate 
Bell's palsy. In the graver cases there may be increase or decrease 
in the flow of saliva, tears, nasal and oral mucus. These alterations 
sometimes lead to secondary ill effects, such as impairment or loss 
of sense of smell through change in the Schneiderian membrane. 
Ophthalmic changes may occur in a similar way. Among these 
symptoms a distressing feature is alteration of the sense of taste 
which is lost or at least seriously impaired over the anterior two- 
thirds of the tongue and to some extent at the posterior portion of 
the tongue. The glossopharyngeal nerve is credited with supplying 
gustatory sensation to the posterior portion of the tongue, and the 
chorda tympani to the anterior two-thirds, but the connection 
between the chorda tympani and the brain as to whether it passes 
by way of the trigeminus or by the facial or glossopharyngeal arch 
is still unsettled. Evidence favoring both theories has been pre- 
sented by many authors in observation of results of operations on the 
Gasserian ganglion, lesions involving the facial nerve, and the pars 
intermedia between the geniculate ganglion and the pons. Cushing 
has reported 13 cases of total extirpation of the ganglion with 
only 1 in which taste perception failed to be reestablished, and 
in this case the chorda tympani had been divided at a previous 
operation. Thus it would appear that the taste fibers do not pass 
exclusively by way of the trigeminal nerve to the brain. The 268 
NERVOUS SYSTEM AND THE BUCCAL REGION 
opposite view is, that the fibers of the chorda tympani pass through 
the geniculate ganglion by way of the pars intermedia to the brain 
in association with the facial nerve, but it is a notable fact that 
lesions of the facial nerve involving the pars intermedia do not 
usually affect the sense of taste. Therefore it seems fair to conclude 
that there are individual differences and that the taste fibers do not 
reach the brain in the same way in all persons. From a surgical 
point of view this is undoubtedly the safer ground to take. 
Pain.-Pain occurs in a great variety of forms and may be at 
the point of injury or include all of the distal portion of the affected 
division of the nerve. It may also be reflected to other divisions 
and manifest itself at some point quite distant from the actual 
lesion or source of irritation. 
Headache.-Pain in the head is caused by disturbance of nutri- 
tion of the brain, and may be a notable feature of syphilitic menin- 
gitis and other diseases of the brain structures and nerves, as well 
as of many other general conditions. The character, form, period 
of continuance, and treatment of such headache is necessarily 
governed by the disease of which it is a symptom. 
Symptoms.-It may be sudden sharp, and excruciating, and of 
short duration, or continue for hours, or may appear in many other 
forms. It is distinguished from the pain of neuralgia because it 
is not limited to a particular nerve trunk, and from migraine, as 
usually considered, because it is not unilateral and does not occur 
periodically. 
Migraine.-Migraine or periodical headache, according to Starr, 
Dunglison, and many others, is considered as identical with hemi- 
crania or periodical unilateral pain in the head. Jelliffe,1 however, 
describes it with certain reservations as follows: "Migraine may 
be defined as a periodical abnormal state in which the patient 
suffers from a peculiar oppressive pain in the head, unilateral or 
bilateral, localized or general, which develops very gradually 
from heaviness or dulness, to pain that is splitting." The tendency 
of the modern writers is to discard the unilateral feature and con- 
sider it as an affection which may be unilateral or bilateral. Usually 
with these attacks there are certain symptoms which have given 
rise to the use of the term "ophthalmic migraine," a form of nervous 
disturbance accompanied by headache and associated with dis- 
ordered vision. 
1 Osler: Modern Medicine, 2d ed., vol. v, 1915. AFFECTIONS OF THE FIFTH NERVE 
269 
Etiology.-Heredity bears an important relation to this affec- 
tion and is one of the most common predisposing influences, the 
family history showing other members to have been affected. 
It rarely affects infants, but sometimes begins at about seven to 
nine years of age, though it usually occurs at puberty. Faulty 
metabolism, whether due to some congenital defect in the chemistry 
of nutrition or to an acquired derangement of metabolic processes, 
is undoubtedly the principal cause, and, as might be expected, 
disturbance of digestion, autotoxemia, gout, arthritis, and similar 
factors with varying degrees of importance, as anemia, want of out- 
door exercise, sedentary habits, indoor, confining, nerve-exhausting, 
eye-straining, and otherwise trying occupations are contributing 
elements. 
Visual Defects.-Walton1 considers it to be an occupation neurosis, 
resulting in individuals of neurotic inheritance from overuse under 
the handicap of refractive error of the parts concerned in vision. 
Gradle2 does not agree with this. He holds that sometimes refrac- 
tive error is of vital importance in these cases and sometimes it is 
not, and gives the following results in treatment of 90 cases which 
are extremely instructive: 22 practically cured by glasses; 22 
benefited by glasses; 31 not benefited by glasses; 15 not requiring 
glasses (except simple convex spheres). 
There is quite commonly a premonitory sensation of scotomata, 
which has been likened to the aura of epilepsy, and for this reason 
migraine has been classed as of "epileptic character" by some 
authors, but this view in its full sense is not generally accepted, 
the chief argument being such large numbers of people are affected 
in whom there is no evidence of epileptic tendency. 
Symptoms.-The attack may be ushered in by certain premoni- 
tory symptoms, such as scotomata and other visual signs. There 
may be partial blindness, temporary aphasia, numbness, loss of 
memory, dulness of mental activity, a sense of chilliness, nausea, 
tinnitus aurium, modifications of taste, smell, or touch, and a 
peculiar oppressive pain in the head which may be localized or 
general, developing from dulness until it may become intensely 
severe. The frontal and temporal regions are most often involved, 
the occipital next, and the vertex seldom ever alone. During the 
attacks the patients are somnolent and sleep for hours and even 
days. Attacks may occur biweekly or within intervals of only 
a few days, monthly, as with many women, or at longer intervals. 
1 Jour. Am. Med. Assn., June, 1908, p. 202. 2 Ibid. 270 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Diagnosis.-The history of the case may usually be depended 
upon for differentiation from other forms of headache, the ophthal- 
mic and other sensory symptoms distinguish it from the different 
forms of trigeminal neuralgia. 
Prognosis.-The probability of complete relief is small; the 
frequency and severity of attacks may usually be benefited by 
change of habits of life and treatment. Usually the attacks subside 
at about the age of fifty, after the menopause in women, and some- 
times after ovariotomy. 
Treatment.-Regulation of diet is a matter of first importance. 
Good hygienic care, including exercise, baths, and proper massage, 
with lots of good air and outdoor exercise, are also helpful. There 
should be thorough cleansing of the bowels, and in anemic patients 
ovoferrin or some similar preparation to improve the red blood 
corpuscles* or tonics should be given. Washing the stomach with 
some alkaline solution is recommended to abort attacks. For the 
relief of pain, heat should be applied to the feet and ice-packs to 
the head; a soothing rubbing which will tend to carry the blood 
toward the extremities and the use of antipyretics are indicated. 
Morphin by hypodermic will of course give relief, but is to be 
avoided if possible because of the danger of acquiring the habit. 
For the relief of the symptom of tooth-grinding and the incidental 
irritation with consequent increase of pain, an appliance devised 
by the author, and called a " soft-rubber bit," has given much 
relief and assisted in overcoming the habit in many cases. This 
appliance is illustrated and described on pages 327 and 328. 
NEURALGIA. 
Trigeminal Neuralgia.-Neuralgia is a disease of a sensory nerve 
characterized by pain in the course of the nerve or in its peripheral 
distribution.1 
The trigeminal nerve is distributed over a wide area, and the 
bony canals through which its several branches pass expose it to 
injury not only in the terminal ends of the nerve itself, but there 
is also the likelihood of fracture, compression, or maldevelopment 
of surrounding bone structures. It is in close association with 
other cranial nerves through which it may become affected. The 
twenty-two teeth of the deciduous set, and the thirty-two of the 
permanent, which are supplied by its branches, all have pulps 
1 Starr: Nervous Diseases, Organic and Functional. NEURALGIA 
271 
and surrounding pericemental structures which are quite commonly 
diseased and therefore frequent sources of irritation. For these 
reasons this nerve, as might be expected, is the one most frequently 
affected by neuralgia. The affection occurs more often in women 
than in men. It may begin at almost any period of life, but is 
more frequent in its serious aspects in middle or later life. 
Classification.-The types of this affection classified in accordance 
with its clinical aspect are: 
Neuralgia Minor.-This, as its name implies, represents the 
less severe forms, and may usually be described with the name 
of the affected branches of the nerve. 
Visceral Referred Pain, Reflex, or Symptomatic Neuralgia.- 
The irritation, of which the reaction of the nerve system is an 
expression, may be referred from the teeth, the eye, ear, nose, 
tongue, and other organs associated in the fifth nerve distribution. 
Neuralgia Major; Tic Douloureux; Epileptiform Neuralgia.- 
This is the generic term for a very acute, exacerbating, or inter- 
mitting, throbbing pain, which follows the course of a nerve, 
extends to its ramifications, and seems, therefore, to be seated 
in the nerve. 
The terms symptomatic and idiopathic, as sometimes used in 
classification by grouping under the former term the two first types 
and the third under the latter, appear to be too indefinite and not 
quite in accordance with recent advances in the study of the 
pathology of tic douloureux. 
Etiology.-The factors which may be concerned in causing the 
various forms of trigeminal neuralgia are so numerous, their 
character is so widely different, and their importance in directing 
methods of treatment so great that division into groups according 
to pathological similarity is necessary. 
The following classification of causes is a modification of one 
first suggested by Wm. Rose and quoted by Murphy and Neff:1 
I. INTRACRANIAL. 
(a) Cerebral: 
1. Sclerosis. 
2. Aneurysms. 
3. Tumors involving some part of the extent of deep 
origin of the nerve. 
1 Jour. Am. Med. Assn., October 11, 1902, p. 897. 272 
NERVOUS SYSTEM AND THE BUCCAL REGION 
(6) Radical: 
Any inflammatory affection of the sheath of the root. 
(c) Ganglionic: 
Chronic interstitial inflammatory changes causing com- 
pression on the nerve cells. 
II. CRANIAL. 
1. All morbid processes at the base of the skull and in foramina. 
2. Callus following fractures. 
3. Syphilitic periostitis. 
4. Inconstancy of shape and size of foramina. 
III. EXTRACRANIAL OR PERIPHERAL. 
1. Dental caries; diseases of the dental pulps, pericemental, 
and dento-alveolar affections. 
2. Contraction of lumina or peripheral bony canals. 
3. Exposure to cold or damp, producing perineuritis; atmos- 
pheric conditions. 
4. Retention of secretion in frontal, maxillary, sphenoidal, or 
ethmoidal sinuses. 
5. Diseases of the eye, ear and nose; nerves cut in cicatrices, 
impacted foreign bodies, malposed unerupted teeth, spiculse 
of bone, etc. 
6. Traumatism. 
IV. TOXIC, REFLEX AND FUNCTIONAL CAUSES. 
Among these are included neurotic temperament, worry and 
anemia, malaria, digestive disturbances, sepsis, diabetes, la grippe, 
febrile diseases, rheumatism, gout, pregnancy, hysteria, alcoholism, 
uterine or ovarian affections, and the influence of any general 
disease that may predispose by causing a debilitated condition 
of the system, and also lead, mercury, arsenic, nicotin, and similar 
poisons. In the great majority of cases the disease process is ascend- 
ing, beginning in the peripheral nerve filaments and later progressing 
to and involving the ganglion. In a few cases, however, probably 
including those benefited by an extirpation of the ganglion, the 
lesion has been central, either in the area of distribution of the 
sensory .root or in. the sensory root itself. 
Heredity plays no part in 'the etiology, though in some cases 
neurotic history is obtained. NEURALGIA 
273 
The foregoing may be either predisposing or exciting causes, or 
both, but it seems best not to attempt any radical distinction 
of this character in classification such as is given by some authors, 
because our present knowledge of the varying degrees in which 
causal influences may be effective does not warrant a distinct 
line of demarcation. 
Fig. 115.-Pulp showing calcific degeneration removed from a molar tooth upon the 
affected side in a case of tic douloureux. 
Pathology.-The pathological alterations which might be accepted 
as being distinctively representative of neuralgia of the fifth nerve 
are indefinite. Certain changes in Gasserian ganglia which have 
been removed have been demonstrated by Cushing, Spiller, and 
others, but while it is recognized that trigeminal neuralgia may be 
due to central causes such as disease of the pons, hemorrhage, 
softening, multiple sclerosis, tumor, or abscess, through which the 
Gasserian ganglion or the fifth nerve may become involved, it is 
also caused by peripheral irritation, and in these cases pathological 
manifestations might be confined to affected branches of the nerve, 
and the Gasserian ganglion would probably not give any indication 
of pathological structural alteration. Certain changes, however, 
which take place in the pulps of otherwise normal teeth in these 
cases (Figs. 115 and 116) lend color to the belief that there is always 274 
NERVOUS SYSTEM AND THE BUCCAL REGION 
structural alteration in the nerve or its affected branches in greater 
or lesser degree, and that in the course of time, with progress of 
the disease, other more remote portions of the nerve undergo 
similar degenerative changes. Gordon1 believes that peripheral 
nerve degeneration is constantly present, and that this degenera- 
tion assumes the form of a neuritis which secondarily involves the 
Gasserian ganglion (Plate X). 
Changes in the bloodvessels, indicative of arteriosclerosis, are 
frequent associates of this affection in patients of advanced age. 
Symptoms.-The essential symptom of neuralgia is pain. Usually 
the pain is described as paroxysmal, but in minor neuralgia or 
visceral referred pain in the distribution of the trigeminus, painful 
symptoms may appear in many forms. It may be more or less 
continuous, appear and disappear quickly, or show a tendency 
to periodic manifestations, as at particular hours of the day, certain 
days of the month, or under special conditions of almost any kind; 
it may be excited by certain acts, the position of the body, as in 
lying down or standing, and by moments of excitement or atmos- 
pheric changes. Usually in minor neuralgia, especially at the 
DESCRIPTION OF PLATE X. 
Fig. 1.-Portion of the Gasserian ganglion at the entrance of the third branch 
of the trifacial nerve. The medullary sheaths are most irregularly swollen, and 
at the right of the field empty nerve sheaths are seen (method of Azoulay). 
Fig. 2.--Portion of the second branch of the trigeminal nerve near the Gas- 
serian ganglion. The axis-cylinders have entirely disappeared, and the medullary 
sheaths are greatly swollen. In many places the medullary substance of two 
or more nerve fibers has united into irregularly shaped masses (osmic acid stain). 
Fig. 3.-One of the nerve bundles within the Gasserian ganglion. Numerous 
swollen and irregularly formed axis-cylinders may be seen. In most portions 
of the field these appear as drops of a red, hyaline-like substance, but in one 
portion an axis-cylinder of considerable length may be seen. 
Fig. 4.-Bloodvessels from the Gasserian ganglion. The walls are greatly 
thickened, and the lumen of the large vessel has been almost entirely obliterated. 
In one place the innermost layers of the vessel have contracted from the outer 
during the process of hardening. Smaller vessels in the upper part of the field 
are entirely closed. 
Fig. 5.-A nerve bundle of the trigeminus close to the Gasserian ganglion. 
Only a few nerve fibers are present, and everywhere an abundance of connective 
tissue is seen. Three much swollen medullary sheaths are in the field. (After 
Starr.) 
i Practical Medicine Series, 1906, x. DESCRIPTION OF PLATE X. 
Fig. 1.-Portion of the Gasserian ganglion at the entrance of the third branch of 
the trifacial nerve. The medullary sheaths are most irregularly swollen, and at the 
right of the field empty nerve sheaths are seen (method of Azoulay). 
Fig. 2.-Portion of the second branch of the trigeminal nerve near the Gasserian 
ganglion. The axis cylinders have entirely disappeared, and the medullary sheaths are 
greatly swollen. In many places the medullary substance of two or more nerve fibers 
have united into irregularly shaped masses (osmic acid stain). 
Fig. 3.-One of the nerve bundles within the Gasserian ganglion. Numerous 
swollen and irregularly formed axis cylinders may be seen. In most portions of the 
field these appear as drops of a red, hyaline-like substance, but in one portion an axis 
cylinder of considerable length may be seen. 
Fig. 4.-Bloodvessels from the Gasserian ganglion. The walls are greatly thickened, 
and the lumen of the large vessel has been almost entirely obliterated. In one place 
the innermost layers of the vessel have contracted from the outer during the process 
of hardening. Smaller vessels in the upper part of the field are entirely closed. 
Fig. 5.-A nerve bundle of the trigeminus close to the Gasserian ganglion. Only a 
few nerve fibers are present, and everywhere an abundance of connective tissue is seen. 
Three much swollen medullary sheaths are in the field. (After Starr.) PLATE X 
FIG. I 
FIG. 2 
FIG 3 
FIG. 4 
FIG. 5 NEURALGIA 
275 
beginning, the pain is confined to the particular branch of the nerve 
that is most affected by the peripheral irritation, whatever it may 
be, and the neuralgia is described as supra-orbital, infra-orbital, 
temporal, frontal, occipital, etc. Visceral referred pain has a ten- 
dency to appear in distant and otherwise unaffected parts. Other 
reflexes may also be associated with the pain. There may or may 
not be hyperesthesia or superficial tenderness over circumscribed 
areas of skin or mucous membrane surfaces (Fig. 117). 
Fig. 116.-Pulp showing calcific degeneration removed from a tooth upon the affected 
side in a case of tic douloureux. 
Diagnosis and Treatment.-In the early stages of neuralgia it 
is sometimes difficult or impossible to distinguish between major 
and minor forms, and it is generally admitted that minor neuralgia 
of peripheral origin may progress until the central portions of the 
nerve are attacked. The diagnosis and treatment of all forms 
of trigeminal neuralgia therefore will be jointly considered. 276 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Tic Douloureux.-Symptoms.-In the violent paroxysms which 
are indicative of this form of neuralgia there is more or less involve- 
ment of all the functional elements of the trigeminal nerve. The 
symptoms that are expressive of all these effects naturally present 
Fig. 117.-The locations of referred pains and their cause. (Dana, after Starr.) 
Area. 
Cerebrospinal 
nerves. 
Distribution. 
Associated ganglia 
of sympathetic. 
Distribution. 
I. 
Trigeminus, facial 
Face and anterior 
scalp. 
4th cerebral. 
Head. 
II. 
Upper 4th cervical. 
Occiput, neck. 
1st cervical. 
Head, ear. 
III. 
Lower 4th cervical 
and 1st dorsal. 
Upper extremity. 
2d and 3d cervical, 
1st dorsal. 
Heart. 
IV. 
Upper 6th dorsal. 
Thorax. 
1st to 6th dorsal. 
Lungs. 
V. 
Lower 6th dorsal. 
Abdomen, upper 
lumbar. 
6th to 12th dorsal. 
Viscera of abdomen 
and testes. 
VI. 
12th dorsal and 4th 
lumbar. 
Lumbar region, 
upper gluteal, 
anterior, and 
inner thigh and 
knee. 
1st to 5th lumbar. 
Pelvic organs. 
VII. 
5 th lumbar and 5th 
sacral. 
Lower gluteal, pos- 
terior thigh and 
leg. 
1st to 5th sacral. 
Pelvic organs and 
legs. 
themselves in two chief divisions: (1) Sensory Manifestations. 
(2) Motor, Vasomotor, and Secretory Abnormalities. 
Sensory Symptoms.-Pain, the all-important symptom, may be 
accompanied by its antithesis, anesthesia, or any one of a consider- NEURALGIA 
277 
able variety of intermediate sensations, such as burning, prickling, 
itching, etc. 
In the paroxysmal form which is typical of tic douloureux pain 
may appear at the very beginning without previous warning or 
apparent cause, or it may begin with symptoms of minor neuralgia 
or visceral referred pain and gradually assume a paroxysmal 
character. The pain is unilateral, most frequently limited to the 
second and third divisions of the nerve, although it occasionally 
affects the first division and in advanced cases all the branches 
may be involved. It seems to occur more often on the right side 
than the left, and to affect women more frequently than men. 
The distinctive feature of pain in tic douloureux is the sudden 
onset of the paroxysms and more or less complete freedom from 
pain during the intervals between them. The intervening periods 
vary from a few seconds or usually a few minutes to hours, accord- 
ing to the progress of the disease and the condition of the patient. 
Both the intensity and length of duration of the painful attacks 
are also similarly governed. In the beginning there are often quite 
considerable periods during which no pain is felt, and at such times 
patients usually believe themselves to be improving, but almost 
always there is recurrence of the symptoms and usually with 
increased severity. This feature is sometimes deceptive in arriving 
at conclusions as to the result of treatment, and much error has 
undoubtedly arisen by reason thereof. The paroxysms may begin 
without apparent cause or be incited by very slight disturbance, 
such as draughts of cold air, slight motions of any kind, particu- 
larly in speaking, movement of the jaws, swallowing, laughing, or 
excitement of any kind. Sometimes the pain is confined to the 
daytime and the patient rests well at night; in other cases it con- 
tinues both night and day. Occasionally the pain is preceded by 
a peculiar sensation variously expressed, and by some authors 
termed an "aura." But this is not always present, and the use 
of the term as in epilepsy does not seem to be fully warranted 
or generally accepted. Usually pain comes with the quickness of 
an electric current when the wires are brought in contact. It 
varies in severity, and is described as a feeling of being cut by 
red-hot knives, and of pricking, tearing, lancinating, or boring. 
It is usually more intense at points of exit of the nerves, such as 
the supra-orbital, infra-orbital, or mental foramina. In rare cases 
it extends to the opposite side, and when this occurs it is assumed 
to be of central origin. The suffering of these patients is beyond 
the possibility of description. Strangely enough, many of them 278 
NERVOUS SYSTEM AND THE BUCCAL REGION 
retain reasonably good health in other respects, notwithstanding 
the continued pain, loss of rest, and other ill effects. In the course 
of time, however, through derangement of the nervous system, 
prevention of mastication of food by the pain thus excited, and 
Fig. 118.-Tic douloureux; paroxysm of 
pain. 
Fig. 119.-The same man as shown in 
Fig. 118 after operation. 
loss of teeth, there is loss of flesh and general breaking down which 
renders such individuals pitiful objects. 
Fig. 120.-Tic douloureux; effect of twenty-five years of suffering. 
Motor Symptoms.-The motor symptoms are evidenced by 
spasmodic contraction of the muscles of the jaw, face and head, 
or twitching of the facial muscles and those of the eyelids, also 
of the nose and angles of the mouth during the paroxysms of pain. NEURALGIA 
279 
There is often a drooping of the features upon the affected side 
which gives evidence of slight paralysis of the muscles (Figs. 118, 
119 and 120). 
Vasomotor Symptoms.-Vasomotor symptoms may appear as 
redness of the affected side of the face. Swelling, which much 
resembles angioneurotic edema, sometimes occurs during periods 
when paroxysms are frequent and does not disappear between 
the paroxysms, but remains for several days or longer and cannot 
be accounted for by any inflammatory condition. Distention of the 
veins, unilateral perspiration, changed appearance of the lips, and 
other similar effects are occasionally noticeable. The secretory 
aberrations are usually marked, tears flow from the eyes, and the 
secretion of saliva, as well as nasal mucus, is actively stimulated. 
The general picture is one of distress and pain. 
Diagnosis.-The diagnosis of tic douloureux is usually clear, 
inasmuch as it differs from headache and other forms of neuralgia 
by its paroxysms and the intervals of freedom from pain and from 
other spasmodic affections by pain. The determination of whether 
the seat of the neuralgia is central or peripheral is most important. 
To determine this any associated symptoms or pathological indi- 
cations which might lead to the recognition of brain affection 
or some general disease that might be accountable for central 
irritation should be carefully considered. Thorough search must 
be made to ascertain any peripheral cause that might exist. This 
includes careful examination of the eyes, ears, nose, and so far 
as possible the maxillary and other associated sinuses, as well as 
search for scars, results of traumatic injury, foreign bodies, and 
diseased conditions of the teeth. (The diagnosis of dental and 
oral forms of irritation are described on page 314.) 
Since the cause may be looked for higher up in proportion to 
the number of divisions and subdivisions of the nerve that are 
affected, it necessarily follows that each of the several branches 
should be examined for evidence of pathological alteration. 
In a general but somewhat practical way this may be tested by 
pressure at the points where the nerve passes through the fora- 
mina upon or near bone surfaces. For example: If pressure be 
made with a finger passed within the mouth along the inner sur- 
faces of the ramus of the lower jaw over the point of entrance 
into the inferior dental foramina, or over the mental, the infra- 
orbital, or supra-orbital foramina, pain is excited if the disease 
is confined to one of the branches, and it will usually react along 
the line of the particular branch that may thus be irritated. If, 280 
NERVOUS SYSTEM AND THE BUCAL REGION 
however, pain excited at any of these or similar points is felt in 
other branches or throughout the entire distribution of the nerve, 
it is an indication that the degenerative process has progressed 
until all of these divisions have become involved, and in all prob- 
ability this has occurred through involvement of the ganglion. 
Treatment of Various Forms of Neuralgia.-The treatment of 
trigeminal neuralgia resolves itself into non-surgical and surgical 
methods. If constitutional diseases are found to be the under- 
lying cause, these must receive proper attention. Every possible 
source of peripheral irritation must be removed, or the likelihood 
of its acting as an excitant guarded against. The eyes must be 
examined not only for visual defects, but for choked disk, partial 
or complete blindness, or other indication of brain affection, or 
any disease of the eye or its associated parts which might directly 
or indirectly be etiological factors. The nose and its secretions, 
membrane, septal, turbinal, or other deformities, should be examined 
and corrected if necessary. In like manner the ear and the frontal, 
ethmoidal, sphenoidal, and maxillary sinuses should be duly 
examined, and treatment applied if indicated. The mouth and teeth 
should be tested and treated as described on page 326. Habits of 
life must be duly considered and their correction directed. Ovarian, 
uterine, or other organic disease should be sought for and treated 
if necessary; the intestinal tract cleansed and duly regulated; 
digestive conditions safeguarded; and occupation, if disadvan- 
tageous, readjusted to give necessary relief. The general nervous 
condition must be patiently studied and insofar as possible con- 
trolled according to the best psychotherapeutic methods. The 
observance of thoroughly good hygienic rules must be insisted 
upon, including diet, abundance of fresh air, exercise, and massage. 
Massage.-Care should be taken in giving massage to these 
patients to see that it is properly .done. The usual rubbing given 
by nurses in hospitals cannot be depended upon, and occasionally 
does more harm than good in exciting the circulation disadvan- 
tageously. Such manipulations should be carried toward the 
extremities away from the head, and central regions, and be chiefly 
in the nature of a gentle stroking with sufficient muscular kneading 
to give continued effect and general stimulation, as well as rubbing 
along the spinal column. The personal effect of the one adminis- 
tering the massage in relation to the subject is important. The 
rubbing of one nurse or attendant may cause increased nervousness 
and wakefulness, with augmentation of the pain, while under the 
manipulation of another in almost precisely the same manner the NEURALGIA 
281 
same patient may feel rested, become relaxed and drowsy, with 
marked diminution, if not complete cessation, of the pain. 
Medicinal Treatment.-Examination of twenty-four hours' urine 
for these patients quite frequently shows more or less marked 
variation from normal quantity, and almost invariably a high 
degree of acidity with marked increase of indican. The latter is 
a product of indol, which is a result of intestinal fermentation, 
and this state is usually further evidenced by tendency to consti- 
pation and other disturbances of the digestive tract. It therefore 
follows that this region should receive attention. Drinking water 
freely or the use of diuretics may be demanded. Purgation with 
calomel sometimes gives a measure of relief in certain forms of 
attacks. 
Castor Oil.-The continued use of small doses of castor oil has 
been highly recommended as being more permanently beneficial. 
Its use is based upon the theory that such neuralgia is of toxic 
origin and that a prolonged evacuant treatment should benefit- 
two or three good-sized doses of castor oil every day for a period 
of two or three weeks. When the laxative effect has been thor- 
oughly produced it ceases to give distress and serves a very effec- 
tive purpose. This treatment was advocated by Strohmeyer in 1864. 
Gelsemium.-Fifteen drops of the green tincture given every 
few hours for a few days, or until the physiological limit is reached, 
which will be noted by the patient beginning to see everything in 
yellow colors, is one of the highly recommended remedies. 
Miscellaneous Drugs and Measures.-Hot foot baths and hot 
applications to the feet tend to draw blood from the head and to 
cause a general relaxation which is often very helpful. Applica- 
tions of heat or cold or liniments over the affected region have a 
grateful effect. Many of these patients are anemic, and for these 
ovoferrin for improvement of the hemoglobin or other tonics, and 
such general restoratives as quinin, cod-liver oil, or the phosphates 
are beneficial. Arsenic, potassium, iodide, and mercury have their 
proper places in the list of remedies, especially when syphilis is 
suspected as a causative influence. Electricity, chiefly employed in 
the form of electrolysis and a high-frequency current, has a measure 
of value, and has been highly recommended. Its possibilities, 
like those of the x-rays and radium, also well recommended, have 
yet to be definitely determined. Hypnotic drugs should only be 
given as a last resort, and then only with the greatest care of adminis- 
tration, because the tendency of all these patients is ultimately 
to seek relief of this character, and the danger of the drug habit is 282 
NERVOUS SYSTEM AND THE BUCCAL REGION 
always a menace. Bromides, chloral, opium in its various forms, 
especially codeine and morphin, and other similar remedies are all 
capable of giving temporary relief, but when once dependence has 
been placed upon them the demand becomes more constant and 
the required doses larger until, with almost unfailing certainty, 
disaster follows. 
Antipyrin, phenacetin, and salicylates have an undoubted place, 
especially with rheumatic persons. In a general way, however, 
it may be safely stated that when no relief can be given by measures 
which without harm in other respects tend to restore normal 
physiological function in deranged parts, upbuild general health 
and resistance or correct nervous states, or when no actual per- 
ipheral cause can be discovered through correction of which relief 
may be given, then, instead of relying upon drugs, the only rational 
treatment must be in the nature of injections into the nerve at 
accessible points in the course of the affected branches, or opera- 
tions upon the nerve or the Gasserian ganglion. 
The Injection of Osmic Acid Directly into the Nerve.-A 1.5 per 
cent, solution has been advocated by Bennet, Murphy, Hammer- 
schleig, and others with reports of cases benefited. Its effective- 
ness depends upon two factors-the destruction of nerve filaments 
and their substitution by connective tissue. 
Favorable results from the use of osmic acid in 9 patients are 
reported by R. Hammerschleig.1 A 1 per cent, aqueous solution 
was injected into the infra-orbital and mental foramina. In 8 of 
the patients the pain has not recurred for intervals varying from 
four months to as many years; in the last case there was great 
improvement. 
Murphy claims that the osmic acid gives a longer period of 
relief on the average than any method except removal of the 
ganglion or the metallic plugging of the foramina. He reports a 
number of his cases as well after the lapse of four years. 
As long as a feeling of numbness which gives a measure of dis- 
comfort is felt in the region supplied by the injected branch of the 
nerve in cases where the trouble is confined to the division so 
treated, there is relief from pain. When, however, the patients 
report that the face feels quite natural again, it usually follows that 
pain quickly returns. 
Injections of Alcohol.-Alcohol by deep injection into the nerve 
trunk was first performed by Schlosser, of Munich. The method 
'Arch. f. klin. Chir., 1906, Ixxix, 1050; Practical Medicine Series, 1907, x, 181. NEURALGIA 
283 
of performing has been improved by Otswald, Levi, Baudouin, 
and Patrick. From 70 per cent, to 90 per cent, alcohol is used 
with a little cocain or stovain to prevent pain or discomfort from 
the injection. Patrick's1 alcohol solution is as follows: 
1}-Cocain hydrochlorate gr. j 
Chloroform Tf[x 
Alcohol giiij 
Distilled water, sufficient to make gss-M. 
Of this he injects 2 c.c. For succeeding injections the propor- 
tion for alcohol is increased gradually up to 90 per cent., the amount 
of cocain being also increased. 
The instrument is a needle of large caliber, about 12 cm. long, 
marked off in centimeters up to 5, beginning at the point. This 
is fitted with a stylet of such length that when pushed home the 
end is flush with the point of the needle. For the injection a syringe 
holding 2 c.c. is employed, the nozzle of which will fit snugly into 
the end of the needle. 
For the inferior maxillary branch of the fifth nerve the needle 
is inserted at the lower border of the zygoma, 2.5 cm. in front of 
the anterior border of the external auditory meatus. The bony 
ridge of the temporal bone, as well as the descending root of the 
zygoma, can always be felt along the front border of the meatus. 
The stylet is partly withdrawn, the point of the needle pushed 
through the skin and subcutaneous tissue, and the stylet is then 
pushed home, so that for the remainder of the penetration the 
blunt end of the stylet serves instead of the sharp point of the 
needle. This is to prevent the possible transfixion of bloodvessels. 
The needle is then pushed inward in a plane at right angles to the 
side of the face and inclined a little backward to the depth of 4 cm. 
At that depth the point should reach the inferior branch of the 
fifth nerve as it emerges from the foramen ovale. The stylet is 
then withdrawn, the syringe fitted to the needle, and the injection 
slowly made. 
For the superior maxillary division of the fifth, the point of 
entrance is at the lower border of the zygoma, 0.5 cm. posterior 
to the point which would be reached by prolonging downward the 
line of the posterior border of the perpendicular process of the 
malar bone. From this point the needle is passed almost perpen- 
dicularly inward, being inclined forward and upward. At a depth 
1 Practical Medicine Series, 1907, x, 172. 284 
NERVOUS SYSTEM AND THE BUCCAL REGION 
of 5 cm. the point should reach the nerve at its emergence from the 
foramen rotundum into the sphenomaxillary fossa.1 
Fig. 121.-Illustration of the point of entrance and direction of the cannula and 
stylet for injection of the superior maxillary division of the fifth nerve at the foramen 
rotundum-is calculated from a point 1 cm. posterior to the external angular process 
in a direct line downward to a point just below the zygoma. The point is inclined 
forward and upward, and forced in to a depth of 5 cm. Care must be taken to have 
the patient look upward to avoid possible injury to the eye muscles. The author 
prefers to have the patient lie on the opposite side with the head supported on a 
pillow, to facilitate accuracy in the direction of the syringe point. 
The author modifies Patrick's procedure by injecting novocain 
with a small syringe at exactly the point, and in the direction to be 
Fig. 122.-Injection o£ the inferior maxillary division of the fifth nerve at the fora- 
men ovale 2.5 cm. in front of the external auditory meatus. The point is forced straight 
in to a depth of 4 cm. 
followed, by the large caliber needle and stylet. This is done by 
injecting a little novocain just under the skin, and from time to time, 
1 Practical Medicine Series, 1907, x, 169. NEURALGIA 
285 
as the point of the needle penetrates. By can-ying the needle in, 
almost but not quite, to the point to be reached by the alcohol 
injection, the insertion of the large syringe is rendered much less 
painful. Care must be taken, however, not to penetrate deeply 
enough to anesthetize the branch of the nerve to be injected. Even 
though the point of entrance, the direction, and the depth of the 
injection may be ever so carefully calculated, slight anatomical 
differences in individuals renders it necessary that the sharp pain 
must be felt when the syringe point reaches the foramen ovale or 
the foramen rotundum. The radiation of pain throughout the area 
of distribution of the injected nerve, gives certain indication that 
the objective point has been reached. (See Figs. 121 and 122.) 
Diseases of the sphenopalatine or nasal ganglion have been 
described by Dunn1 and Sluder.2 Sluder says that such attacks 
of pain resemble those of maxillary and vidian neuralgia excited 
from within the sphenoidal sinus. If due to an affection of Meckel's 
ganglion cocainization of this structure gives relief, which is not 
the case when it originates from the sphenoidal district. Applica- 
tions of 2 per cent, silver nitrate or 1 per cent, formaldehyde to the 
membrane of the sphenopalatine foramen often cure the mild and 
subacute cases, while in severe ones injections of alcohol are required. 
Offerhaus3 gives the following measurements of sixty skulls to 
perfect the landmarks for the location of the foramen rotundum 
and the foramen ovale, upon which he bases the rules for his 
improved method of locating foramina for deep indications of the 
trifacial nerve: 
"(1) The distance between the foramina ovale (D. F. 0. on 
Fig. 123) equals that between the alveolar processes of the upper 
jaw, measured in the mouth between their outer borders behind 
the last molars at the tuberosities (pyramidal processes) of the 
palate bone (2). A. E., Fig. 123). (2) On making frontal sections 
through the skull just in front of the tuberosities (tuber maxillare), 
the foramina ovale are seen either in the section or, more fre- 
quently, 1 to 6 mm. posteriorly, and 3 or 4 mm. above a line (linea 
intertubercularis, L. T., Fig. 123) uniting the inferior borders of 
these tuberosities. (3) The distance between the foramina rotunda 
equals the distance between the alveolar processes of the upper 
jaw, measured internally, behind or at the last molar (J). A. I., 
Fig. 123). (4) The foramina rotunda lead to the upper and posterior 
1 Glasgow Med. Jour., August, 1915, p. 98. 
2 Lancet-Clinic, April 24, 1915. 
3 Practical Medicine Series, 1910, x, 149; after Arch. f. klin. Chir., 1910, xcii, 47. 286 
NERVOUS SYSTEM AND THE BUCCAL REGION 
part of the sphenopalatine fossa, while the sphenopalatine foramina 
are on the mesial side. A line (linea interzygomatica, L. Z., Fig. 123) 
uniting the latter crosses the upper border of the zygoma at its 
middle or at the junction of its temporal and malar portions. The 
foramina rotunda lie 2 to 4 mm. above and slightly behind this 
line. (5) The distances from the foramen ovale to the outer border 
of the tuberosity (tuberculum articulare) (D. 0. T., Fig. 123), and 
from the foramen rotundum to the outer border of the zygoma, 
are equal on the right and left sides except in the few very asym- 
metrical skulls. 
Fig. 123.-To show measurements to be taken for locating foramen ovale and foramen 
rotundum. Explanation in text. (Offerhaus.) 
" In vivo, in order to determine the depth of the foramen ovale 
it suffices to measure the distantia interalveolaris externa (D. A. E.) 
and the distantia intertubercularis (L. T.}. If the former, for 
example, is 5 cm. and the latter 14 cm., then the foramen ovale is 
at a depth of 142~5 = 4.5 cm. The same is true of the second 
branch of the trigeminus and the foramen rotundum, mutatis 
mutandis. In the living, however, it is not easy to determine the 
exact direction of the linea intertubercularis and interzygomatica, NEURALGIA 
287 
so I have constructed a caliper with movable rod at the ends (Fig. 
124). The caliper is placed on the tubercula articularia, which are 
readily felt through the skin, and the distance measured; then the 
caliper is removed, placed at the same width, the rods are placed 
in line, and the instrument put back on the tubercula, when the 
rods indicate the proper direction in which to introduce the needle 
(Fig. 125)." 
Fig. 124.-Instrument used for determining direction of needle. (Offerhaus.) 
The author also gives rules for directing a curved needle from 
the mouth through the foramen ovale in such a way that the 
Gasserian ganglion itself may be injected (Fig. 126). 
The Hartel method of injecting the Gasserian ganglion is the one 
now more generally adopted. The left index finger is placed 
between the jaw and cheek with the patient's mouth closed. The 
space between the coronoid process of the mandible and the maxil- 
lary tubercle is located. The cannula is introduced into the cheek 
at a point opposite the second molar. With the finger inside the 
mouth as a guide, the cannula is forced subcutaneously between 288 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Fig. 125.-Instrument in situ preparatory to injection of inferior maxillary nerve at 
foramen ovale. (Offerhaus.) 
Fig. 126.-Method of reaching Gasserian ganglion through foramen ovale. 
(Offerhaus.) NEURALGIA 
289 
the mandible and the maxillary tubercle, directly upward until 
the hard smooth surface of the sphenoid bone is felt. Hartel calls 
particular attention to the necessity for proper alignment of the 
cannula at this point in the procedure, so that a line drawn vertically 
upward from the point of entrance of the needle into the skin will 
bisect the pupil of the eye when looked at from the front, but if 
looked at from the side it will bisect the articular eminence of the 
zygoma (see Fig. 127). The cannula is now pushed backward and 
slightly upward until the guard on the cannula which has been fixed 
at 6 cm. indicates that this depth has been reached. Slight move- 
Fig. 127.-Illustration of the point of entrance through the cheek and the direc- 
tion of the cannula for alcoholic injection of the Gasserian ganglion. Hartel's line 
to bisect the pupil of the eye when looked at from the front is marked as recom- 
mended by Dorrance. 
ment of the point of the cannula over the smooth surface of the 
bone gives indication, when the resistance is no longer felt, that the 
point has penetrated into the skull through the foramen ovale. 
Approximately 2 c.c. of 80 per cent, alcohol is injected into the 
ganglion, a few drops at a time. Dorrance advocates moving the 
point of the syringe from side to side in order to come in contact 
with as much of the ganglion as possible. 
The after treatment consists in covering the point of the puncture 
of the skin surface with collodion dressing. The eyes need protec- 
tion and care following the alcohol injection of the Gasserian gan- 
glion, the same as after the ganglion operation. They shotdd be 290 
NERVOUS SYSTEM AND THE BUCCAL REGION 
flushed with boric acid solution and protected with watch-glass 
crystals, suitably arranged with cotton or felt rings. Close obser- 
vation and care of the eyes should be given for eight to ten days 
after the injection. The chief danger appears to be loss of vision 
of the eye on the affected side. 
But there is also danger of a puncture of the internal maxillary 
artery, of injection into the Eustachian tube, of coming in contact 
with a rough bone surface and therefore being below the foramen. 
Complications of the oculomotor nerve, facial nerve, and the soft 
palate, herpes facialis, keratitis, corneal ulcer, and paralysis of the 
sixth nerve have been reported by Hartel and others. 
A few deaths from ulcer have been reported and in most of these 
cases there appears to have been some other complication. There 
seems to be freedom from these objections with improved technic, 
and it is not unlikely that this may, in the course of time, entirely sup- 
plant more serious operative features for the relief of tic douloureux.1 
The reports of the result of this treatment vary considerably, 
and but few authors claim that trigeminal neuralgia can be per- 
manently cured in this way. All, however, are agreed that a 
measure of relief can be given, which may last from a few days 
to months or even a year or more. Schlosser reports 123 cases with 
cessation of pain during the average period of ten and two-tenths 
months. Brissoud,2 Cicard, and Tanon report 18 cases, with an 
average relief from three to five months. Patrick urges in its 
favor that the operation is practically devoid of danger, requires 
no anesthetic, that relief can be given in many cases for a year or 
more, with but little inconvenience to the patient. 
The author's experience, based upon the observation of many 
patients who have come under his care after having previously had 
alcohol and osmic acid injections, according to the old methods of 
peripheral treatment are not favorable. In almost all of these cases 
the period of relief was hardly sufficient to compensate for the 
discomfort following the injection, and in some of them even 
repeated injections had failed to give the desired relief. More 
modern technic in the deep alcoholic injections of the superior 
maxillary division at the foramen rotundum, and the inferior 
maxillary division at the foramen ovale, have been so satisfactory 
in their results as to make many of the peripheral operations, which 
the author performed frequently in the past, quite unnecessary. 
1 Dorrance, Geo., Phila.: "Injection Gasserian Ganglion," Dental Cosmos, Janu- 
ary, 1916; Byrnes, C. M., "Alcohol Injection Gasserian Ganglion," Johns Hopkins 
Hospital Bulletin, January, 1915. 
2 Revue Neurolog., March 30, 1907. SURGICAL METHODS OF TREATMENT IN NEURALGIA 
291 
There is a considerable difference in individual cases in the results 
of these injections. Occasionally the severe immediate pain is 
quickly followed by numbness along the line of the distribution of 
the nerve, and relief from pain. Sometimes this disappears quickly, 
sensation, and ultimately pain returning. In other cases there seems 
to be a hard battle between the nerve tissues and the alcohol, and 
more or less pain continues for some time, after which there may 
be a long period of relief. Occasionally it is necessary to make a 
reinjection in a short time, and even then the desired relief may 
come very slowly. But the difficulties of injection are so slight 
when compared with any kind of operation, and the suffering of 
these patients is so great, that this feature of the treatment is com- 
paratively inconsiderable when the more or less continuous torture 
is considered. The necessity for repeating the injection is after 
all not a serious matter. The continued injection of alcohol in the 
close vicinity, or in actual contact with the nerve must almost 
surely cause degenerative changes which will give ultimate relief 
of sufficiently enduring character. 
SURGICAL METHODS OF TREATMENT IN NEURALGIA. 
Neurotomy.--Simple division of the nerve was suggested by 
Albinus and Galen and first performed by Schlichting in 1748. 
It is of little value because of rapid regeneration. 
Neurectomy.-Excision of a section of a nerve was first per- 
formed in 1793 by Abernethy. The piece removed should not be 
shorter than 1 cm., but even with this method regeneration is not 
entirely prevented. 
Nerve Extraction.-According to the method of Thiersch exten- 
sive extirpation of nerves is done by grasping the ends of the nerve 
with a forceps which is slowly turned a half-turn every second or 
slower, until as much as possible of the nerve has been removed 
(Fig. 128). 
Nerve Stretching.-This operation was first performed on the 
trigeminus by Vogt in 1876 but it is not permanently effective. 
Other Methods.-Thiersch recommended the removal of painful 
scars with neurotomy or in combination with other operations. 
Crushing and cauterizing the central end of the divided nerve was 
done by Klein in 1822, and the peripheral end by Boyer. Galvano- 
cautery has been used to divide the nerve. Splitting one or both 
ends and turning them back into a loop was suggested by Malgaigne. 292 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Plugging of the foramina to prevent regeneration of the nerve has 
also been employed. 
Fig. 128.-Inframaxillary nerve extracted, according to Thiersch, from a man 
aged forty-three years. Ch. t., chorda tympani; I., lingual nerve; a. i., inferior dental 
nerve. Five-sixths natural size. (After Bull-Von Bergmann.) 
Operations for Exposure of the First Trigeminal Branch (Ophthalmic 
Nerve).-The eyebrows are shaved, the skin surface is properly 
prepared, and an incision following the outline of the eyebrow 
is made of sufficient length to give freedom in exposure of the SURGICAL METHODS OF TREATMENT IN NEURALGIA 
293 
nerve. The tissues are divided down to the supra-orbital notch 
through which the nerve passes. The nerve is grasped with a 
forceps, separated from the surrounding orbital fat, which may be 
facilitated by care to avoid laceration in separating the perios- 
teum. The nerve is then drawn out until the supratrochlear nerve 
is brought into view. The nerve is divided behind this branch and 
a sufficient amount of the peripheral portion of the nerve is 
removed. It is possible to reach the lacrimal nerve where it 
leaves the ophthalmic far back in the cavity of the orbit, and the 
ethmoid nerve at its point of entrance into the anterior ethmoidal 
foramen at the inner and upper aspect of the orbit. The com- 
Fig. 129.-Exposure of the supra-orbital and supratrochlear -nerve at the right eye. 
Incision to expose the infra-orbital nerve at the left eye. Two-thirds natural size. 
parative unimportance of these branches, however, when weighed 
against the possibility of serious affections of the eye following 
disturbance of the contents of the orbit makes it doubtful whether 
search for these smaller, more deeply seated branches is warranted 
except under rare conditions. Krause states that he has seen very 
severe iritis develop after extraction of the supra-orbital nerve 
which left behind a spot on the cornea (Fig. 129). 
Operation upon the Second or Infra-orbital Division of the Fifth 
(Figs. 130 and 131).-The approach of the infra-orbital foramen 
through which this nerve passes may be accomplished in two ways. 
The one is through an external incision begun about 0.5 cm. beneath 
the mesial end of the infra-orbital margin and extended obliquely 294 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Fig. 130.-Various incisions for reaching different branches of the trifacial nerve: 
a, supra-orbital; b, external nasal; c, Bruns' incision; d, inf. dent, at mental foramen; 
e, internal nasal; f, infra-orbital; g, Carnochan's incision. (Marion.) 
Fig. 131.-Exposure of the supra-orbital and infra-orbital branches of the fifth nerve. SURGICAL METHODS OF TREATMENT IN NEURALGIA 
295 
downward and outward to the lower border of the malar bone. 
Sometimes a circular incision following the outline of the orbit is 
used, and for more extensive dissections a T-shaped incision is used, 
the perpendicular portion extending from the infra-orbital to a point 
near the angle of the mouth. On account of the unsightly scar the 
larger incisions are to be avoided if possible. When the nerve is 
exposed at the infra-orbital foramen it may be raised with a hook 
or grasped in a forceps, a portion is resected, and the infra-orbital 
canal is plugged with a screw, as recommended by Mayo, or else 
by a metal plug such as the silver buttons used by Mosch cowitz1 
and illustrated in Fig. 132, or a plug of metal, wax, or other 
non-irritating substance. Otherwise the more 
extensive operations as described by Krause2 
may be performed. 
"The length of the incision is 4 cm. At first 
the incision is carried only through skin and 
fasciae down to the levator labii superioris 
(musculus quadratus labii superioris), care 
being taken to avoid the branches of the 
facial nerve. The fibers of the muscle run 
downward and across the incision. The upper 
branches of the infra-orbital nerve (palpebral 
and nasal) appear in the incision, since they 
run upward to the upper edge of the wound. 
They are to be spared. Search is then made 
for the infra-orbital foramen; it lies in the 
uppermost part of the canine fossa, as a rule 
1 cm. beneath the bony infra-orbital margin 
and generally somewhat on the inner side 
of its center. Over it the origin of the 
levator labii superioris and the periosteum 
are divided down to the bone transversely, and the peri- 
osteum then reflected downward with a raspatory until the infra- 
orbital plexus is completely exposed. The latter is dissected free 
from the infra-orbital artery, freed bluntly for a distance from 
the surrounding fatty tissue, and grasped with a clamp. Now the 
periosteum of the orbital margin and of the floor of the orbit is 
reflected as far as possible into the latter. If the entire contents 
of the orbit are carefully raised with a broad hook the nerve can 
Fig. 132. - Silver 
buttons used by 
Moschcowitz to plug 
the infra-orbital fora- 
men in treatment of 
trigeminal neuralgia. 
1 Alexis von Moschcowitz: Med. Record, September 29, 1906; Practical Medicine 
Series, 1907. 
2 Bull and von Bergmann: System of Practical Surgery, vol. i, p. 574. 296 
NERVOUS SYSTEM AND THE BUCCAL REGION 
almost always be seen shining through the thin upper wall of the 
canal as a white streak as soon as the hemorrhage, which is always 
slight, has ceased. Farther backward it is often seen lying free in 
the sulcus. The canal runs a rather straight course from behind 
forward; its bony walls are thin, except in its most anterior portion, 
where for the distance of about 0.5 cm. the upper wall is formed by 
the broad infra-orbital margin. Here a wedge-shaped piece of bone 
is removed with a small chisel; farther backward the protecting 
layer of bone can generally be broken off with anatomical forceps. 
In this way all the structures filling the infra-orbital canal are laid 
bare up to the sphenomaxillary fissures, and are then bluntly lifted 
out of the bony furrow. They consist of the infra-orbital nerve, 
artery, and veins; the artery accompanying the nerve lies on its 
inner and under side." 
The author believes that external openings for operation upon 
this branch of the nerve are unnecessary and to be avoided because 
of the unsightly scars. The class of cases in which peripheral 
operation upon this division of the nerve is successful is usually 
quite as much benefited without the danger and difficulty of follow- 
ing the nerve into the deeper portions of the bone, because cases 
of central origin or those in which the disease has progressed beyond 
the limits of more external peripheral limitations are usually such 
as require operations upon the ganglion, or at least* extracranial 
operations at the base of the skull or deep injections. While it is 
admitted that this might not always be true, the objection to dis- 
turbances of the orbital contents is one that on general principles 
should require careful consideration and absolute certainty of its 
necessity before being undertaken. 
Buccal Incision for Exposure of the Nerve at the Infra-orbital Foramen. 
-External scar and consequent disfigurement may be avoided 
by an incision through the mucous membrane and periosteum 
carried down to the bone in the region of the canine fossa, the peri- 
osteal and overlying tissues being separated from the bone with 
a periosteotome. The bone surface is followed up to the infra- 
orbital foramen, which should be found in direct line above the 
interproximate space of the bicuspid teeth. Variations through 
irregularities of the teeth or upper jaw, however, render such guiding 
lines uncertain. In the author's experience it has been found safer 
and more satisfactory after having separated a sufficient periosteal 
surface to insert the first finger and to continue the periosteal separa- 
tion by pressure in this way. The same finger of the other hand 
serves as guide, and is placed over the foramen, which can usually SURGICAL METHODS OF TREATMENT IN NEURALGIA 
297 
be felt from the external surface until the nerves and vessels as they 
pass through the foramen can be followed with the tip of the finger 
inserted into the wound from within the mouth. With the finger 
in this position, as shown in Fig. 133, a hook can then be inserted 
and guided into place, the nerves and vessels caught and sufficiently 
withdrawn to make it possible to grasp them more firmly in a forceps. 
By making tension, a sufficient portion of the nerve can readily 
be resected at this point. Instead of resorting to the use of screws 
or metal plugs a very simple and satisfactory procedure is the 
author's modification of this operation as usually performed. It 
Fig. 133.-Resection of the second division of the fifth nerve at the infra-orbital 
foramen through an intrabuccal incision. 
has proved to be exceedingly satisfactory to obliterate the canal by 
enlarging the external opening with a bur in a dental engine, 
following the nerve as far in its bony canal as may be safely done 
without risking injury to the contents of the orbit, and by freshen- 
ing bony surfaces with the bur, to insure new bone growth, which 
will completely fill and block the external opening, thus preventing 
the likelihood of nerve regeneration. When it is found necessary 
to follow the nerve back to the sphenomaxillary fossa, in cases 
where the internal opening is made, this is best done by opening 
into the maxillary sinus. Objection to this is made by some authors 
on the ground that there is more likely to be infection when the 298 
NERVOUS SYSTEM AND THE BUCCAL REGION 
maxillary sinus is opened. Therefore the external opening is to be 
preferred. This, according to the author's experience, is an erro- 
neous view, because in large numbers of patients suffering from tic 
douloureux he has found that the maxillary antra were enlarged 
and either diseased or a continued menace in offering the likelihood 
of irritation in that region. Therefore entirely outside of the ques- 
tion of neurectomy it is frequently a safeguard to have the maxillary 
sinus properly opened and its condition definitely ascertained. 
Whenever there is the slightest suspicion of maxillary sinus trouble 
he believes that the proper method is to open through the external 
wall of the sinus, selecting a point in the region of the canine fossa 
at which the wall may be found to be most yielding, and extending 
this opening until the entire external wall of the maxillary antrum 
has been removed. In enlarged sinuses, such as those usually 
found in these cases, an opening of this kind will, in most cases, 
be large enough to admit the insertion of a finger, and when hemor- 
rhage has been checked permit a good view of the floor of the orbit. 
The distance from the upper border of the external opening to the 
foramen is usually very slight, and therefore exposure of the nerves 
at this point is easily accomplished. Frequently the nerve is found 
to be almost completely exposed when the mucoperiosteal lining of 
the antrum has been removed. These are the cases in which the 
portion of the nerve posterior to the infra-orbital canal is likely to 
suffer continued irritation after resection at the infra-orbital foramen. 
They are also the ones in which the nerve may be most easily fol- 
lowed back in the direction of the sphenomaxillary fossa. To those 
who are accustomed to treat the maxillary sinus by radical opera- 
tion, this procedure will not be a matter of serious consideration. 
The danger of infection with proper care is not significant. The ulti- 
mate closure of the opening without external deformity is assured, 
and the danger of future disease and irritation reduced to the 
minimum. Results in the author's cases have been exceedingly 
satisfactory. 
Carnochan reaches the nerve at the foramen rotundum through 
the maxillary sinus by a large external incision which joins the 
incision made near the lower orbital border at the infra-orbital 
margin, and is extended down the cheek close to the nose. A 
flap is reflected downward and upward and the maxillary sinus 
opened just below the infra-orbital foramen. He follows the 
nerve back, trephines the posterior antral wall to expose the spheno- 
maxillary fossa, and through this continues backward to the foramen 
rotundum, where the nerve is twisted and cut with curved scissors. SURGICAL METHODS OF TREATMENT IN NEURALGIA 
299 
This appears to be unnecessarily severe in view of the fact that 
removal of the Gasserian ganglion may after all be necessary and 
no kind of peripheral operation sufficient. 
Third or Inferior Maxillary Division of the Fifth Nerve.-The 
mental branch can be readily exposed at the mental foramen, 
the foramen enlarged with a surgical or dental engine bur, and 
the inferior dental canal exposed as much as may be necessary 
Fig. 134.-Third or inferior maxillary division of the fifth nerve exposed at the mental 
foramen and the inferior dental canal opened for resection. 
to give opportunity for resection of a sufficiently large portion 
of the nerve. Cryer has called attention to the fact that the direc- 
tion of the nerve at its exit through the mental foramen is slightly 
backward, so that it is usually impossible to enter the inferior 
dental canal with a .probe passed through the mental foramen 
in a backward direction. It is therefore necessary to enlarge the 
foramen and extend the opening backward along the line of the 
canal until a sufficiently clear entrance has been effected. The 300 
NERVOUS SYSTEM AND THE BUCCAL REGION 
nerve may be grasped, drawn forward, and a section evulsed 
according to the Thiersch method, or a long flexible dental engine 
drill, especially made for the purpose, can be passed into the canal, 
and its nerve and vessel contents cut out for a considerable distance. 
Sometimes this can be done almost completely to the angle of the 
jaw (Fig. 134). 
The author formerly used to fill the inferior dental canal after 
the removal of the nerve with a gutta-percha point which had 
been softened in a solution of gutta-percha and chloroform, and 
was forced into the canal after controlling hemorrhage and flood- 
ing the canal with oil of eucalyptus. Such a gutta-percha plug 
was found to offer no resistance to healing processes which took 
place upon the mucous membrane surface quite promptly, and 
covered the gutta-percha at the foramen completely. But in the 
course of time the gutta-percha was eventually thrown out. During 
recent years he has adopted a modification of Garretson's operation, 
and instead of endeavoring to remove a section of the nerve through 
an enlarged opening at the mental foramen and filling as described, 
he has carried the bur back from one to two inches and removed 
the external wall of the canal. This portion of the nerve is of course 
entirely destroyed and the inferior dental canal practically elimi- 
nated as the result of a complete obstruction of the canal by new 
growth of bone and connective tissue. If the source of irritation 
happens to be in the anterior portion of the lower jaw this operation 
will be effective. But if situated farther back the result will natu- 
rally be unsatisfactory. In some cases it is therefore necessary to 
reach this division of the nerve at its more central portion. 
The nerve may be reached by perforating the jaw at any point 
along the line of the inferior dental canal. Cryer has suggested 
entrance through the ramus of the jaw by deepening the sigmoid 
notch until the nerve is reached at its entrance to the mandibular 
foramen. To accomplish this and to avoid scarring, the incision 
is carried down along the posterior border of the jaw, the peri- 
osteum separated from the bone with the overlying muscular 
attachment of the masseter, and retracted until the external 
surface of the ramus is exposed. The nerve may be divided by 
an incision within the mouth, carried through down to the inferior 
side of the anterior border of the ramus, separating the pterygoid 
muscles and periosteum, which are forced away with the perios- 
teotome and finger until the mandibular foramen can be felt. The 
difficulty, however, in attempting this operation is that it does 
not give the best opportunity for resection of a sufficient portion SURGICAL METHODS OF TREATMENT IN NEURALGIA 
301 
of the nerve. In the recent case of a patient in whom the vessels 
of the mandibular foramen were severed, severe hemorrhage fol- 
lowed, with tendency to recur whenever the packing was removed. 
This has convinced the author that whenever an operation is 
performed which is likely to involve the inferior maxillary artery 
accidentally or otherwise, the method of approach should be such 
as to offer opportunity for direct control of the vessel. A number 
of authors advocate trephining the jaw at a point midway between 
the anterior and posterior border of the ramus just above the angle 
of the jaw. To do this an incision is made, as recommended by 
Krause, directly through the skin, masseteric fascia, masseter 
Fig. 135.-Relation of the inferior dental artery to the inferior dental nerve in the 
canal in the lower jaw, chiselled open for operation. Three-quarters natural size. 
muscle, and periosteum to the bone. The incision may also be 
carried around the lower border of the jaw, around the angle of the 
jaw, dividing the skin and superficial fascia, isolating the two upper 
branches of the facial nerve and Stenson's duct. After retraction, 
the incision is carried through the masseter muscle down to the 
ascending ramus of the jaw which is trephined just above the angle. 
The nerve is grasped with forceps and followed upward for an inch 
and divided. By either incision the facial nerve has to be avoided 
and scarring upon the external surface of the cheek prevented. 
The lingual nerve may be found directly under the mucous mem- 
brane of the tongue in the region of the three last molar teeth, 302 
NERVOUS SYSTEM AND THE BUCCAL REGION 
just after it has entered the base of the tongue between the ramus 
of the lower jaw and the palatoglossal arch. The mouth is opened 
with a suitable gag, the tongue pulled to the healthy side and upward, 
the mucous membrane divided at a point just anterior to the lower 
molar tooth, and the incision carried from before backward with 
care to avoid the tongue. With the nerve thus exposed a portion 
can be extracted and the wound sutured (Fig. 135). 
Fig. 136.-Exposure of the second and third branch of the trigeminal nerve close 
to the foramen rotundum and foramen ovale (Kronlein's temporal method): 1, 
turned-up skin flap; 2, turned-down flap of zygoma and masseter; 3, anterior sawed 
surface of the zygoma; 4, posterior sawed surface of the zygoma; 5, turned-up flap 
of coronoid process and temporal muscles; 6, cut surface of the coronoid process; 
7, infratemporal crest; 8, external pterygoid muscles; 9, pterygoid process; 10, maxil- 
lary tuberosity; 11, sawed surface upon the upper jaw; 12, sawed surface upon the 
zygomatic process of the temporal bone; 13, spinous tubercle; 11/, superior maxillary 
nerve; 15, palatine nerve; 16, inferior maxillary nerve at the foramen ovale. 
Extracranial Operations at the Base of the Skull.-The number 
of these operations represent almost unlimited modifications of 
Lucke's original method, which included osteoplastic resection of 
the malar bone and an opening through the sphenomaxillary 
fossa to the foramen rotundum. Entrance through the antrum 
of Highmore has already been described. The incision through the 
cheek from a point close to the angle of the mouth to the lobule 
of the ear is carried down to the buccinator muscle, but cautiously 
so as not to divide the mucous membrane of the mouth, the fibers SURGICAL METHODS OF TREATMENT IN NEURALGIA 
303 
of the facial nerve, the parotid gland, and Stenson's duct are avoided, 
the intervening bone and muscle structures are removed, and the 
lingual and inferior dental branches located and traced back to the 
foramen ovale. Mikulicz makes an incision from the mastoid 
process at the anterior edge of the sternomastoid down to the hyoid 
bone and upward and forward in a curve to the margin of the lower 
jaw at the anterior border of the masseter muscle. At this point 
the incision is carried down to the bone of the lower jaw, which is 
divided behind the third molar tooth, the ramus is turned upward 
and the body of the jaw pulled forward, and the divided dental 
and lingual nerves are found located upon the internal pterygoid 
muscle which has been separated from its attachment. Of all the 
operations suggested, the most important seems to be Kronlein's 
temporal method for exposure of the second and third branches 
of the trigeminal nerve close to the foramen rotundum and foramen 
ovale (Fig. 136). 
Removal of Gasserian Ganglion.-Operation for the removal of 
the Gasserian ganglion should be resorted to under the following 
conditions: 
1. When all efforts to check the pain by medical treatment and 
the correction of sources of peripheral irritation have failed. 
2. When peripheral operations have been unsuccessfully tried 
for the relief of pain, apparently confined to individual branches. 
3. When all the branches of the nerve are involved. 
4. In almost every case it should supplant operations for divi- 
sion at the base of the skull. When the gravity of operations like 
those described for reaching the foramen ovale and the foramen 
rotundum is considered, the greater certainty of success and the 
increasing freedom from danger and ill effect that improved technic 
has brought about in removal of the ganglion should unquestion- 
ably make this the operation of choice. 
In 1884 J. Ewing Mears, of Philadelphia, first recommended 
the removal of the Gasserian ganglion for relief of major neuralgia. 
Professor Rose, of King's College, London, first performed the 
operation in 1890. His method of approach was by trephining 
the base of the skull beneath the ganglion and removing it with 
a curette. Dr. Edmund Andrews, of Chicago, was the first to 
perform this operation in America. Cushing1 has perfected what 
he calls the transzygomatic route, and has published the sketch 
shown in Fig. 137, which at once illustrates and describes the 
1 Jour. Am. Med. Assn., April 28, 1900. 304 
NERVOUS SYSTEM AND THE BUCCAL REGION 
methods of approach. Many modifications of the older methods 
have been suggested by Keen, Frazier, Spiller, Doyen, Poirier, 
Coelho, and other surgeons. Since the operations most often per- 
formed by American surgeons, and therefore the ones upon which 
most of our evidence of success depends, are the Hartley-Krause 
and the Cushing, it seems necessary to describe only these two. 
Fig. 137.-Cushing's illustration of transzygomatic route in removal of the Gas- 
serian ganglion. Sketch from a coronal section of the head, schematizing the three 
chief methods of approach: Oblique methods: (1) The high temporal root (Horsley 
and Hartley-Krause); (2) the low or pterygomaxillary (Rose, Andrews, etc.). Hori- 
zontal direct method transzygomatic (Lexer, Cushing, etc.). The Doyen method 
demands the space included by all three. (Jour. Am. Med. Assn., April 28, 1900.) 
Victor Horsley1 resected the second and third division with 
a high temporal opening in 1900. The operation known as the 
Hartley-Krause operation was devised by Krause, and first per- 
formed by Horsley August 8, 1891, and by Krause February 23, 
1892. In neither of these operations was the ganglion removed. 
Only the second and third divisions were divided. January 31, 
1893, Krause removed the ganglion by this operation.2 
Krause calls attention to the necessity of washing out the eye 
with boric acid solution before the operation, and to the need of 
the protection of the eye. This he accomplishes by the use of a 
large unground watch-glass held in position with a zinc-oxide 
adhesive plaster. 
1 Practitioner, September, 1903. 
2 Jour. Am. Med. Assn., October 11, 1902, p. 900. SURGICAL METHODS OF TREATMENT IN NEURALGIA 
305 
Under chloroform anesthesia the incision is begun just anterior 
to the tragus. It is "uterus-shaped," first extending upward, 
then forward, and then downward with base of flap and zygoma. 
The base of the zygoma is 3 or 3.5 cm. wide, and the height in the 
center is 6.5 cm. The greatest width is 5 or 5.5 cm. This incision 
is through all of the tissues down to the base, and is then carried 
through the bone by means of a circular saw. Sometimes the 
bone is removed, but is usually preserved, attached to its peri- 
osteum, forming the Wagner flap. In the second step the dura 
is separated from the floor of the fossa to the foramen spinosum, 
Brain retractor. 
Dura, mater. 
Trunk of tri- 
geminus. 
J. Branch. 
Middle meningeal 
artery (ligated).. 
II. Branch, 
Skin, muscle, and bone-flap. 
Fig. 138.-Field of operation to remove the Gasserian ganglion, according to Krause 
and the brain retracted upward only so far as is absolutely neces- 
sary. The middle meningeal artery is always ligated, usually 
with two ligatures, and cut between them. In the third step the 
hemorrhage is stopped by packing gauze between the bone and 
the retractor, holding the brain upward. After the hemorrhage 
is stopped and the retractor is in position, work with the elevator 
is begun. The third division is first found and exposed, and then 
the second. The dura is pushed back from these two nerves and 
from the ganglion, and the three structures are lifted successfully 
from the base (Fig. 138). 306 
NERVOUS SYSTEM AND THE BUCCAL REGION 
In separating the dura from the upper surface of the ganglion 
it may be opened, but this is usually of no importance. The third 
division is grasped with Pean forceps and lifted upward. The 
first division is not exposed at any time during the operation, 
except at its junction with the ganglion, because of its position in 
the wall of the cavernous sinus and its proximity to the third, 
fifth, and sixth nerves. 
After isolation of the ganglion it is grasped with forceps at 
its junction with the sensory root; the second and third divisions 
are cut off at their exit from the foramina, and the sensory root 
is twisted out by means of the attached forceps. It is sometimes 
taken off at the pons. The first division usually tears off close to 
Fig. 139.-Gasserian ganglion, with its roots enlarged; a, external view; 1, small 
motor root; 2, large sensory root; 3, semilunar ganglion, over which the motor root 
passes to get to the third branch; first branch; 5, second branch; 6, third branch. 
(After Riidinger, Bull-von Bergmann.) 
the ganglion. The ends of the nerves are pushed down into their 
foramina; the retractor is removed and the flap brought into posi- 
tion. So far the motor root has not been separated from the gan- 
glion in the performance of the operation, but experiments have 
shown that it may be possible to do it. 
Cushing's operation, as shown in his illustration (Fig. 137), is 
somewhat lower than the Hartley-Krause. The U-shaped incision, 
with its base directed downward, is made between the eye and the 
ear, with its upper part slightly above the center of the zygoma, 
the lower points a little below. The zygoma is divided at each end 
and turned down with the flap. The incision is carried through 
the temporal muscle to the temporal bone, which is separated 
from its attachments, including the periosteum, in such a manner SURGICAL METHODS OF TREATMENT IN NEURALGIA 
307 
as to expose the lower portion of the temporal fossa down to the 
attachment of the external pterygoid muscle below the temporal 
crest. An opening is then made with a trephine and enlarged until 
it is about 3 cm. in diameter. The middle meningeal artery is 
Fig. 140.-Scheme showing effects of total extirpation of Gasserian ganglion 
forty-seven days after operation. Sensation of heat spoken of as slightly warm; 
sensation of cold absent. Fi, F2, Vs, first, second, and third branches of fifth nerve; 
oma, occipitalis major, omi, occipitalis minor; am, auricularis magnus; cs, subcu- 
taneous colli. (Friedrich.) 
Zone of absolute anaesthesia and analgesia; complete loss of temperature area. 
Zone of nearly complete anaesthesia and analgesia. 
Zone of distinct but diminished hypalgesia and hyperajsthesia. 
Area of normal sensation 
Outline of innervation zones of trigeminal. 
avoided by continuing the operation in a slightly anterior direction. 
The dura is elevated to expose the foramen ovale and its elevation 
continued until the foramen rotundum is reached. Division 
of the commissure of the under layer of the dura admits of its 
being gently raised from the ganglion back to the sensory root. 308 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Operator and 
reference. 
Date of opera- 
tion. 
Dura- 
tion of 
disease. 
Years. 
Sex, 
age, 
side. 
Previous operations. 
1 
Bartlett, Willard, Ann. 
Surg., June, 1901, p. 
683 
October 10, 
1900 
17 
Female, 
60 years, 
left 
All teeth removed 15 
years previous; intra- 
orbital evulsed, 1898. 
2 
Bartlett, Willard, Ann. 
of Surg., June, 1901, 
p. 683 
November 27, 
1901 
Many 
Female, 
50 years, 
right 
All teeth removed. 
3 
Beck, Carl (Chicago), 
personal communica- 
tion 
November, 
1897 
4 
Male, 
48 years, 
left 
Third div. resected 2 
years ago; second div. 
li years ago. 
4 
Ibid. 
May, 1899 
10 
Male, 
42 years, 
left 
Fourteen previous oper- 
ations; all possible 
methods from neurec- 
tomy to removal of 
bone. 
5 
Ibid. 
October, 
1899 
i 
Male, 
60 years, 
right 
Three previous opera- 
tions: 1, removal of 
cyst of face; 2, neu- 
rectomy of first div.; 3, 
neurectomy of first and 
second divisions. 
6 
Ibid. 
December 10, 
1900 
Several 
Male, 
68 years, 
right 
Neurectomy of second 
division, neurectomy of 
third division. 
7 
Coelho, S., Revue de 
Chir., Paris, May 10, 
1899 
February 28, 
1898 
6 
Female, 
40 years, 
right 
Infra-orbital resection in 
1894; inferior maxillary 
in 1895. 
8 
Cushing, Harvey, Jour. 
Am. Med. Assn., April 
28, 1900 
August, 1899 
10 
Male, 
63 years, 
right 
Infra-orbital evulsed in 
1896, inferior dental in 
1897. 
9 
Ibid. 
December, 
1899 
12 
Male, 
55 years, 
right 
Infra-orbital evulsed in 
1892. 
10 
Ibid. 
January, 1900 
2 
Male, 
38 years 
Infra-orbital and inferior 
dental evulsed in 1899. 
11 
Ibid. 
January, 1900 
7 
Female, 
60 years, 
left 
Infra-orbital evulsed in 
1897 and 1899. 
12 
Erdmann, J. F., IN. Y. 
Med. Jour., May 6, 
1899 
August 8, 
1898 
4 
Male, 
53 years, 
left 
Supra-orbital, supra- 
trochlear and infra- 
orbital nerves excised 
in 1897. 
13 
Halstead, A. E., per- 
sonal communication 
November 9, 
1900 
6 
Male, 
53 years, 
right 
None. 
14 
Ibid. 
March 3, 
1901 
7 
Female, 
57 years, 
left 
Inferior maxillary divided 
2 years before. 
15 
Ibid. 
May 12, 
1901 
10 
Male, 
50 years, 
left 
None. 
16 
Krause, F., Munch, med. 
Woch., June 25, 27, 
February 9, 1901 
March 24, 
1899 
12 
Female, 
41 years, 
right 
Resection of first and 
second divisions in 1898. 
17 
Ibid. 
August 26, 
1899 
10 
Male, 
63 years, 
left 
Resection of second divi- 
sion twice. 
18 
Ibid. 
November 2, 
1899 
Female, 
59 years, 
right 
Second and third divisions 
resected in 1896. 
19 
Ibid. 
January 23, 
1900 
8 
Female, 
44 years, 
right 
Lucke-Braun of 1898; 
remained during next 
pregnancy. 
20 
Ibid. 
February 23, 
1900 
Several 
Female, 
58 years, 
left 
Second and third divi- 
sions operated upon 
many times. 
21 
Ibid. 
May 7, 
1900 
4 
Female, 
30 years, 
left 
Four previous opera- 
tions; infra-orbital re- 
sected. 
22 
Ibid. 
June 13, 
1900 
17 
Male, 
46 years, 
right 
Infra-orbital resected in 
1888; second division 
resected in 1892. SURGICAL METHODS OF TREATMENT IN NEURALGIA 
309 
Method used. 
Result. 
Remarks. 
Immediate. 
Final. 
Cushing 
Cushing 
Hartley-Krause 
Hartley-Krause, 
with removal of bone 
Recovery 
Recovery 
Recovery 
Recovery 
Paralysis of 3d, 4th, 
and 6th nerves, 4 
weeks; recovered 
Eye palsies as in 
above; recovery 
Recovery 
Recovery 
Slight corneal ulcer, which 
soon healed, followed opera- 
tion. 
No corneal ulceration. 
Ibid. 
Ibid. 
Temporal method 
Hartley-Krause 
Death 54 hours 
after operation 
Recovery 
Recovery 
Recovery 
Recovery 
Carcinoma of parotid; opera- 
tion undertaken to relieve 
pain without hope of radical 
cure. 
Cushing 
Cushing 
Cushing 
Cushing 
Recovery 
Recovery 
Recovery 
Recovery 
Recovery 
Recovery 
Recovery 
Results learned by persona 
communication. 
Hartley-Krause 
Recovery 
Recovery from 
pain 
Eye lost 7 weeks after opera- 
tion from ulceration. 
Cushing, modified 
by Hartley 
Ibid. 
Recovery 
Recovery 
Recovery 
Recovery 
Ankylosis of jaw followed 
operation. 
Ibid. 
Hartley-Krause 
Death 5 days 
after operation 
Recovery 
Recovery; pain in 
left side later 
Developed suppurative men- 
ingitis; had chronic neph- 
ritis. 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Failure 
Recovery 
Recovery 
Failure 
Recovery 
Recovery 
Pain was not confined to left 
side before operation; lesion 
evidently central. 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Death 6 hours 
after operation; 
collapse 
Recovery 
Recovery 
Recovery 
Recovery 
Had chronic nephritis. 310 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Operation and 
reference. 
Date of opera- 
tion. 
Dura- 
tion of 
disease. 
Years. 
Sex, 
age, 
side. 
Previous operations. 
23 
24 
25 
26 
27 
28 
29 
30 
Ibid. 
Ibid. 
Ibid. 
Ibid. 
Ibid. 
Keen, W. W., Jour. Am. 
Med. Assn., April 28, 
1900 
Levings, A. H„ personal 
communication 
Mammen, E., personal 
communication 
August 27, 
1900 
August 29, 
1900 
March, 1901 
June 6, 
1901 
June 17, 
1901 
Two opera- 
tions 
November 9, 
1899 
October 24, 
1900 
November 20, 
1894 
7 
15 
8 
7 
25 
i 
9 
2 
Female, 
50 years, 
left 
Female, 
65 years, 
right 
Female, 
60 years, 
right 
Male, 
64 years, 
left 
Male, 
63 years, 
left 
Male, 
32 years, 
left 
Female, 
41 years, 
right 
Male, 
56 years 
Infra-orbital, auriculo- 
temporal and inferior 
dental nerves resected. 
First and second divi- 
sions resected in 1898; 
no relief. 
Second division resected 
in 1898; pain recurred. 
Infra-orbital resected in 
1894; pain recurred. 
Second division resected 
in 1893; third division 
in 1895. 
Infra-orbital removed in 
November, 1899. 
Infra-orbital nerve re- 
moved in 1898. 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
Murphy, J. B. 
Murphy, J. B. 
Murphy, J. B. 
Murphy, J. B. 
Murphy, J. B. 
Murphy, J. B. 
Murphy, J. B. 
Renton, J. C., Brit. Med. 
Jour., November 17, 
1900 
Same as above 
Spellisy, J. M., Ann. of 
Surg., 1900, vol. xxxi 
Thomas, J. Lynn, Brit. 
Med. Jour., October 
28, 1899 
Williams, N. T., Phila. 
Med. Jour., August 
10, 1901 
November 5, 
1898 
November 25, 
1899 
October 5, 
1899 
October 31, 
1899 
April 15, 
1899 
May 30, 
1900 
June 15, 
1901 
November, 
1898 
August, 1899 
July 19, 
1899 
February 9, 
1899 
September 2, 
1899 
9 
8 
7 
4} 
2i 
4 
2 
7 
9 
3 
More 
than 
8 
Male, 
59 years, 
right 
Female, 
43 years, 
right 
Male, 
67 years, 
right 
Female, 
51 years, 
right 
Male, 
66 years, 
right 
Male, 
50 years, 
left 
Male, 
44 years, 
right 
Male, 
57 years, 
left 
Female, 
67 years, 
right 
Male, 
55 years, 
right 
Male, 
34 years, 
right 
Female, 
38 years, 
right 
Dental operations only. 
Dental operations only. 
Dental operations only. 
Second division of fifth 
resected August 8, 1899; 
no pain for 8 months. 
Inferior dental excised; 
pain returned in 3 
months. 
Several teeth removed 
also infra-orbital and 
inferior dental nerves 
in 1895 and 1896. 
Teeth extracted. 
Nerves divided in 1893; 
teeth extracted, supe- 
rior maxillary ganglion 
removed in 1894; in- 
ferior maxillary resected 
in 1896; intracranial re- 
section of nerves August 
30, 1899. SURGICAL METHODS OF TREATMENT IN NEURALGIA 
311 
Method used. 
Result. 
Remarks. 
Immediate. 
Final. 
Hartley-Krause 
Recovery 
Recovery 
Hartley-Krause 
Recovery 
Recovery 
Hartley-Krause 
Recovery 
Death in 21 days: 
Hartley-Krause 
Recovery 
cardiac disease 
and pneumonia 
Death on 20th day; 
Grayish patch of softening 
Hartley-Krause 
Recovery 
coma 
Recovery 
at base due to pressure 
from retractor. 
Sclerotic middle meningeal 
Hartley-Krause 
No improvement 
Pain continued 
torn. 
Endothelioma involving the 
Hartley-Krause 
Recovery 
Recovery 
Gasserian ganglion. 
Hartley-Krause 
Recovery 
Recovery 
Entire ganglion not re- 
Hartley-Krause 
Hartley-Krause 
Death; November 
13, 1898 
Recovery 
Recovery 
moved; second division 
between ganglion and 
foramen caught by for- 
ceps and evulsed; com- 
plete relief resulted. 
Hartley-Krause 
Hartley-Krause 
Death; meningi- 
tis; October 22, 
1899 
Recovery 
Recovery 
Hartley-Krause 
Death; April 17, 
1899 
Hartley-Krause 
Recovery 
Recovery 
Hartley-Kraupe 
Recovery 
Recovery 
Hartley-Krause 
Recovery 
Recovery 
Hartley-Krause 
Recovery 
Recovery 
Hartley-Krause 
Recovery 
Recovery 
- 
preliminary liga- 
tion of external 
carotid 
i Hartley-Krause 
Recovery 
Recovery 
Hartley-Krause 
Recovery 
Recovery 
Curetted out ganglion. 312 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Fig. 141 
( Zone of assolute anesthesia and analgesia. Sixty-three days later than 
in Fig. 140. (After Bull-von Bergmann.) 
Zone of hypalgesia and hyperesthesia. Sixty-three days later than in 
Fig. 141. (After Bull-von Bergmann.) 
Fig. 142 SURGICAL METHODS OF TREATMENT IN NEURALGIA 
313 
The ganglion is then elevated, freed from its attachment to the 
dura, and the first branch of the nerve is separated with care 
to avoid the cavernous sinus. The three peripheral branches are 
then elevated with blunt hooks and sutured close to the foramen, 
the ganglion grasped with forceps and evulsed. The parts are 
replaced, and held in position with sutures without drainage 
(Fig. 139). 
The effect of removal of the Gasserian ganglion as evidenced 
by altered sensation is shown by Figs. 140 to 143. 
Fig. 143.-Photograph taken on the tenth day after operation. (Cushing.) 
Mortality.-In 100 cases collected by Tiffany1 the mortality 
rate was 22 per cent.; in a second series of 100 cases reported by 
Carson2 the mortality was 11 per cent. Most of these operations 
were according to the Hartley-Krause method. Murphy and Neff's 
report of 42 cases with 6 deaths, which is here given because of 
its valuable record of other operative aspects as well as mortality, 
shows about 15 per cent. Cushing reports 20 cases of his own 
operated upon according to his own method, with a mortality of 
5 per cent. The steadily improving mortality rate under improved 
operations and technic is encouraging. 
The records of 42 cases gathered by Murphy and Neff (see 
pages 308 to 311) are given in detail because these cases appear 
to show the best possible data upon which to base judgments 
of many features of operative results as well as the question of 
mortality. 
1 Annals of Surgery, 1896, xxiv, 575. 
2 Med. Review, St. Louis, 1899, xxxix, 199. 314 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Later reports by Cushing of over 100 cases with almost no 
mortality, and the results obtained by Frazer and many other 
operators who have followed the improved methods of these two 
operators, have reduced the question of mortality almost to a negli- 
gible factor. Nevertheless, the ease and safety of alcoholic injec- 
tions still warrant the employment of this treatment before the 
more radical Gasserian operations are resorted to. It is even possible 
that alcoholic injections of the Gasserian ganglion may be found 
to be entirely sufficient. 
THE DENTAL ASPECT OF TRIGEMINAL NEURALGIA. 
The dental and oral aspect of trigeminal neuralgia is generally 
conceded to be a matter of great importance. Many vital features, 
however, are but little appreciated, and there is much confusion 
in the views of dentists, oral and general surgeons, and practitioners 
of other divisions of medicine in regard to the importance and the 
character of the effect of local influences in the region of the mouth. 
In the description of real or fancied effects from treatment or removal 
of teeth, dentists have made exaggerated and often unscientific 
claims and have done much to destroy the confidence, particularly 
of those who believe in the more or less definite pathological prin- 
ciples which govern all divisions of the body as affected by various 
forms of diseases. On the other hand, only those who are familiar 
with diseases of the teeth and their treatment could be expected to 
diagnosticate or fully understand dental irritation. As a result, the 
importance of the mouth and the effect of its deformities and diseases 
is both underestimated and overestimated in its relation to the 
etiology of trigeminal neuralgia. 
Judging from long years of experience in dealing with the special 
or at least unusual affections observed in a practice limited to 
diseases and deformities of the mouth and jaws, and from a wide 
observation of cases noted in clinics and reported by others, the 
author has ventured upon the following classification of pathological 
conditions of the mouth which he hopes may serve to distinguish 
the affections capable of inducing long-continued painful forms of 
peripheral irritation, and thus becoming factors of first impor- 
tance in causing trigeminal pain of neuralgic character, from those 
that are not, which, however, may be serious enough in themselves. 
It is further hoped that the simple but essentially practical methods 
of diagnosis may also be generally helpful. DENTAL ASPECT OF TRIGEMINAL NEURALGIA 
315 
Developmental Factors.-A study of the embryonic sections and 
other illustrations (pages 617, 61S, 631 and 639) clearly demon- 
strates that arrested development or restricted growth from any 
cause in the region of the mouth, the most common evidences of 
which are found in high, narrow palatal vaults, contracted dental 
arches, and irregular teeth, is chiefly an expression of abnormal 
developmental tendencies. These defects are usually indicative 
of neurotic tendency and therefore of predisposition to painful 
as well as other neuroses. Moreover, such restricted growth 
invariably manifests itself by alterations in the form of surrounding 
structures. This is noticeably true of the general form and char- 
acter of the maxillse. Corresponding deviations from the normal are 
likely to occur in the maxillary and other closely related cavities, 
foramina, and canals, and the passage of nerves through such 
abnormal openings subjects them to irritation. Nasal defects, such 
as narrow nares, deviated septa, spurs, and hypertrophic and other 
pathological alterations of structure, are similarly frequent evidences 
of perverted development. A more detailed description of these 
conditions is given on page 616. Direct opportunity is thus offered 
for diseased conditions of the nose and associated parts, including 
the ethmoidal, sphenoidal, and maxillary sinuses and cells, as well 
as the orbital and aural regions. Through any of these the nerves 
may be involved in the disease itself or become affected by actual 
alteration in size or form. Anomalous communicating openings and 
channels may also favor pathological states. Many branches of the 
fifth nerve are thus exposed to disease or more or less direct irritation. 
Oral deformity or perverted maxillary development can unquestion- 
ably so change the shape of the orbits that the adjustment of its 
contents to their bony encasement may cause visual defects which 
may also be etiological factors of no small significance. 
Disease of the middle ear through Eustachian infection, the 
cause and effect of which is well understood, and the pressure of 
crowded teeth incident to arrested growth of the jaw frequently 
cause irritation of the nerve. The effect of tooth grinding and 
jaw clinching in producing nerve exhaustion or irritation is described 
on page 316. 
The reflection of restricted growth in the maxillary region as 
affecting other bones, gives at least a reasonable ground for belief 
that by arrested or perverted development in infancy, important 
foramina at the base of the skull, notably the foramen ovale and 
the foramen rotundum, through which the vessels and nerves 
emerge, may also be sufficiently restricted in size or altered in 316 
NERVOUS SYSTEM AND THE BUCCAL REGION 
form to favor pressure upon the nerve when for any reason the 
accompanying vessels may become distended. 
This is worthy of due consideration, since the premonitory signs 
often appear for all the foregoing conditions at such an early age 
and the remedy at this stage is so simple. 
BUCCAL CONDITIONS WHICH MAY EXERT PREDISPOSING 
OR EXCITING INFLUENCES, THEIR DIAGNOSIS 
AND CORRECTION. 
Jaw Clinching and Tooth Grinding.-Almost without exception 
the grinding surfaces of the teeth of patients suffering from tri- 
geminal affections show marked evidence of the effect of this habit. 
This usually makes it possible to diagnosticate the tendency to pain 
even without knowledge or history of the case. Cause and effect 
are, however, so closely interwoven that it is practically impossible 
to differentiate between the two with sufficient certainty and 
exactness to warrant definite distinctions. This may be better 
understood by the explanation that tooth grinding and the dis- 
turbed rest which is associated with this habit may be caused 
by eye-strain, whether due to astigmatic or other visual defect, 
fatigue from long-continued use, nervous states induced by auto- 
intoxication or other toxic effects, neurasthenia, and similar nervous 
conditions. On the other hand, given any local or general excitant 
which may give rise to the habit of grinding or clinching the teeth 
at night, and we have at once a factor capable of exercising most 
potent influences in the production of pain in the head in a number 
of different ways. 
1. The continued activity of the muscles of the jaws prevents 
perfect rest and is fatiguing in much the same sense as eye-strain, 
with this difference, however, that the ocular muscles are usually 
only active when the eyes are in use, whereas activity of the jaw 
muscles, when the habit is fully formed, continues both day and 
night. Relief of pain and prompt increase in weight and improve- 
ment of general health in patients for whom this trouble has been 
relieved by treatment, and the use of an appliance as described 
on pages 327 and 328 has shown this to be a factor of no small 
importance, whether primary or secondary. 
2. The continued overuse of the teeth in this way gives rise 
to certain changes in the pericementum, the vessels and the nerves 
surrounding the apical ends of the roots of the teeth involved, and 
the cementum of their roots. This may be in the nature of a chronic DISEASES OF THE DENTAL PULP 
317 
pericemental hyperemia, which is the natural result of ischemia 
caused by forcing the blood out of the vessels of the pericementum 
during the active pressure that is made upon the teeth, and the 
consequent hyperemia which follows the relief of this pressure. 
This congestion can and does cause pressure upon the nerve filaments 
as they pass from the end of the root of the tooth to join the main 
branch of the nerve, which in neurotic individuals is amply sufficient 
to set in motion very serious painful conditions. 
Pericementitis.-In the acute form pericemental inflammation 
gives rise to pain which is frequently referred to other parts. The 
chronic forms, however, are alone significant in relation to neuralgia, 
and these only rarely, if at all, because of the effect that the tendency 
to culminate either in pericemental abscess or interstitial gingititis 
prevents the continuous persistent form of irritation that is necessary 
for chronic reflex nervous manifestations. 
Hypercementosis.-Hypercementosis, or thickening of the peri- 
cementum surrounding the end of the root by involving nerve 
fibers or by pressure upon surrounding nerve structures due to 
enlargement as this abnormal growth proceeds, is also a cause of 
pain. 
Ankylosis.-Perhaps the most serious of all pathological changes 
that take place in the structures surrounding the roots of the teeth 
as a result of this tooth-grinding habit is the tendency of the roots 
of such teeth to become ankylosed. This belief is confirmed by a 
very large number of patients of the author, the crowns of whose 
teeth were abraded and worn in evidence of long years of tooth 
grinding. Their histories described pain of various kinds in the 
distribution of the fifth nerve, particularly periodical headaches. 
When effort was made to extract such teeth, large masses of alveolar 
process came away with roots. Cross-sections of these, made by 
decalcification and cuttings from microscopic slides, disclosed the 
condition of ankylosis as shown by Fig. 144. With the disappearance 
of the pericementum as the encroachment of bone proceeds in the 
process of the development of the ankylosis, there appears to be 
constriction of the little nerve fibers which during the periods of the 
attack appear to be capable of giving rise to the most excruciating 
exacerbations of pain. 
Diseases of the Dental Pulp.-Pulpitis.-The dental pulp is so 
richly supplied with nerves and bloodvessels, and by its very 
nature so highly susceptible to vasomotor stimuli, that enmeshed 
as these vessels are in connective tissue, the whole being sur- 
rounded by unyielding walls of dentin, its possibilities for giving 318 
NERVOUS SYSTEM AND THE BUCCAL REGION 
rise to pain, and particularly pain of reflex character, are very 
great. Fortunately the tendency of an acute circumscribed pulpitis 
is rapidly to become diffuse and pass to the stage where strangula- 
tion of the nerve by vascular pressure causes its devitalization, and 
through infection the formation of pus leads to dento-alveolar 
abscess. Although the process is often an exceedingly painful one 
throughout, its natural time limitation is such as to preclude the 
likelihood of its becoming a factor in causing chronic neuralgia 
in any form. There are, however, certain pulp degenerations which 
result from chronic pulpitis, long-continued irritation, and con- 
Fig. 144.-Ankylosis of tooth root. Cross-section, showing root and attached 
alveolar process in case of chronic trigeminal neuralgia. 
stitutional influences, or toxic effects in which no outward mani- 
festation is given. Pulps under these conditions often retain vitality 
for many years, and may give rise to reflex pain of almost any 
character. Because of the absence of the usual appearance of 
diseased teeth, and as there frequently are no carious cavities nor 
outward signs of disease, their etiological importance is quite 
generally overlooked in diagnosis. Atrophy, fibroid, calcareous and 
other forms of degeneration, pulp nodules, and pulp tumors aie 
vicious degenerative forms which affect pulps of teeth with a fre- 
quency not fully appreciated because not always detected. Each DISEASES OF THE DENTAL PULP 
319 
of these conditions has repeatedly been found associated with 
trigeminal neuralgia that has disappeared or been markedly benefited 
by treatment of the pulp canals or removal of the teeth. 
Pulp Nodules.-Pulp nodules (Fig. 145) are undoubtedly present 
in the pulps of many persons who suffer no inconvenience by 
reason of the fact. When, however, there is individual predis- 
position to nerve disturbance or the presence of an excitant sufficient 
Fig. 145.-Section of the pulp of a 
tooth from the mouth of one of the 
author's patients, a woman, aged forty- 
five years, who had suffered for several 
years with tic douloureux. The tooth 
from which this pulp was removed was 
on the affected side and at the point 
where the earliest pain appeared to 
begin: a, b, pulp nodules. 
Fig. 146.-Another section of the 
same pulp shown in Fig. 145. In addi- 
tion to the nodules a, b, an accompany- 
ing pulp degeneration is particularly 
evidenced at c. 
to induce hyperemia, the activity of the bloodvessels of such a pulp 
is insufficient to allow reaction in relief of temporary engorgement 
with the same rapidity as the vessels of a pulp not so affected. The 
hard substance of the pulp stone forced against the nerve fibers 
through counter-pressure of the unyielding dentinal walls of the pulp 
chamber, does, as might be expected, give rise to excruciating exacer- 
bations of pain. In the absence of infection or traumatic injury 
such pulps may remain alive for many years, in fact almost 320 
NERVOUS SYSTEM AND THE BUCCAL REGION 
indefinitely, their hyperesthetic condition becoming worse as time 
goes on. This is the condition found so often in association with 
tic douloureux (Figs. 146 and 147). The adventitious growth of 
dentin upon the dentinal pulpal walls may cause similar constric- 
tion and pain. 
It must be understood that the foregoing cannot be relied upon 
as absolute indications that the first cause is in the teeth. Some 
of these symptoms are also found when the primary etiological 
factor is elsewhere, and are symptomatic of brain and other affec- 
tions. For many years, however, they have served to point the way 
Fig. 147.-Pulp from the molar tooth of a man, aged forty years. Case of tic 
douloureux. The crown of this tooth showed no carious or other serious' defect. 
a, pulp nodule. 
in large numbers of the author's patients, and have often helped to 
bring about the relief which has been given. On this account their 
importance cannot well be overestimated, recommended as they 
are by directness and simplicity as well as the possibility of con- 
servatism and the avoidance of disfigurement and discomfort 
through loss of teeth which is thus offered. There is a wide differ- 
ence of opinion among authorities as to the frequency with which 
neuralgia may be central or peripheral. Most writers, however, 
are agreed that in a considerable number of cases the affection 
primarily is peripheral, and that in the course of time, as the disease JAW CLINCHING AND TOOTH GRINDING 
321 
continues to advance, more branches and deeper portions of the 
nerve become involved, until finally the Gasserian ganglion is 
attacked. In addition to this many cases are on record of patho- 
logical conditions of the teeth, mouth, and tooth pulps which could 
without doubt have caused reflex pain of serious character in patients 
suffering from tix douloureux and other forms of neuralgic pain. Figs. 
115,116,145,146 and 147 are photomicrographs of sections of tooth 
pulps removed from the teeth of patients suffering from tic dou- 
loureux. They were isolated and their conditions diagnosticated 
by the methods given below. They show fibroid and calcareous 
degeneration with marked alteration of form, distribution, and 
character of the nerve fibers not dissimilar to indications (Plate X) 
of Gasserian ganglia. There seems every reason to believe that, 
either as a primary cause or as a result of the paroxysmal character 
of exacerbations of pain due principally to other and remote causes, 
the continued irritation of tooth pulps because of their peculiar 
histological character and environment first gives rise to degenera- 
tive changes in these organs which later affect the nerve branches 
in more general distribution. Certainly, search in this direction 
and the treatment of even suspected tooth pulps should precede 
other graver methods of treatment. 
Diagnosis.-General examination of the mouth and teeth with 
a view of determining the likelihood of peripheral irritation in 
this region should include examination of the general outline of the 
dental arch, face, and nose to note the possibility of ill effect from 
imperfect development as described. 
Early Diagnosis.-Children of delicate nervous organization, 
especially when there is a known hereditary tendency, require 
close observation during their important development periods to 
detect any tendency to arrest of growth or asymmetrical form of 
the nose or mouth before harmful results have had opportunity 
to give serious manifestation. At later periods irregular dental 
arches, high, narrow palatal vaults, adenoids, enlarged tonsils, 
mouth-breathing, and the symptoms of imperfect oxygenation, 
and ill-nourishment that are associated with these conditions 
when present in conjunction with pain in the region of the fifth 
nerve render the diagnosis of causal factors of this character quite 
simple. 
Diagnostic Indications after the Eruption of Teeth.-Examina- 
tion of the occlusal surfaces of the teeth is of first importance, 
particularly in cases in which they are abraded at points which 
do not come in contact in normal occlusion, as this is an indication 322 
NERVOUS SYSTEM AND THE BUCCAL REGION 
of the jaw-biting habit. Patients are almost invariably uncon- 
scious of the habit, but usually after tooth surfaces that they have 
been accustomed to bite upon are ground until they no longer 
meet in occlusion, such patients, when next seen, as a rule, admit 
having noticed the loss of the grinding surfaces and are therefore 
convinced. Elongation or looseness of teeth points to chronic 
pericemental thickening. This may or may not be noticeable 
when the jaws are closed. It may be diagnosticated by placing 
a finger inside the cheeks or lips, allowing its palmar surface to 
rest against the buccal or labial surfaces of the teeth with light 
pressure. When the jaws are closed a slight movement of the 
affected tooth can sometimes be felt, even though not noticeable 
in other examinations. 
Study of the color of the mucous membrane of the lips and mouth 
and the appearance of the gums, salivary and other glands in 
the buccal region indicates the general state of the patient, and 
shows whether he is anemic or affected by auto-intoxication or 
any other general disturbance which might be an etiological factor. 
The presence or absence of carious or diseased teeth should be noted, 
with particularly careful search for a carious tooth cavity through 
which a pulp might have become exposed to undergoing chronic 
degeneration of any kind. Metal crowns or bridge-work that might 
indicate tooth grinding should also be noted. The occlusal surfaces 
of the molars and bicuspids and incisal portions of the six anterior 
teeth should be examined, with careful observation of the worn 
surfaces of the enamel or bright shining spots in fillings. The 
mandibular articulation must receive attention to note whether there 
be undue enlargement or other abnormality in the region of the 
temporomaxillary articulation. The teeth must be carefully counted 
and the presence or absence of each tooth accounted for, particularly 
the third molars. If there be doubt or uncertainty in this respect, 
a radiograph should always be taken to determine whether malposed, 
unerupted, or supernumerary teeth exist. The necks of the teeth 
should be examined at points where recession of the gum may have 
exposed sensitive dentin to irritation. This has been reported as a 
cause by Inglis. Difference in color must be carefully observed with 
reflected light through the crown of the teeth, if possible with an 
electric mouth lamp. Discoloration indicates devitalized pulps or 
pulp calcification, teeth of this character being somewhat darker 
than the crowns of normal living teeth. The size of aW fillings must 
be compared in proportion to crowns of teeth filled, to form an idea 
as to the likelihood of the filling having been placed too close to DIAGNOSIS OF DENTAL FACTORS 
323 
the pulp chamber. Improperly constructed bridge-work with imper- 
fect occlusion and cases in which teeth or roots have been used 
as abutments and suffer too great strain in carrying too many 
bridged teeth should be noted; also cases in which there is an 
abutment at only one end of the bridge, one tooth being allowed 
to support crowns to supply one or more missing teeth. Any of 
these conditions would lead at once to suspicion of pericemental 
diseases which might be expected to lead to chronic pulp affections. 
In certain forms of trigeminal neuralgia the pain quite frequently 
is greater at night or when the patient is lying down. While this is 
sometimes a symptom due to other causes, it is at least a reasonably 
good indication that the causative factor lies in some form of pulpitis, 
as in diseases of the dental pulp. The change in posture favoring 
increased circulation of blood in the upper portion of the body 
almost invariably gives the onset or increase of pain. This was very 
marked in one of the author's patients. The history of this case 
as given by the physician who referred him was that during a period 
of a number of weeks the man had suffered from excruciating 
unilateral trigeminal pain. Morphin had been administered up to 
the limit of safety, but it seemed to be impossible to give relief when 
the patient was lying down. When he stood up relief was so prompt 
that he slept without difficulty by leaning against the wall in an 
erect position. Diagnosis of the cause was quickly made, and an 
upper molar tooth extracted which to all outward appearances was 
perfectly sound. Upon breaking the tooth open the pulp chamber 
was found to be filled with pulp nodules, and the pain disappeared 
almost immediately. 
Percussion with a light steel instrument may disclose tenderness 
to tapping, or there may be no abnormal evidences other than a 
slight dulness of sound which distinguishes teeth having patho- 
logical conditions of the pericementum. Ankylosed teeth give a 
slightly sharp or ringing sound on percussion, because the deadening 
effect of the pericementum which normally acts as a cushion is lost 
by its obliteration. 
Bulging or Enlargement of the Alveolar Surface Over Boots.- 
Hypercementosis that has progressed to a sufficient extent by 
encroachment upon surrounding alveolar structures sometimes 
gives the appearance of growth at certain points over the roots, 
which, taken with the altered resonance of percussion, assists the 
discovery of this condition. This form of diagnosis has many times 
led to the location of teeth which were exciting factors in painful 
neuralgias. In one of the author's cases, a woman with hyper- 324 
NERVOUS SYSTEM AND THE BUCCAL REGION 
esthesia so marked that she admitted not having washed her face 
for more than three months, the sensitiveness was such that touch- 
ing the lips almost anywhere brought forth extreme paroxysms of 
pain, and under these conditions, which made diagnosis extremely 
difficult, no important guiding symptom was found other than 
dulness on percussion of an upper bicuspid tooth. Immediately 
following the extraction of this tooth the hyperesthesia disappeared 
and upon breaking it open the pulp chamber was found filled with a 
finely granulated powder resulting from calcareous degeneration 
of the pulp. This did not completely relieve the patient, but the 
distressing hyperesthesia was at once relieved and other painful 
symptoms much improved. 
Skiagraphs carefully taken sometimes assist diagnosis very 
materially, especially when hypercementosis is marked. They 
are exceedingly useful in disclosing diseased conditions of the roots 
of teeth sufficiently, when these have been imperfectly filled. 
Many interesting examples of the value of skiagraphy might be 
shown in which the cause of long-continued irritation at the apical 
portion of the root of the tooth has proved to be the projection of a 
root filling beyond the apical foramen or through some opening in the 
side of the root. Dento-alveolar abscesses, pericemental abscesses, 
and diseased conditions of surrounding alveolar structures, par- 
ticularly unusual necrotic conditions, have been disclosed in this 
way. In the various forms of pathological dentition, such as mal- 
posed, unerupted, or supernumerary teeth, especially with delayed 
dentition, dentigerous cysts, and odontomes, the z-rays are useful 
beyond all other diagnostic aids. Pus, tumors, and foreign bodies 
in the maxillary sinus may sometimes be advantageously determined 
by the use of the x-rays. 
No other agent is equally useful in ascertaining the exact con- 
ditions of recent fractures of the jaws in which union has been 
delayed or faulty, is complicated by necrosis and malposition of 
the bones, or has taken place without correct approximation with 
consequent permanent deformity or pain from pressure upon 
nerves and palate vessels. 
Sensitiveness to Heat and Cold.-The most important test of a 
tooth pulp as indicating healthfulness on the one hand, or impaired 
vitality on the other, is its reaction to heat, cold, and other forms 
of irritation. A normal pulp should react quickly to irritation with 
sharp pain if sufficiently disturbed, but with the vitality and its 
vascular supply unimpaired, the transient hyperemia induced by 
stimuli of this character should be promptly relieved. Therefore DIAGNOSIS OF DENTAL FACTORS 
325 
the pain should disappear quickly. Lessened sensitiveness indicates 
lowered vitality. Slowness of disappearance of pain indicates loss 
of circulatory activity probably due to chronic hyperemia and the 
impaired ability of the coats of the vessels to free themselves, 
indicating the partial stasis of inflammatory processes or other 
degenerative changes. 
The temperature test of a pulp then consists in the suddenness 
of the onset of pain upon application of heat or cold and the prompt- 
ness with which the pain disappears. The same is true of other 
irritations. When pulpitis is present the pain may continue for a 
few minutes or a few hours, or reflex disturbance of important serious 
character may be excited. This also is an indication that degenera- 
tive processes have become sufficiently advanced to involve more 
distant portions of the nerve supply. Applying this knowledge to 
the diagnosis of neuralgia, we recognize that the onset of pain when 
breathing cold air through the mouth, when riding or walking, or 
increase of pain upon entering a warm room from outer cooler air, 
may be taken as indications of peripheral irritation from some hyper- 
sensitiveness or diseased tooth pulp. The onset or increase of pain 
when hot, cold, sweet, or sour substances are taken into the mouth 
may be taken as a fairly good indication of tooth pulp disturbance. 
The cessation of pain when the mouth is filled with iced water which 
is held there and changed with sufficient rapidity to insure continued 
cold is another indication, because at a certain stage of pulpitis the 
application of ice, iced water, or any form of sufficiently cold applica- 
tion will stop the pain. At an earlier or later stage of the pulpitis, 
even in the same tooth pulp, this might excite intensely painful 
symptoms, but at just the right moment the contraction of the 
vessels by cold gives prompt relief. In testing individual teeth 
for temperature changes care must be exercised to isolate each 
particular tooth in order that one may accurately determine exactly 
which tooth is the exciting cause. Too often both heat and cold 
are applied in a more or less general way, and although the indica- 
tions may lead to diagnosis of dental trouble the particular teeth 
involved are not so readily discovered. A simple way of applying 
heat is to take a mass of dentist's base-plate gutta-percha as large 
as the first joint of a little finger, hold with an instrument in the 
flame of a spirit lamp to soften the gutta-percha, roll into a mass, and 
point it at one end so that when applied to the tooth only one may 
be touched at a time. When this is applied as hot as it can be made 
without burning and with care to avoid touching the gums, the 
response of each particular tooth in the mouth to heat may be 326 
NERVOUS SYSTEM AND THE BUCCAL REGION 
accurately noted. Teeth which fail to respond are probably devital- 
ized, and care should be taken to know that each tooth of this kind 
has been properly treated and its roots filled. If pulps are alive 
the response of all teeth will be approximately the same. Variations 
from this should be noted. When pain appears immediately in the 
track of a neuralgia at some more or less distant point in the dis- 
tribution of the fifth nerve upon the application of heat in this way, 
and this pain continues longer than the normal time required for 
the tooth to regain its usual temperature, it is an indication that the 
pulp of such a tooth or teeth must receive treatment. 
The simplest way to apply cold is to take a piece of ice, sharp- 
ened to a point at one end, of such shape that it can be wrapped 
in a napkin and held without difficulty, and each tooth touched 
one after the other with the sharp pointed exposed portion of the 
ice. The indication and inequality and situation of pain excited, 
and the time required for its disappearance are the determining 
factors as with heat. Tests of this kind are particularly useful 
in leading to the discovery of pulp nodules or fillings that have been 
placed too close to the pulp chamber. Quite frequently pulp stones 
are discovered in this way when tooth pulps having such symptoms 
have been removed that could have been discovered in no other. 
Treatment.-With children or young persons as a prophylactic 
measure the natural remedy is expansion of dental arches, by sep- 
aration of the maxillee to widen the nose. This gives the benefit 
of more perfect physiological respiration, assists the natural erup- 
tion of developing teeth, and gains the general developmental 
benefit of improved respiration. This is described more in detail 
in illustrations, pages 626-630. 
The question of treatment of teeth in neuralgic patients, par- 
ticularly those suffering from major neuralgia or tic douloureux, 
is often a serious matter. With or without real cause patients 
quite often suffer pain in a particular tooth, and they are always 
desirous of its extraction. But it should be remembered that 
almost invariably as much can be done to give relief by removal 
of the pulp and the proper treatment of the root canals, thus dis- 
posing of the irritating factor as completely as if the tooth had 
been extracted. On the other hand, every time a tooth is extracted 
the occlusion of the jaws is disarranged, as has been already noted. 
Such patients during the paroxysms of their suffering always 
clinch and grind their teeth. While temporary relief can be given 
by the extraction of a particular tooth that is elongated, tender 
to touch, or that has a diseased pulp, almost invariably within a DENTAL AND ORAL TREATMENT 
327 
short time after its extraction one of the adjoining teeth becomes 
similarly affected. Being deprived of the natural support which 
each tooth gives to its fellow in the dental arch, it more readily 
succumbs to the overuse thus brought about, and pulpitis from 
irritation of the pericementum affecting the nerves and vessels 
where they enter the apical foramen is quickly conveyed to the 
tooth pulp itself. Thus it is a common experience to find patients 
who have had all of the teeth upon the affected side extracted 
one after the other, or when all have not yet been removed and 
a few taken out, the remaining teeth are found leaning at a very 
considerable angle, having been forced out of position by the 
unusual stress to which they have been subjected. The indis- 
criminate extraction of teeth in this way seldom ever does permanent 
good and almost always more or less harm. 
Dentists are sometimes reluctant to destroy more or less ruth- 
lessly the pulps of teeth that are outwardly perfect in appearance, 
and such opinion, based as it is upon true conservatism, is entitled 
to respect. But it must be remembered that the value of a dental 
pulp or even of teeth when compared with the suffering and other 
physical disadvantages which follow in the train of neuralgia of 
grave character should not be allowed to weigh in the balance to 
any considerable extent. It is an exceedingly simple procedure 
for a skilful dentist to open a suspected tooth, and by cocainizing 
the pulp with pressure anesthesia to remove it painlessly, and with 
proper treatment to fill the root canals, thus preserving the use- 
fulness of the tooth, not only for its original masticatory and cos- 
metic purposes but as a safeguard against the continued progress 
of the dental irritation through the influence of the affection itself. 
Malocclusion must be corrected by grinding the surfaces of 
teeth that have become elongated or by proper dental operations 
to prevent undue stress upon the affected teeth. Grinding the 
surfaces of teeth which are most abraded to overcome the habit 
and various other expedients have been found useful to prevent 
tooth grinding at night, such as tying rubber, cotton, or other 
materials over the surface of one or more back teeth to keep the 
jaws slightly apart, gum held between the jaws at night, etc. 
Much relief has been given to large numbers of patients during 
several years past by the insertion of an appliance called, for want 
of a better name, the author's soft-rubber bit (Fig. 148). This is 
an exceedingly simple but very useful appliance, made as shown 
with a hard-rubber plate fitting the palate and having soft velum 
rubber extending over the crown surfaces of the teeth one-eighth 328 
NERVOUS SYSTEM AND THE BUCCAL REGION 
to one-quarter of an inch in thickness. The soft yielding surface 
of the rubber, when the jaws are brought in contact, prevents undue 
irritation of individual teeth. The effect of the appliance in the 
mouth and the inability to bring into contact the tooth surfaces 
that have been held tightly together or have been ground during 
subconscious moments and sleep in time helps to overcome the 
habit. The steadiness which is given to the lower jaw when forced 
against the upper relieves nerve tension in such individuals very 
materially. In most cases certain changes in the way of enlarge- 
ment have taken place in the region of the temporomaxillary 
articulation which allows a much greater irregularity of movement 
of the jaw than is normally the case. The continued seeking for 
a proper resting place is one of the marked symptoms, and has 
Fig. 148.-The author's rubber appliance to relieve stress in case of "jaw-clinching 
habit" and nervous tooth grinding. The palatal portion is made of hard vulcanized 
rubber, and the covering for the occlused surfaces of the teeth is of soft velum rubber. 
invariably proved to be an important factor in relation to nerve 
strain and irritation. Many patients could be cited who have 
been completely relieved by this treatment. 
A young lady, aged twenty-three years, suffered for five years 
almost constant pain, chiefly in the occipital region, but at times 
involving also other regions. Iler sleep was much disturbed, and 
she usually awoke in the morning with the pain much worse. Her 
symptoms finally became so bad that she lost self-control almost 
entirely. No other treatment was given except the constant wearing 
of this appliance, hygienic care, and rubbing with alcohol for 
relief during acutely painful periods. In a little while she became 
absolutely dependent upon the appliance, and in the course of time 
the trouble gradually and completely disappeared. 
Another young woman, aged forty years, a chronic sufferer from TEMPOROMAXILLARY ARTICULATION 
329 
neuralgia, who, although five feet three and one-half inches in 
height, weighed only ninety-seven pounds when the appliance 
was inserted, was relieved in the same way. 
Temporomaxillary Articulation.-Examination of skulls in the 
cadaver and dried specimens as well as observation and study 
of the movement of the condyles show great variation in size and 
form of the glenoid cavities of different individuals and often on 
the two sides of the same individual. This manifests itself as a 
factor in the production of certain diseases of the teeth and their 
surrounding structures. It also may become an influential factor 
in the production of pain. There are many cases on record in which 
trigeminal neuralgia has been relieved by the insertion of suitable 
plates to hold edentulous jaws sufficiently apart to keep the condy- 
loid and coronoid processes of the lower jaw in right relation to the 
surrounding parts. In the same way persons have been relieved by 
elongation of teeth by dental operations when the crowns have 
become so abraded as to allow the jaws to come too close together. 
Cysts, particularly the dentigerous cysts of erupting teeth, some- 
times cause pressure upon important nerve branches. Engorgement 
or empyema of the maxillary sinus through pressure of fluid is a 
frequent source of irritation of the second division of the nerve. 
BIBLIOGRAPHY. 
1. Deutsch. Ztschr. f. Chir., 1899, Band xlii, Heft 3 u. 4. 
2. Verhandl. d. Deutsch. Gesell. f. Chir., 1899. 
3. St. Louis Med. Rev., March 18 and 25, 1899. 
4. Annals of Surgery, 1896, xxiv, 575 to 619. 
5. Head: Trigeminal Neuralgia, Allbutt's System, 1899, vi, 728. 
6. Horsley, Victor: An Address on the Surgical Treatment of Trigeminal 
Neuralgia, Practitioner, 1900, Ixv, 251. 
7. Rose: Lancet, 1892, i, 295. 
8. Coehlo: Rev. de Chir., 1899. 
9. Lexer, E.: Arch. f. klin. Chir., 1902, Ixv, 843. 
10. Jour. Am. Med. Assn., April 29, 1900, p. 1035. 
11. Frazier: Univ. Penna. Med. Bull., December, 1901. 
12. Spiller: Am. Jour. Med. Sc., 1898, p. 532. 
13. Barker: Protocols of Microscopic Examination of Several Gasserian Ganglia, 
Jour. Am. Med. Assn., May 5, 1900, p. 1093. 
14. Spiller and Frazier: Division of the Sensory Root of the Trigeminus for the 
Relief of Tic Douloureux, etc., Univ. Penna. Med. Bull., xiv, 34. 
15. Baer, Dawson, Marshall: Regeneration of the Dorsal Root Fibers of the 
Second Cervical Nerve within the Spinal Cord, Jour. Exper. Med., 1899, iii, No. 1. 
16. Jour. Am. Med. Assn., April 28, 1900. 
17. Centralbl. f. Chir., 1900, No. 44, p. 1089. 
18. Bartlett: Contribution to the Surgical Anatomy of the Middle Cranial 
Fossa, Annals of Surgery, 1902. 
19. Bartlett: Excision of the Intact Gasserian Ganglion, Annals of Surgery, 1901. 
20. Lexer: Arch. f. klin. Chir., 1902, Ixv, 14. 
21. Dorrance: Dental Cosmos, January, 1917. 330 
NERVOUS SYSTEM AND THE BUCCAL REGION 
LESIONS OF THE FACIAL (SEVENTH) NERVE. 
Anatomical Relations.-The commonly accepted belief that the 
seventh or facial nerve is entirely a motor nerve is questioned by 
more recent investigators. Its main distribution, however, is to the 
muscles of expression. Its point of origin is the inferior portion of 
the general motor areas ventral of the fissure of Rolando. The 
axons pass into the pons accompanying the general motor tract. 
The peripheral nerve in its passage from the nucleus forms a 
loop about the nucleus of the sixth nerve, thence passes ventrally 
to emerge in close relation with the auditory nerve, separated by 
it from the pars intermedia (nerve of Wrisberg). These nerves 
together pass into the internal auditory meatus. Centrally it is 
connected with the upper part of the glossopharyngeal nucleus, 
and may improperly be regarded as forming the sensory portions of 
the seventh nerve and the main part of the chorda tympani. The 
seventh nerve, peripheral to the geniculate ganglion, passes into the 
Fallopian canal, runs between the cochlea and vestibule into the 
inner wall of the tympanum, separated from the tympanum by 
a thin lamella of bone and lining membrane of the middle ear, 
finally emerging from the skull through the stylomastoid foramen. 
The geniculate ganglion lying at the bend of the nerve corresponds 
to a ganglion of a dorsal root. In addition to the supply of the 
facial muscles of expression, the facial nerve sends fibers to the 
platysma, posterior belly of the digastric, the stylohyoid, and a 
small twig within the Fallopian canal to the stapedius muscle of the 
ear. 
Facial Paralysis.-Paralysis of the seventh nerve is more fre- 
quent than that of any other nerve in the body. In a large majority 
of cases the affection is unilateral and caused by a lesion in peripheral 
distribution of the nerve. 
Etiology.-Its known and suspected causes are many, and given 
in the order of their importance are approximately as follows: 
Exposure.-It has been estimated that 70 per cent, of all cases 
show this etiological factor, and though the reason does not seem 
to be clear, facial paralysis occurring after exposure to draughts 
or similar conditions so overshadows other factors in frequency 
as to warrant its enumeration as an exciting cause. 
Suppurative Ear Disease.-Suppurative ear disease is extremely 
common because of the close proximity of the Fallopian canal 
through which the nerve passes to the frequently diseased auditory 
region. LESIONS OF THE FACIAL NERVE 
331 
Trauma.-Injury of direct character to the nerve itself or sur- 
rounding structures is a common cause, especially surgical or other 
division of the nerve. 
Basal Fractures.-Thomas states that in 69 cases of nerve involve- 
ment from skull fracture, 34 showed an affection of the facial nerve. 
Disease of the Base of the Brain.-Meningitis, new tumor growths, 
and affections of the medulla and pons, readily lead to involvement 
of one or both facial nerves. 
Neuropathic Tendency .-While predisposition of this character 
plays a part in this as with other nerve affections, it does not seem 
to warrant important consideration as a direct factor, although 
instances of the occurrence of facial paralysis affecting more than 
one member of the same family prevents complete exclusion of this 
contributing factor. 
Constitutional Disease.-Gout, diabetes, leukemia, syphilis, tuber- 
culosis, and similar conditions may be factors of primary or second- 
ary importance, as may also the puerperal state and diphtheria. 
Emotional Shock.-Emotional shock has in a number of instances 
been followed by facial paralysis. 
Neuritis.-Neuritis or a primary degeneration of the nerve 
within the aqueductus fallopii have, in a limited number of cases 
reported by Andre Thomas, been demonstrated to be active factors 
in this affection. 
Polyneuritis.-Polyneuritis may occur in conjunction with this 
condition, and in these cases the paralysis is usually double-sided. 
Poliomyelitis.-Atrophy and paresis of the tongue and pharynx 
sometimes follow the symptoms of general emaciation and mus- 
cular fibrillation, which are indicative of degenerative conditions 
of the spinal cord. 
Periods of Life.-Pericds of life bear their usual importance 
in this relation. Paralysis of the facial nerve is more frequent 
before forty and more severe though less frequent in later life. 
Symptoms.-The onset of the facial paralysis is usually rapid. 
Pain located in the ear, the mastoid region, or neck sometimes 
occurs as a premonitory symptom, but with too little certainty 
to warrant diagnostic or prognostic dependence. There may be 
fever and other signs of infection at the onset. The most prominent 
symptom is complete or partial loss of movement of the muscles 
upon the affected side of the face. Paralysis of the orbicularis 
oculi prevents closing of the eyelid. Attempts to close the eye 
result in the globe being rolled upward. In smiling, the mouth 
is drawn toward the unaffected side. The lips cannot be properly 332 
NERVOUS SYSTEM AND THE BUCCAL REGION 
adjusted in attempts to whistle. Drinking and speech are inter- 
fered with (Figs. 149 and 150). 
Spasmodic Contraction.-Spontaneous twitching, of the face 
muscles, particularly the zygomatic muscles, may be a secondary 
symptom, and continue for years or be totally beyond hope or 
recovery. Without conclusive evidence it is generally assumed 
that this occurs through degenerative progress, which involves the 
pons and causes loss of control of nerve impulse, which therefore 
proceeds irregularly and in excessive degree. (Facial spasm, tic, 
etc., see Spasmodic Neuroses, page 342). 
Fig. 149.-Facial paralysis of the 
side. Attempt to raise the eyebrows. 
(Starr.) 
Fig. 150.-Facial paralysis of the 
side. Attempt to close the eyes. 
(Starr.) 
Location of the lesion is sometimes possible through considera- 
tion of the following symptomatic distinctions: 
1. Between the exit of'the nerve from the stylomastoid foramen, 
taste is not affected because the chorda tympani joins the nerve 
above these points. 
2. Between the stylomastoid foramen and the geniculate ganglion 
within the Fallopian canal. Taste in the two-thirds of the anterior 
part of the tongue so affected through constant involvement of the 
chorda tympani. 
3. Between the geniculate ganglion and pons. There is no 
involvement of taste, deafness is often associated through involve- 
ment of the auditory nerve. 
4. In the pons, taste and hearing are unaffected, and almost 
invariably the six principal other nerves are all affected. In the 
central course of the facial nerve no changes in the electrical reaction LESIONS OF THE FACIAL NERVE 
333 
occur, the upper branch of the nerve is much less involved than 
the two lower. 
Diagnosis.-In a general way diagnosis is obviously simple, 
but it is especially important to differentiate between a central 
disturbance in the nerve and one due to a peripheral cause. The 
distinguishing features in making this differential diagnosis are as 
follows: 
CENTRAL. 
1. No change in electrical reaction. 
2. Upper branches of the peripheral 
nerve are slightly involved. 
3. Reflex conditions of the nerve in- 
creased but electrically unchanged. 
4. A crossed or alternating hemi- 
plegia indicates a lesion in the pons 
below the crossing of the pyramid. 
PERIPHERY. 
1. Electrical reaction always present. 
2. All branches of the nerve equally 
involved. 
3. Reflex activities diminished with 
tendency to ultimate atrophy. 
4. No such condition possible. 
Traumatic injury to a special branch of the nerve may in a 
measure modify all radical lines of distinction. 
Prognosis.-The duration as well as the final outcome in these 
cases varies from one or more weeks to months or may be per- 
manent. There may be recovery even with complete reaction 
of degeneration. When this condition, however, persists for 
months and a quantitative diminution of electrical excitability 
results, the prognosis is grave because of permanent changes in 
the nerve or destruction of the pontine nucleus. In a general 
way it may be assumed that with electrical reactions normal or 
nearly so and the. period short, prognosis would be favorable, 
and with loss of electrical reaction and increased length of time 
hope for recovery be correspondingly diminished. 
The following clinical example illustrates the difference between 
central and peripheral causes in the author's cases: 
A young man, aged twenty-four years, unmarried, with facial 
symptoms as indicated in Figs. 151 and 152, gave a history of 
paralysis having continued through a period of several weeks. 
He had also extensive necrosis of the lower jaw involving several 
teeth which was treated by the removal of the diseased tissue, 
but no portion of the facial nerve was found to be directly involved. 
His death, some time after leaving the hospital, revealed the fact 
that his affection was of central origin. There was no opportunity 
for definite location of the nature of the lesion by autopsy. 
Another of the author's patients, a young woman, aged about 
twenty-six years, married, had symptoms affecting the right side 334 
NERVOUS SYSTEM AND THE BUCCAL REGION 
of her face quite similar to those of the young man just described. 
Paralysis occurred a few days before presentation for treatment. 
There was suspicion of syphilis in this case, but no definite diag- 
nosis. The removal of a diseased third molar upon the affected 
side caused marked improvement an hour or so later. When she 
returned home her husband was surprised and astonished at the 
change. Following this, the symptoms improved slowly, and in 
the course of a few weeks completely disappeared. Whether the 
irritation from the pulp of the third molar was merely a contribut- 
ing factor, and removal of the tooth through the stimulating 
effect of the shock of pain aroused was responsible for the improve- 
ment, or if by some anomaly there was in this individual an 
Fig. 151.-Facial paralysis. 
Fig. 152.-Facial paralysis. The effect 
of an attempt to close the eyes. 
unusually close interweaving of sensory and motor elements, or 
if such relation is really more common than generally supposed, 
is of course impossible to say. There can be no doubt, however, 
of the fact that irritation in the maxillary region, especially when 
the living pulps of the teeth are involved, has an active influence 
in such cases of secondary if not primary character. For an old 
lady, aged sixty years, with muscular spasm which affected the 
right side of the face and involved the superior and inferior branches 
of the fifth nerve, the removal of diseased pulps and correction of 
malocclusion, which was aggravated by long-continued tooth- 
grinding habit, as commonly noted in many nervous states, seemed 
to give a measure of benefit even though complete relief from the LESIONS OF THE FACIAL NERVE 
335 
muscular twitching was not accomplished, and the affection was 
undoubtedly due to a central cause. 
Treatment.-The treatment is radical or otherwise. Effort 
should be made to correct any associated pathological condition 
which might possibly be an exciting or contributing factor. Nature 
must be assisted in every possible way to further natural correc- 
tive processes. Medical treatment should therefore be to keep 
the bowels freely active, and include the administration of sali- 
cylates when indicated, treatment of syphilis, if this disease be 
recognized as an etiological factor, by the use of iodides and mer- 
cury, and the relief of any etiological factor that may be benefited 
by external medication. If there be symptoms of neuritis within 
the Fallopian canal, hot fomentations may be applied in the mas- 
toid region, or direct treatment of the affected parts is still better. 
Electricity is probably more extensively employed than any other 
agent, and though there seems to be some doubt as to its permanent 
benefit, it appears to be the most rational means of stimulating 
nerve and muscle activity and protecting against degenerative 
progression. 
Dr. E. Farquhar Buzzard gives the following outline of electrical 
treatment: "In treatment by these means, presuming that a 
reaction of degeneration is present, the galvanic current should 
be employed, using over the affected muscles the pole which pro- 
duces the most marked contraction. No more than four or five 
milliamperes should be used, and the muscles should be stroked 
by an electrode for a period not exceeding ten minutes. As the 
faradic irritability returns, this form of electricity may be sub- 
stituted for the constant current, but it is well to discontinue 
any form of electric treatment when the tendency to contracture 
and spasm of the muscle becomes apparent. There is no adequate 
evidence to show that the application of electricity plays no part 
in the production of secondary contracture, but the treatment 
becomes more and more superfluous as voluntary control over the 
muscles increases, and may well be discontinued before such 
voluntary control becomes complete." 
Surgical Treatment.-Anastomosis of the facial with the spinal 
accessory was accomplished by Ballance in 1895. The objection 
proved to be tendency to paralysis of the trapezius and sterno- 
mastoid muscles and involuntary movement of the shoulder. 
Through similar efforts by Cushing, Faure, Hackenbruch, Kennedy, 
and others, the hypoglossal nerve was substituted for the spinal 
accessory, and by only partial division of the hypoglossal difficulties 336 
NERVOUS SYSTEM AND THE BUCCAL REGION 
of deglutition and speech, which followed complete division of this 
nerve, were avoided. 
Surgical intervention of this character could only be expected 
to be efficient in cases of traumatic injury or division of the facial 
nerve, destructive middle-ear disease, and conditions of similar 
character. To be effective, the operation should be done at the 
earliest possible day after it has been determined that construc- 
tive processes cannot be looked to for improvement because of 
the danger of muscle disintegration through inactivity. 
Fig. 153.-Nerve anastomosis: A, intact nerve; B, paralyzed nerve; I, lateral 
anastomosis (peripheral implantation); II, lateral anastomosis (central implanta- 
tion). (After Brewer.) 
Improvements in the surgical technic and better understanding 
of the possibilities of nerve anastomosis are encouraging efforts 
in this direction (Figs. 153 and 154). Good results have been 
obtained by Keen, Ochsner, and other surgeons in directly suturing 
the ends of divided nerves and bridging across with gut sutures 
between them, when the nerve ends could not be brought into 
direct contact. The wonderful regenerative power of nerve struc- 
tures which enables them to cross bridges of this character and 
become perfectly united with restoration of function has thus been LESIONS OF THE AUDITORY NERVE 
337 
demonstrated. These facts lead to the belief that in the future 
divided ends of the facial nerve may thus be united without resort- 
ing to anastomosis of the hypoglossal. Certainly, wherever the 
point of injury or division of the nerve is so situated as to make 
direct union possible, this method would be favorable. 
Fig. 154.-Illustrating method of fascio-accessory anastomosis. (Harvey Cushing, 
after Brewer.) 
LESIONS OF THE AUDITORY (EIGHTH) NERVE. 
The two distinct divisions of the auditory nerve, first the cochlear 
portion, in which the organ of Corti with its delicate mechanism 338 
NERVOUS SYSTEM AND THE BUCCAL REGION 
for the special sense of hearing is situated, and the vestibular 
portion, which bears such an important relation in the phenomena 
of equilibrium, are both closely related in various ways to disease 
in the oral region. 
Deafness is most commonly due to diseases within the ear 
affecting the peripheral fibers of the nerve; occasionally, however, 
hearing is disturbed by affection of the acoustic nerve. In these 
cases there is loss of power of perceiving sound through the bones 
of the head, and it is thus distinguished from deafness in the outer 
or middle ear, in which the sound of a tuning-fork can be heard 
when applied to the teeth, forehead, etc. 
Tinnitus Aurium.-Ringing, ticking, hissing, roaring, or whist- 
ling sounds in the ear occasion the individuals so affected much 
distress. 
Although the auditory apparatus accustoms itself to the almost 
constant sounds of daily life, so that they make little or no con- 
scious impression, subjective sounds due to morbid processes cause 
an increase rather than a decrease in distressing effect upon the 
individual. 
Etiology.-Pathological Conditions of the Ear.-These are located 
especially in the labyrinth, but include also wax in the external 
auditory meatus and affections of the middle ear. Quinine, the 
salicylates, and other drugs may give rise to tinnitus. 
Circulatory Disorders.-Circulatory disorders, such as anemia, 
abnormal pulsation of the carotid artery, intracranial aneurysm, 
vasomotor palsy of the labyrinthian vessels, arterial sclerosis, 
high or low bloodJpressure, may cause tinnitus. 
Nervous States.-Tinnitus is not uncommonly associated with 
hysteria, neurasthenia, epilepsy, and migraine, or the higher 
centers of the cerebral cortex may be so affected as to give rise 
to more complicated auditory hallucinations. 
Muscular Movements.-Movement of the palatal muscles or 
drumhead, which may be voluntary or involuntary, accompanied 
by spasmodic contraction of the muscles of the face or otherwise, 
gives rise to a clicking sound produced by sudden separation of 
the moist agglutinated walls of the Eustachian tube. 
Diagnosis.-The oral surgeon's special interest in this affection 
lies in the possible relation between diseased conditions of the 
mouth and maxillary sinus to middle-ear disease; in local irrita- 
tion from tooth grinding, diseased pulps, or similar factors, which 
tend to aggravate general nervous conditions; the influence of buccal 
pathological states upon the blood and general disorders, which are LESIONS OF THE AUDITORY NERVE 
339 
recognized as factors of etiological importance, and in results of 
operations for correction of cleft-palate involving the palatal 
muscles and their part in control of the Eustachian opening. In 
the author's practice a considerable number of cases have had 
chronic empyema of the maxillary sinus, coincident with tinnitus, 
which was undoubtedly due to middle-ear disease. The general 
involvement of mouth, nose, maxillary sinus, Eustachian and mas- 
toid regions, usually make it difficult to determine the exact primary 
cause. In some cases, however, direct connection with dento- 
alveolar abscesses and the history of onset of the symptoms follow- 
ing development of the abscess upon the root of a tooth, left little 
doubt as to the rightful precedence of this cause. Certainly no 
treatment could be expected to be permanently effective so long 
as reinfection of the ear from the sinus or the mouth was possible. 
Therefore the diagnosis of these conditions and their proper 
treatment is exceedingly important. Recognition and correction 
of other mouth affections are also in varying degree important for 
the same reason. 
Differential Diagnosis.-Differential diagnosis in these cases is 
sometimes extremely difficult, and only examination by an otolo- 
gist can be effective in distinguishing between the different forms 
of this affection when due to diseased conditions of the ear. To 
recognize pathological states which might be of etiological impor- 
tance and apply the test of their correction when possible appears 
to be the only safe rule for diagnostic guidance when the true 
cause is not apparent. Deafness does not seem to bear a definite 
relation to this trouble, since it may decrease with increasing 
deafness or remain unchanged. 
Prognosis.-The prognosis is usually not hopeful. In large 
numbers of cases the affection tends to persist in spite of every 
treatment. 
Treatment.-Although treatment is usually ineffective, the 
utmost effort should be made to remove or correct any predisposing 
or exciting cause that may be indicated. Diseases of the ear, 
maxillary sinus, nose, throat, or mouth should be given immediate 
attention. The psychic element always requires intelligent con- 
sideration with patients so afflicted, for cheerful, helpful, hopeful 
suggestions are at least encouraging and often beneficial. Con- 
ditions of the blood and general disorders of that character must 
be corrected if possible. Change of air, scene, and occupation, 
and the administration of nervines, tonics, or other internal medica- 
tion may be required. 340 
NERVOUS SYSTEM AND THE BUCCAL REGION 
LESIONS OF THE GLOSSOPHARYNGEAL (NINTH) AND PNEU- 
MOGASTRIC (TENTH) NERVES. 
The ninth nerve contains both sensory and motor fibers, and 
is the nerve of common sensibility of the pharynx, palate, and 
middle ear. It is believed that it supplies sensation of taste to 
the posterior third of the tongue, the anterior two-thirds passing 
in through the lingual nerve. Confusion on this point has occurred 
by reason of the fact that division of the root of the trigeminal 
nerve has sometimes caused total loss of taste, and there is reason 
to believe that individuals differ somewhat in this respect. 
The association of this nerve in both its motor and sensory 
fibers with the vagus or tenth nerve (pneumogastric) is so inti- 
mate that clinically a radical division is practically impossible. 
Injury of the motor branches causes anesthesia of the pharynx 
and larynx, with difficulty in swallowing. In bulbar paralysis 
there is loss of action of the esophagus, pharynx, and larynx. 
The wide distribution of the tenth nerve, however, with its con- 
trol of respiratory and cardiac centers, and its well-known sus- 
ceptibility to sympathetic effect, renders the association of diseases 
of these nerves with pathological conditions of the mouth matters 
of much general importance. 
LESIONS OF THE SPINAL ACCESSORY (ELEVENTH) NERVE. 
Paralysis.-Etiology.-Among the usual causes of paralysis of 
the accessory nerve, we find swollen glands, abscess of the neck, 
and similar affections. The frequency with which these condi- 
tions occur from buccal infection requires at least a passing con- 
sideration. 
Symptoms.-Paralysis of the sternocleidomastoid and trapezius 
muscle through loss of compensatory action causes the head to 
be turned backward and over the shoulder, which is also elevated. 
There is loss of power to raise the arm above the horizontal line 
through failure of the trapezius to counteract the serratus muscle, 
which retains the scapula in such manner as to produce a slight 
elevation upon the one side of the neck by the projection upward 
of its inner angle. Torticollis, or wry-neck, may be due to con- 
genital lesions of the eleventh nerve, defects of deformity, or 
injury. 
Diagnosis and Treatment.-Treatment, except when other causes 
are obvious, should include thorough examination for sources of LESIONS OF THE HYPOGLOSSAL NERVE 
341 
infection in mouth or its associated glands and immediate correc- 
tion of such existing conditions if any. Beyond this its considera- 
tion passes outside of the oral surgical and therapeutic domain. 
LESIONS OF THE HYPOGLOSSAL (TWELFTH) NERVE. 
Paralysis.-The hypoglossal nerve being purely motor and 
supplying all of the tongue muscles except the glossopalatini and 
geniohyoid, paralysis of this nerve is evidenced by motor and 
trophic changes in the tongue. 
Etiology.-As with facial or other paralysis, its primary cause 
may be central or peripheral, although rarely involved in lesions 
upon the base of the brain. It is a-quite prominent feature in 
bulbar paralysis. Traumatic injury, tuberculosis, syphilis, and 
other diseases identical with those enumerated as leading to other 
forms of paralysis may be causes (Fig. 155). 
Fig. 155.-Gunshot section of left hypo- 
glossal nerve. (After Roberts.) 
Fig. 156.-Right hemiatrophy of the 
tongue. 
Symptoms.-Prominent symptoms are inability to move the 
muscles of the tongue or to protrude it from the mouth. One or 
both hypoglossal nerves may be affected. If both, there will be 
general loss of lingual motion. If one nerve only be involved, 
when the tongue is moved its tip will project toward the paralyzed 
side. This becomes more and more apparent as the tongue is 
extended out of the mouth. Mastication and deglutition are 342 
NERVOUS SYSTEM AND THE BUCCAL REGION 
interfered with. Atrophy is a marked symptom if the lesion be 
peripheral and folds or ridges upon the otherwise smooth surface 
give indications of its progress (Fig. 156). 
Prognosis.-Its termination naturally depends upon the seat 
of origin and the nature of the causative factor. 
Treatment.-As with other forms of paralysis, treatment must 
be directed toward relief of the underlying condition. 
SPASMODIC NEUROSES. 
Convulsions.-Clonic spasm is an alternate muscular contraction 
and relaxation that is violent and involuntary. Tonic spasm is 
a rigid contraction of muscles without relaxation. When slight it 
is called tremor; when strong and permanent, tetanus, trismus, etc. 
Etiology.-In most cases fits occur before the completion of 
the first dentition. Of 300 cases studied by Cautley, 44 were in 
the first six months of life, 52 in the second, 76 in the second year, 
and 44 in the third year. Of these, no less than 216 were infants, 
under three years of age, 27 were in the fourth year, and the 
remainder under twelve. 
McCarthy1 calls attention to the following pathological influences: 
Irritation of the skin as from excessively hot baths, scalding, and 
burning; sudden and violent variations in the surrounding tem- 
perature; painful wounds and foreign bodies; herpes vaginalis; 
phimosis; pressure on the testicles; irritation of the genitals from 
irritation of yarn, etc. Carious conditions of the mastoid and 
disease of the middle ear may be associated with convulsions 
without evidence of signs of meningeal trouble. Reflex conditions 
in the gastro-intestinal tract affect a large class of cases. 
The eruption of the teeth is given as an important factor by 
many authorities. Ulcerative conditions of the oral mucous mem- 
brane, enlarged tonsils, and nasopharyngeal adenoids may act 
in a purely reflex manner, or assist in the lowering of general nutri- 
tion and nerve tone. 
Overloading the stomach of a person with a finely balanced 
nervous system with indigestible food may be the determining 
factor in a convulsive seizure not only in childhood but at any 
period of life. The ingestion of irritating substances, such as 
alcohol, reacts in a like manner, as may also intestinal auto-intoxi- 
cation with chronic constipation, intestinal parasites of various 
1 Osler: Modern Medicine, 1915, 2d Ed., vol. v. SPASMODIC NEUROSES 
343 
kinds, reflex conditions in the genito-urinary tract, catarrhal con- 
ditions, congenital anomalies, bladder and kidney stones, and 
congenital kidney diseases. 
While given recognition in common with other reflex irritations, 
the full importance of pathological dentition is evidently not appre- 
ciated. Although primarily a physiological process, dentition is 
frequently disturbed. As it occurs at about the period of rapid 
brain development, which results in temporarily increased sensi- 
bility on the part of the individual, the unusual sensitiveness to 
irritation of the brain cells and nerve structures at this period 
opens the way for grave manifestations of delayed or disturbed 
tooth eruption. Study of the illustration on page 64 will' show 
that the rapidly organizing mass of cells from which the tooth 
pulp is forming becomes daily more sensitive to pressure from the 
sharp borders of the calcifying tooth crowns, when the resistance 
of toughened overlying gum tissues makes counter-pressure against 
the force which would otherwise naturally crowd the erupting 
dental organs toward the surface. Such pressure occurring at a 
time of unusual individual sensitiveness must and does exert a 
very important influence in precipitating ill results for which there 
are often predisposing inherent tendencies. Many symptoms of 
both central and peripheral irritation which appear under these 
conditions may thus be accounted for. 
Many infants have been relieved in the author's practice, and 
prompt and efficient relief has been reported by many others, or 
at least the way to recovery from grave infantile nervous states 
has been pointed out, by the simple operation of opening the 
toughened .gum tissue covering tooth crowns. For this reason 
the procedure is certainly worthy of due consideration and adop- 
tion as a prophylactic, even though it may not always be a curative 
measure. 
(For further consideration of the effect of buccal irritation see 
page 316.) 
Chorea, St. Vitus' Dance.-This disease is manifested by irregular 
muscular contraction resulting in purposeless movements some- 
times associated with psychic manifestations. 
Etiology.-Its predisposing cause is a neurotic tendency represented 
by lack of equilibrium in the nervous inhibitory. The exciting 
cause may be an infectious agent or its toxin or some affection 
of the central nervous system. Age seems to bear an important 
relation in this regard, since it most often occurs in childhood, 
particularly in the later years during adolescence. Osler's record 344 
NERVOUS SYSTEM AND THE BUCCAL REGION 
of 535 cases shows that 33 occurred in the first hemidecades, 228 
in the second, and 62 in the fourth.1 
Granasso2 says that central auto-intoxication following emotional 
disturbance may account for some cases. 
Symptoms.-Choreic movements are spasmodic, unexpected, and 
although they cannot be checked by an effort of will, are likely 
to be increased by excitement, concentration of attention, and 
efforts to control the muscles involved. Such muscular twitching 
is generally of quick transition and does not exhaust the patient, 
but in rare cases it becomes so violent and continuous as to 
jeopardize the patient's life. Any of the muscles of the body 
may be involved, but those of the face and extremities are most 
commonly affected. 
Movement of the eyelids, lips, cheeks, and tongue occurs suddenly. 
The facial appearance may thus be distorted into a grimace, or 
there may be snapping together of the jaws, grinding of the teeth, 
or evidences of the involvement of the respiratory and laryngeal 
muscles. 
In a large proportion of cases the affection is unilateral and 
occurs upon the right side more frequently than the left. Mental 
irritability, as a rule, becomes noticeable early in disease. It 
occurs most frequently in childhood, but may appear in adult life. 
Prognosis.-The prognosis is often unfavorable. Recoveries are 
estimated at about 5 per cent. Hopeful conditions are when treat- 
ment can be begun at a sufficiently early date by the removal of 
some known irritating cause or where surgical treatment is suc- 
cessful. Its duration is uncertain. Anemias, mental excitement, 
rheumatism, and endocarditis render its aspect more serious. 
Treatment.-Since chorea is a symptom and not a disease per se, 
its treatment must be directed to the cause of the choreic symptoms 
which should be carefully sought for in every case. Every possible 
form of peripheral irritation or any pathological state that might 
have an etiological influence must be duly corrected or treated; 
particularly is this true of the class of cases which give evidence of 
etiological factors which are the subject of our special interest, 
such as those described in connection with convulsions, epilepsy, 
etc. It of course must be understood that every effort should be 
made to build up the general system and to favor psychic healthful 
influences. The administrations of medicines must be directed 
to the improvement of general conditions that might have predis- 
posing influences. Fowler's solution, 3-drop doses, three times a 
1 Copezinski, Review Neurologique, 1903, p. 1157. 
2 Riforma Medica, 1903, p. 429. SPASMODIC NEUROSES 
345 
day, increased one drop daily until a puffiness of the eyelids, nausea, 
or pain indicates its limit, and chloretone, 5 grains three times a 
day, are highly recommended remedies. The aspect of this disease 
which most concerns our subject is given on page 346, in connection 
with treatment of epilepsy and other neuroses. 
Facial Spasm.-Facial spasm is a spasmodic twitching of the 
muscles supplied by the facial nerve. It is a disease of adult life, 
and does not usually develop until after the age of forty years. 
Etiology.-Sensory rather than motor irritations are believed 
to be its causes. Local disease of the eyelids or visual strain of 
the ocular muscles are held accountable in most cases for the act 
of winking. Irritation of the trigeminal nerve at some point or 
points in its distribution are the most frequent causes of the sudden 
contractions in the facial muscles. Therefore conditions which 
might lead to irritation from teeth and other parts of the mouth, 
nose, throat, or scalp may be active etiological factors. 
Tic.-Effort has recently been made to limit the meaning of 
this quite broadly used term to the definition given by Brissaud 
and Meige:1 "A primary act caused by an external irritation 
or by an idea coordinated for a special end." 
Etiology.-The habit of the act is acquired by constant repeti- 
tion, and then occurs involuntarily. The impulse is uncontrollable, 
but the act can be controlled by sufficient effort. Such habits 
of abnormal muscular movement are easily acquired by children 
who are imitative or excited by slight sensations. 
Symptoms and Differential Diagnosis of Facial Spasm and Tic.- 
These affections have a symptomatic similarity which Patrick2 
distinguishes by calling attention to six contrasting points. Grouped 
in opposite columns for the sake of convenience these are as follows: 
TIC. 
1. Tic is more common than spasm 
and affects nervous and neuropathic 
individuals. 
2. Tic is a volitional movement (even 
when automatic and subconscious), 
with extensive psychic sensory associa- 
tions. 
3. Subject to control of the will and 
involuntary emotion or intellectual in- 
fluence. 
4. Physiological. 
5. Has the appearance of natural 
movement. 
6. Does not necessarily cause speech 
inability during spasm. 
FACIAL SPASM. 
1. More rare disposition and tempera- 
ment not significant. 
2. Is a real spasm, isolated and con- 
fined to motor innervation of the face. 
3. Devoid of voluntary or involuntary 
control. 
4. Anatomical. 
5. Unnatural in appearance and 
cannot be voluntarily imitated. 
6. Speech or other physiological 
action is impossible. 
1 Starr: Nervous and Mental Diseases, after Jour, de med., Paris, 1905, et chir. 
pract., January 24, 1894, and Traite de m6d., tome x, p. 330. 
2 Jour. Nerv. and Ment. Dis., 1909. 346 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Treatment of Facial Spasm and Tic.-The treatment of facial 
spasm and tic depends upon recognition of their essential differ- 
ences. The relief of every possible source of peripheral irritation 
in the region of the involved muscles upon the one hand and control 
of habit upon the other. 
Epilepsy.-Epilepsy is a disease or disorder afflicting the brain, 
characterized by recurrent paroxysms which are abrupt in appear- 
ance, variable in duration, but generally short, and in which there 
is impairment or loss of motor coordination, with or without 
convulsions. 
Etiology.-The etiological factors which have been associated 
with this disease are almost without number. There is undoubtedly 
a primary neurotic tendency in all such patients, and in large 
numbers of them direct heredity is in evidence, either through 
epileptic parents or family history, showing insanity, alcoholism, 
syphilis, or other constitutional diseases. Personal history fre- 
quently shows record of spasms in infancy, difficult dentition, 
traumatic injuries to the head or spine, and acute infectious or 
other diseases of childhood. All of these are looked upon as predis- 
posing conditions. Electrical shock, arteriosclerosis, brain disease, 
insanity, nephritis, disorders of menstruation, pregnancy, and 
maternity occasionally bear a close relation to the onset of epileptic 
symptoms. Affections of the heart are also frequently found in 
these subjects. Elydrocephalus is sometimes present in incurable 
cases. Under the heading of Miscellaneous Causes, Spratling 
sums up questions which are of vital importance from our present 
point of view in the following manner: 
"Given a marked hereditary tendency, there are numerous 
agencies capable of causing epileptic convulsions in addition to 
those mentioned. Gastro-intestinal disorders have not received 
the consideration they deserve. Intestinal toxemia may cause 
convulsions in two ways, either by approximating the peripheral 
nerves (visceral) in that locality or by the absorption of certain 
toxic substances." 
Protein poisoning and the influence of vagotonic conditions in 
the light of recent investigations assumes an increased importance 
in this relation. 
Pathology.-The pathology is not clearly defined beyond certain 
theories with reference to organic diseases, toxemia, and the effect of 
well-known nerve irritations or excitants of unusual nervous activity. 
Symptoms.-In a considerable number of cases the symptoms 
are preceded by an aura, or conscious sensation, which in time SPASMODIC NEUROSES 
347 
becomes a sort of warning of an attack. Detailed consideration 
of the many forms in which symptoms of this affection appear 
would be quite beyond our present purpose. All may be grouped 
in two chief divisions, known as petit mal, or slight attacks evidenced 
by loss of consciousness lasting for a short time and accompanied 
by a variety of symptoms but without actual convulsion, and 
grand mal, accompanied by loss of consciousness, a considerable 
period of stupor and convulsions, with loss of memory during the 
attack. Many of these patients show stigmata of degeneracy, as 
explained by Talbot and others, and have abnormal contours 
of the skull, peculiarly shaped ears, eyes, hands, feet, and other 
features. High arched palatal vaults and irregular teeth are 
extremely common and worthy of due consideration, and such 
subjects are almost invariably "tooth grinders." 
Treatment.-Treatment should include careful search for and 
relief by proper correction of every possible form of peripheral 
irritation in the jaws and mouth. Long before the onset of the 
characteristic symptoms in neurotic individuals, even though 
epileptic tendencies may not be suspected, it should be a routine 
practice to warn the parents of every growing child with con- 
tracted dental arches and high palatal vault, or the teeth erupting 
in such irregular form as to predispose to this kind of development 
with its inevitable ill effect in narrowing the nose and leading 
the intranasal deformities and diseases, that expansion, particu- 
larly the upper dental arch, by separation of the maxillae and thus 
widening the nose is imperatively necessary. When there is evidence 
of the beginning of this affection, careful search should be made 
for unerupted teeth, and every missing tooth properly accounted 
for, and if necessary its presence and situation or absence demon- 
strated by carefully taking radiographs (Fig. 157). The possibility 
of supernumerary teeth should always be borne in mind when none 
are missing from the regular set. Pulp stones, fillings that may 
cause chronic irritations of dental pulps, carious cavities, and tooth 
crowns which may expose their pulps to chronic irritation, the 
abraded occlusal surfaces of teeth which indicate tooth-grinding 
habits, chronic pericemental and other similar affections should 
be sought for with great care and properly treated if any such 
should be discovered. 
When traumatic or other brain lesions exist, surgical treatment 
by location of the primarily affected area and removal of the 
cause if possible, gives the only possibility of permanent relief. 
Even with cases .so treated there is always an element of uncer- 348 
NERVOUS SYSTEM AND THE BUCCAL REGION 
tainty, because it is well known that almost any operation in some 
subjects may cause a cessation of the attacks for considerable 
periods of time, though no real permanent good may have been 
accomplished. 
Fig. 157.-Radiograph of an unerupted impacted third molar, the removal of 
which relieved a young man, nineteen years old, of attacks of unconsciousness, 
with muscular twitching, preceded by an aura, and diagnosed as epilepsy. 
Fenestration of the Skull.-The removal of intracranial pressure 
by this and similar expedients is a procedure that is undoubtedly 
growing in favor among surgeons for the relief of affections of 
various kinds, and in certain forms of epilepsy might be expected 
to afford unusual relief. 
Other treatment in a general way includes building up the 
strength and normal vital energy of the patient by good hygienic 
care, dietetic regulations, and favorable psychic influences, baths, 
massage, daily flushing of the bowels, appropriate treatment for 
improvement of intestinal conditions, and the administration of 
bromides, which should be given in large doses. 
It is claimed by Prior and Jones1 that there is a diminished 
amount of free calcium in the blood of epileptics, and that they 
1 Med. Jour., Australia, March 4, 1916, and Practical Medicine Series, page 19, 
Nervous and Mental Diseases. SPASMODIC NEUROSES 
349 
may be benefited by the administration of calcium. Wherry and 
Oliver1 recommend the administration of calcium combined with 
bromides. 
With reference to all of the spasmodic affections such as infantile 
spasm, chorea, epilepsy, and similar diseases, the purpose of giving 
them consideration in this volume is to emphasize the features 
which are properly connected with the effect and relief of dental 
and oral irritation. Therefore no attempt at detailed description 
of the many methods of treatment of these is undertaken. 
The Relations of the Mouth and Teeth to Spasmodic Neuroses. 
-It is a significant fact that the onset of the symptoms of chorea, 
epilepsy, and kindred affections in the great majority of cases 
occurs at periods of development termed by Talbot "Periods of 
Stress." Kierman pointed out that they are coincident with the 
development and eruption of both temporary and permanent 
sets of teeth, particularly at about the age of five or six years, 
when the first permanent molar is erupted. He showed that in 
persons of unstable nervous system their neurotic tendencies 
predispose to these affections. Irritation from pressure of the 
sharp borders of the undeveloped open ends of the growing roots 
against the underlying nerve structures is caused by resistance of 
overlying structures in the process of tooth eruption as previously 
described (page 63), or by the crowding of malposed teeth in 
contracted dental arches. On account of the bell-shape of the 
tooth crowns and the conical form of the roots there results a 
slight nerve stretching when the force of the jaws is applied upon 
these crowded teeth. Thus a more or less continuous nerve irrita- 
tion arises, which at this time of weakened resistance intensifies 
already existing tendencies and precipitates attacks of these affec- 
tions. Kiernan also expresses the belief that if such persons could 
be guarded from irritation of this character at such periods, choreic 
and epileptic attacks would be avoided in many instances, for with 
increased age and natural correction of the irritation the tendency 
would probably disappear and disorders of that character not be 
manifested. 
Spratling2 states: "Difficult dentition probably never acts as 
an unqualified cause when not influenced by another agency, 
but there is little doubt that when dentition becomes pathological 
in a strongly tainted neuropathic subject it may cause a type of 
convulsion which, if permitted to go unchecked, may evidently 
1 Jour. Am. Med. Assn., October 7, 1916. 
2 Osler: Modern Medicine, 1915, 2d Ed., vol. v. 350 
NERVOUS SYSTEM AND THE BUCCAL REGION 
pass into a more or less true form of the disease. No one would 
think of designating as epilepsy a single convulsion caused by 
painful dentition in a rachitic child, accompanied by high tempera- 
ture, irritability, and great restlessness. But should there be 
several convulsions which continue with more or less regularity, 
showing the essential characteristics of the true disease, including 
the aura, the epileptic cry, and the various postconclusive 
phenomena, common reason would lead us to designate them as 
epileptic. So while dentition may never be an unqualified factor, 
it has under special conditions the power to incite a type of con- 
vulsion that may pass into epilepsy so far as the general results, 
by prognosis, and the treatment are considered. In 30 cases the 
palsy originating between the sixth and eleventh month of life, 
and all persons known to the writer, difficult dentition was the 
assigned cause." 
In this connection it should be borne in mind that delayed tooth 
eruption, particularly the third molars, may occur and be a source 
of serious irritation at later periods of life. One of the author's 
patients, a young lady, aged twenty-six years, suffered from intense 
and more or less continuous pain at various points of distribution 
of the fifth nerve on the left side, accompanied by choreic move- 
ment of the muscles of the arm and leg upon the affected side, with 
occasional manifestations in the facial region. It was found that 
the crown of the left superior third molar was crowded between the 
roots of the second molar upon the same side, and the left lower third 
molar was so impacted as to cause continued crowding of the lower 
teeth. The removal of these teeth gave a measure of relief, although 
the long continuance of the symptoms before this cause was dis- 
covered had undoubtedly led to general involvement which made 
immediate cure impossible. 
Such conditions are very common causes of nervous disturb- 
ance. Large numbers of the author's patients with varying symp- 
toms of neurasthenia, chronic neuralgia of the head and face, and 
other neuroses have been relieved or completely cured by the dis- 
covery and removal of malposed or impacted teeth delayed in 
their eruption. (For further references see pages 65 to 73.) 
A case of Jacksonian epilepsy in a man, aged twenty-two years, 
is an example of the effect of surgical maxillary separation in cer- 
tain epileptics. 
History.-Nervous troubles began in 1904. The seizures 
started with spasmodic contractions, or numbness, sometimes 
partial or complete unconsciousness. The symptoms usually SPASMODIC NEUROSES 
351 
began in the right foot and ascended to the head, and across the 
forehead, but only in the more profound attacks was the left side 
involved. An extract from the records of St. Mary's Hospital 
shows the frequency of these attacks at the time of his entrance, 
during one day and one night. The record for every day and night 
was practically the same: 
Record. 
7.10 a.m. Slight spell lasting thirty seconds. Muscular twitch- 
ing of left arm and eyes. Sleeping. 
7.20 a.m. Slight spell lasting twenty seconds. 
7.30 a.m. Twitching of left side. 
7.45 a.m. Slight spell lasting fifteen seconds. Twitching of 
left limb and arm. 
8.00 a.m. Slight spell lasting twenty seconds. Twitching of 
left arm. 
8.05 a.m. Slight spell lasting twenty seconds. Twitching of 
left and right limb. 
8.30 a.m. Slight spell lasting thirty seconds. Muscular twitch- 
ing of eyes and left side. 
8.50 a.m. Severe spell lasting forty seconds. Twitching of 
muscles. 
8.54 a.m. Slight spell lasting twenty seconds. Muscular 
twitching of left limbs. 
8.57 a.m. Slight spell lasting twenty seconds. Muscular 
twitching of face. 
9.10 a.m. Slight spell lasting ten seconds. Twitching of feet. 
9.20 a.m. Slight spell lasting thirty seconds. Twitching of left 
limbs. 
9.30 a.m. Slight spell lasting forty seconds. Muscular twitch- 
ing of eyes and left arm. 
9.45 a.m. Slight spell lasting fifteen seconds. Muscular twitch- 
ing of feet and left arm. 
9.55 a.m. Slight spell lasting thirty seconds. Twitching of left 
limbs. 
10.00 a.m. Slight spell lasting five seconds. Twitching of left 
hand. 
10.07 a.m. Slight spell lasting forty seconds. Muscular twitch- 
ing of feet and eyes. 
10.10 a.m. Slight spell lasting twenty seconds. Twitching of 
left limbs. 352 
NERVOUS SYSTEM AND THE BUCCAL REGION 
10.15 a.m. Slight spell lasting fifteen seconds. Throwing left 
foot from body. 
10.20 a.m. Slight spell lasting twenty seconds. Twitching of 
left limbs. 
10.30 a.m. Slight spell lasting ten seconds. Twitching of limbs. 
10.34 a.m. Slight spell lasting thirty seconds. Muscular twitch- 
ing of eyes. 
10.43 a.m. Severe spell lasting fifty seconds. Muscular twitching 
of limbs, tossing about, coughs at intervals. 
10.50 a.m. Slight spell lasting thirty seconds. Twitching of left 
limbs, pulling at clothing. 
11.00 a.m. Slight spell lasting ten seconds. Twitching of eyes. 
11.10 a.m. Slight spell lasting twenty seconds. Twitching of 
limbs. 
11.20 a.m. Slight spell lasting five seconds. Twitching of eyes. 
11.30 a.m. Slight spell lasting thirty seconds. Twitching of 
limbs. 
This record is typical of his other days up to the time of the opera- 
tion. His maxillary bones were separated through an incision under 
the upper lip. A wide separation was immediately effected, and 
pressure with the appliance continued by tightening the nut for 
several days, until he said it felt like a gale of wind through his 
nose when he breathed. Following the operation diplopia was 
noted. The double vision soon disappeared and in the course of 
three or four days the attacks began to be less frequent, and 
had ceased altogether by the ninth day, when he was discharged 
from the hospital. 
He was quite free from further trouble, grew strong and well 
and increased in flesh, for a period of about two years. At this 
time it was learned that he had had more or less recurrence of the 
attacks. As he has not reported, the author is unable to state the 
character or duration of the relapse. 
The expression of his eyes and his whole appearance changed, 
as the effect of the improved respiratory condition became apparent. 
All cases that have been treated in this way, thus far, have evi- 
denced improvement, but some have not been completely relieved 
for any considerable period of time. 
The young woman shown in Fig. 158' is at the present time and 
for several weeks has been free from epileptic seizures, which up to 
the time of surgical maxillary separation for intranasal enlargement 
had gradually been becoming more frequent and serious in their SPASMODIC NEUROSES 
353 
character. It seems unnecessary to make an attempt to report these 
and other cases in detail, for this brief reference is only intended to 
call attention to' the possibilities of intelligent oral treatment as a 
helpful measure for the relief of at least some of the sufferers from 
epilepsy and similar affections, but not in any sense as a sovereign 
remedy. When indicated by high narrow palates, contracted dental 
arches, and nasal conditions which favor the habit of mouth-breath- 
ing, this should be a routine measure in all cases of epilepsy to 
prepare for and increase the efficiency of any other treatment that 
may be given. 
Fig. 158.-An epileptic young woman who seems to have been entirely relieved 
by this surgical immediate separation of the maxillae. Shows a type of face that 
indicates the need of this treatment. 
Bacillus Epilepticus.-Dr. C. A. L. Reed,1 of Cincinnati, claims 
to have discovered that the cause of epilepsy is a bacillus which 
he has isolated and named the "Bacillus epilepticus." 
Terhune reports that the Bacillus epilepticus has been isolated 
from 75 per cent, of 24 of the cases of epileptics, from which cultures 
were made during, or immediately following seizures, and 18 in 
whom no convulsions had occurred for several days. Wherry, 
Oliver, Canavan, and other investigators have failed to identify 
this bacillus, and its etiological identity with epilepsy is not yet gen- 
erally accepted. Reed has also reported a large number of cases in 
which he believes a cure has been effected by operations to overcome 
colonic stasis. 
1 Practical Medicine Series, Nerv. and Ment. Dis., 1916, p. 19. 354 
NERVOUS SYSTEM AND THE BUCCAL REGION 
HYSTERIA. 
Hysteria is a neurosis characterized by abnormal cessations, a 
morbid susceptibility to emotions, and inability to restrain their 
manifestations. 
Etiology.-Hysteria plays a part in nervous affections of the 
mouth and associated parts, as in other regions of the organism 
as a whole. Its extended consideration would be outside the 
province of this work, except insofar as general conclusions may 
be indicated to avoid error in diagnosis and treatment. 
Symptoms.-Babinski1 states that the reason for the excessive 
extension of the symptomatology of hysteria is due to.three lead- 
ing causes: (1) Errors of diagnosis, many organic cases being 
considered hysterical; (2) failure to detect simulation; (3) failure 
to distinguish various nervous states which ought to be distin- 
guished one from another. 
He differentiates between two great groups of symptoms, as 
(1) those which can be produced by suggestion, and (2) those 
which cannot be so produced. 
Symptoms which may be produced by suggestion, and are 
therefore hysterical, are: Convulsive crises, paralysis, contractures 
of every sort and location, various tremors, choreic movements, 
disturbances of phonation and of respiration, sensory disturbances 
such as anesthesia and hyperesthesia. Symptoms not capable of 
being produced by suggestion, and therefore not hysterical, are: 
Exaggeration or loss of the tendon reflexes, vasomotor, secretory, 
and trophic changes, hemorrhage, anuria, albuminuria, and fever. 
Diagnosis.-It is sometimes very difficult to determine whether 
pain in teeth or other points of distribution of the fifth nerve, 
spasmodic affections of the muscles and other similar disturbances 
in the region of the mouth are wholly or even partially of hysterical 
origin or their apparent gravity exhibited from the same cause. 
Too often real though hidden pathological conditions are overlooked, 
and through imperfect diagnosis there is failure to give relief, and 
much consequent suffering because the symptoms have been erro- 
neously pronounced imaginary after superficial examination. 
On the other hand, it has not infrequently occurred that teeth 
have been needlessly extracted, pulps of teeth removed, useful 
1 La Semaine Medicale, January 6, 1909. Babinski's articles on the Dismember- 
ment of Traditional Hysteria Pithiatism, published in La Semaine Medicale, as the 
first paper in 1909, translated by Charles Gilbert Chaddock, and published in the 
Interstate Medical Journal, March, 1909. NEURASTHENIA 
355 
fillings or other dental work destroyed, and no local real pathological 
conditions of the parts so treated. No set rule for the avoidance 
•of such errors can be given, and the operator must necessarily 
rely upon his own knowledge and skill as a diagnostician to deter- 
mine indications of actual disease, supplemented by good judg- 
ment in determining the mental attitude of each patient. With 
the foregoing division of affections that might or might not be 
evidence of hysteria as a guide, differentiation will be much simplified. 
NEURASTHENIA. 
Neurasthenia may be defined as debility or impaired activity 
of the nerves or of the nervous system generally, nerve causation. 
Etiology.-The leading causes of neurasthenia summed up 
according to Schofield,1 who is in accordance with other writers, 
are: 
1. Poisons from influenza, syphilis, enteritis, dyspepsia, alcohol, 
drugs, zymotic and other diseases. 
2. Malnutrition. 
3. Fatigue from overwork, worry, insomnia, pain, sexual excesses, 
suppression. 
4. Emotional strain from shock, grief, accidents, religion, love, 
etc. 
5. Indirect causes, as enteroptosis, floating kidney, eye-strain, 
also bad environment, suggestion, and other psychic factors. 
The principal predisposing cause is hereditary. Psychologically 
neurasthenia is a disease of exhaustion of the higher nerve centers, 
since poisoning produces toxic effects similar to those from over- 
work. To weakness of these centers by fatigue or poison from 
some of the above causes we may attribute even the most psychical 
symptoms of this disease, such as "phobias" and "obsession," 
provided always that the patient be free from any underlying 
mental taint. 
To these should be added, for our special purpose, conditions 
of the mouth which can, and do in many instances, predispose 
or directly or indirectly contribute to any or all of the foregoing 
etiological influences. 
It is well known that there is no more common factor associated 
with the cause of stomach and intestinal disturbances and mal- 
nutrition than diseased, uncleanly, or defective teeth. The question 
1 British Med, Jour., September 19, 1908; Practical Medicine Series, 1909, x, 31, 356 
NERVOUS SYSTEM AND THE BUCCAL REGION 
of food trituration in mastication and its proper insalivation from 
active proper use of the jaws, the necessity of sufficiency or insuf- 
ficiency of ptyalin from the saliva for assistance in the digestion of 
starch foods, and the effect of all these combined influences upon me- 
tabolism are so obvious as to make elaborate discussion unnecessary. 
The same may be said of bacterial influences, exerted by pathogenic 
microorganisms from uncleanly, decaying, or diseased tooth roots, 
gums, and other structures being carried through the intestinal tract 
and focal infection via other channels. It is also well understood that 
there is no more active or constant poison in general disease than the 
autotoxemia which goes hand in hand with these conditions. The 
question of fatigue, however, requires distinct consideration on 
account of the fact that tooth grinding, especially at night, is an 
almost constant symptom of general nervous states and particularly 
neurasthenia. On account of the teeth being crowded in the dental 
arch, imperfect occlusion through loss of teeth, malposition, or other 
conditions that may tend to produce irritation, the habit of clenching 
and grinding teeth is induced. Patients are seldom ready to admit 
the fact until absolutely proved, because the habit is an unconscious 
one, active at subconscious moments in the daytime, but more par- 
ticularly at night during sleep, which is therefore not sufficiently 
restful. The constant exertion of the muscles of mastication with 
the incident brain-cell stimulation prevents perfect rest, which 
in the course of time may undoubtedly lead to quite as grave 
conditions as eye-strain or any of the other similar factors which 
are much better understood and in consequence more often recog- 
nized in diagnosis. The jaws, teeth, and other structures or tissues 
connected therewith, as well as the contents of the mouth and its 
use, including hygienic care and habits which concern conscious or 
unconscious use, are inevitably matters of importance in considering 
causative factors and bear an important relation to all divisions 
of the foregoing etiological classification. To say that these oral 
influences are the most important causes would be ridiculous in 
the face of broader knowledge of contributing affections. It has 
been, however, a matter of frequent occurrence in the author's 
clinical experience that the correction, treatment, and care of the 
teeth and mouth for relief of patients suffering from neurasthenia 
have been efficient in setting them on the road to recovery. The 
results have been so satisfactory in helping build up resistance 
against other pathogenic influences that in this light the subject 
warrants the fullest possible attention under every circumstance. ANGIONEUROTIC EDEMA 
357 
ANGIONEUROTIC EDEMA. 
Angioneurotic edema is a transient edematous swelling affecting 
limited portions of the surface of the body. 
Fig. 159.-Condition, in 1889, before enlargement of head and neck began. (Starr.) 
Fig. 160.-Condition, in 1894, showing uniform enlargement of the head. (Starr.) 
Etiology.-The cause is not fully understood' "Exposure to 
cold seems to have an effective immediate influence. Osler recog- 
nizes an hereditary influence. 358 
NERVOUS SYSTEM AND THE BUCCAL REGION 
Pathology.-The pathology is not known. 
Symptoms.-The symptoms may affect any part of the body, 
bnt usually appear in the face and extremities. There is swelling, 
which may come and go quickly or continue for several days. 
Color may vary from red to whitish yellow or pale. There is 
stiffness and numbness of the part. 
Treatment.-The treatment is not well understood, but massage 
and strychnin are recommended. Most of the cases reported have 
been those in which the symptoms were quite marked, but a slight 
transient edema of the face quite unaccompanied by any inflamma- 
tory symptoms is frequently noticed in patients suffering from tic 
douloureux and other affections due to irritation of the trigeminal 
nerve. Although no claim is made that these are identical with 
angioneurotic edema, yet in the absence of full etiological and 
pathological knowledge there is at least sufficient similarity to war- 
rant careful search of the teeth and mouth for possible chronic 
irritations of dental pulps, malposed impacted teeth, and other 
similar factors that might be aggravating influences. The immediate 
correction of any such condition is certainly indicated. 
TROPHIC CHANGES. 
Trophic changes as evidenced by atrophy due to nervous causes 
is well understood. Hypertrophy that can only be satisfactorily 
accounted for as a neurosis occurs occasionally. Starr accounts 
for the marked increase in the size of the head and face shown in 
Figs. 159 and 160 as due to one of the trophic neuroses. These 
are of interest to our subject because of the region affected. There 
may also be alterations affecting the hair, face, and lips of similar 
origin. 
PROGRESSIVE LIPODYSTROPHY. 
Progressive lipodystrophy, a condition in which there is progres- 
sive disappearance of adipose tissue of the face, upper chest, and 
arms. There are no symptoms except loss of subcutaneous fat of 
the affected parts, with increase of adipose tissue in the lower parts 
of the body. The condition is very rare, approximately 16 cases on 
record. Enlargement of the thyroid indicates excessive thyroid 
functioning. The cause of this affection is not definitely known. CHAPTER VI. 
DISEASES OF BONE. 
Among the elements pertaining to processes of bone develop- 
ment, consideration of which belongs more properly to the text- 
books on Histology and Embryology, there are some which have 
such an important bearing upon morbid processes affecting bones 
of the face and jaws in common with other osseous structures that 
they deserve brief consideration. 
Osteogenesis.-In growing bone while absorption is taking place 
in the interior of the bone, through the agency of the osteoclasts, 
additional bone is formed by the osteoblasts upon the external 
surface from the generic layer of the periosteum. This is called 
osseous apposition. 
Osseous Resorption.-Bone absorption takes place through the 
action of nucleated masses of protoplasm directly acting upon the 
calcified matrix, to form small cavities, called Howslip's lacunae. 
Osteoclasts are the cells which accomplish this result. Lacunar 
absorption is not only important in physiological processes, but is 
frequently concerned in the pathology of atrophic bone absorption. 
Atrophy of Bone.-Atrophy of bone may be eccentric when it 
progresses from within outward, concentric when it begins imme- 
diately under the periosteum and progresses inward with tendency 
to lessen the circumference of the bone. 
The processes by which bone absorption takes place are: 
Lacunar Absorption.-Described above. 
Perforating Canal Absorption.-This consists in the penetration 
of newformed bloodvessels through the lamella which communi- 
cate with the Haversian canals and increase the area of excavation 
along these channels, thus leading to osteoporosis. 
Ilalisteresis.-This consists in the removal of lime salts, with 
subsequent changes in the osseous matrix. There is some question 
whether this is a true atrophic process, but it is usually so con- 
sidered and may be. 
Local.-In connection with some pathological process; or, 
General.-As an evidence of constitutional conditions, and is 
then called osteomalacia. 360 
DISEASES OF BONE 
Osteomalacia.-Osteomalacia is characterized by absorption of 
the bone salts with other changes in the bone that cause extreme 
flexibility, and is probably a form of trophic neurosis, although its 
exact cause is not definitely understood. It is frequently found 
in puerperal women, and may be accompanied by distortions, 
bends, and even fractures of bones. 
Regeneration of Bone.-Regeneration of bone occurs when 
fracture or loss of bone structure takes place through injury or 
disease. As a result of irritation, proliferative changes take place, 
new bloodvessels are formed, and the tissue becomes hardened 
from deposit of calcareous matter and cartilaginous formation. 
Gradually bone is formed through the renewed activity of bone- 
forming processes thus excited. 
In recent years much discussion has taken place, and quite 
opposite opinions have been expressed, concerning the osteogenetic 
activities of the periosteum. To one accustomed to plastic opera- 
tions, involving the transposition of periosteal structures, it is not 
surprising that one experimenter will find that the periosteum is 
incapable of bone formation when unassisted by other influences, 
and another will report, quite as positively, that the preservation 
of the periosteum is important for bone regeneration following 
operative procedures. Undoubtedly the personal equation is an 
important, often a deciding, influence in determining such experi- 
mental results. Personally, the author has no doubt of the osteo- 
genetic functions when the periosteum is preserved intact, and 
uninjured, in its natural situation. Evidences of this may be seen on 
pages 496 and 526. The testimony of successful bone grafts may also 
be adduced to prove this contention. Quite naturally it is the com- 
bination of periosteum with extension of bone growth from fractured 
or divided bone ends that is required, and shell combination should 
be contemplated in designing surgical procedures. 
Pressure Atrophy.-Pressure atrophy occurs from constantly 
applied pressure. This may be mechanical or due to tumors, 
aneurysms, the accumulation of fluid in cavities surrounded by 
bone, as in the air sinuses of the face, abscess, cysts, and similar 
conditions. It is upon this principle that the effectiveness of 
orthopedic and orthodontic appliances depends. 
Surgically, questions of bone formation, resorption, and regen- 
eration are of great importance as affecting restoration of bone 
when destroyed by disease or surgically removed; the possibility 
of bone formation taking place from periosteum that has been 
left intact after the removal of sequestra of necrosed bone, and RICKETS 
361 
the renewed activity of osteoblasts in persons of advanced years, 
or who have passed the period of normal bone growth; in repair 
of fractures and reconstruction following operations. Such ques- 
tions also constantly arise in connection with bone absorption 
incident to the movement of teeth in orthodontic treatment and 
in operations for cleft-palate, particularly as related to the results 
from mucoperiosteal flaps. 
Malformations of Bone.-Etiology.-The many perversions of 
osseous development, which are usually evidenced by defective 
or perverted bone formation, may be due to general disease, 
inherent tendency, achondroplasia, i. e., defect in the laying down 
of primary enchondrial matrix from which most of the bones of the 
skeleton are formed, and in which such defects are later evidenced, 
arrested development, affections of the central nervous system, 
traumatic injuries, abnormal muscular action as influencing per- 
version of form, imperfect metabolism, rachitis (rickets), and other 
causes which are more specifically described in chapters relating 
to deformities. 
Agenesis.-Entire failure of development may be restricted to one 
bone, a part of a bone, or the entire skeleton, as in microsomia, 
nanosomia, the terms used to describe dwarfs. 
Changes in bone marrow result from systemic conditions and 
from local disease; usually this is a marked feature in pernicious 
anemia, acute leukemia, and acute infections. 
Osteogenesis Imperfecta.-Congenital insufficiency of the bone- 
building elements results in a condition of osseous structure which 
is in effect much like osteomalacia. Such children are usually 
very small at birth, with evidence of more or less imperfection 
of general form. The bones are extremely fragile and fracture 
easily. Not infrequently there is mental defect also. 
RICKETS, RACHITIS, RACHITISMUS, MORBUS ANGLICUS. 
Rickets.-Rickets is a constitutional disorder characterized by 
abnormal development of the bones and other structures with 
lack of normal calcification. 
Etiology.-The etiology is not fully understood. It is believed 
to be a disorder of nutrition during the period of active growth. 
Pathology.-Osteoporosis results from lacunar absorption. Osteo- 
phytes are formed from unusual periosteal activity. There is 
abundant production of osteoid matrix penetrated by medullary 
vessels, but there is a lack of normal deposits of bone. Ligamen- 362 
DISEASES OF BONE 
tons attachments of bone are imperfect, there is deficient muscular 
development as well as pathological abnormalities of the internal 
organs, with catarrhal affections of the mucosa. 
Prognosis.-Prognosis depends upon the possibility of inducing 
natural or forced improvement; the developmental processes before 
prognosis of the disease has rendered such improvement possible. 
Treatment.-Treatment should be governed by such measures 
as may tend to improve nutrition and facilitate normal general 
development. There should be a nourishing diet, which should 
include fats and nourishing oils in such quantities as may be properly 
assimilated. Cod-liver oil and phosphorus may be beneficial, 
baths, massage, open-air exercise, and generally healthful condition 
must be insured, and supplemented by proper support and correc- 
tion of osseous deformities. In these cases there is usually more 
or less marked abnormality in development of the teeth and jaws. 
Proper regulation of these conditions offers favorable opportunity for 
rendering assistance to these patients, both directly and indirectly. 
Hypertrophy of Bone.-Hypertrophy of bone may be local or 
general. 
Local Hypertrophy.-Etiology.-Increased or unusual develop- 
ment of muscles sometimes causes ridges and thickening of the 
bone surface to which the muscles are attached. Chronic irritation 
of the periosteum may also cause increase of bone structure. 
Symptoms.-The symptoms are ridges or excrescences upon 
bone surfaces, abnormal thickness or giant growth which may 
affect certain bones or part of the skeleton. In children this is 
usually noted in the upper extremities. 
General Hypertrophy.-Gigantism, general hypertrophy, or com- 
plete giant growth is usually first noted about the age of puberty. 
The bones become large, thickened, and irregular, and the indi- 
vidual sometimes attains an enormous size. 
Acromegaly.-This disease is characterized by giant growth 
which affects both flat and long bones, but is most frequently 
noticeable in the face, particularly the lower jaws and nose, the 
hands and feet, forearms and legs. It is accompanied by more 
or less hyperplasia of the soft tissues in the affected regions. 
Etiology.-That there is some etiological relationship between 
gigantism and acromegaly as well as leontiasis ossea and hemi- 
hypertrophy of the face is generally conceded, although not fully 
understood. The most commonly accepted theory at the present 
time is that it results from some pathological condition of the 
hypophysis cerebri and enlargement of the sella turcica found in ACROMEGALY 
363 
the skeletons of giants has been accepted as evidence of the enlarge- 
ment of the pituitary body. Cushing, Sajous and others have 
gathered evidence to prove that there is a direct relationship between 
pituitary disease and bone hypertrophies. 
Symptoms.-The lower jaw increases in length and thickness, 
becomes swollen, prognathous, and may project much beyond 
the upper. This together with growth in the length and thickness 
Fig. 161.-Acromegaly. (Park.) 
of condyles sometimes renders occlusion of the teeth impossible. 
The nose becomes thick and broad, the lips thick and protruding, 
the facial sinuses much enlarged, with more or less bulging in this 
region. The hands and feet become enormously large and thick. 
Similar changes may take place in the pelvic bones, the sternum, 
ribs, and in the spine, which with a drooping forward of the head 
and the prognathous lower jaw give an ape-like deformity (Fig. 1G1). 364 
DISEASES OF BONE 
Prognosis.-As there is no exact knowledge of the cause, and 
treatment is uncertain, the prognosis must necessarily be grave. 
The progress of this disease', however, is often very slow and does 
not directly shorten the period of life. 
Treatment.-Aside from such operative procedure as in rare 
instances may be required to overcome the inconvenience and ill 
effect of the deformity, especially to make possible the use of the 
jaws in mastication, the only hopeful treatment seems to lie in 
the administration of pituitary extract, with rest, change of occu- 
pation, and such supplementary measures as may tend to restore 
general nervous balance. 
Cushing has suggested and reported good results from opera- 
tions for removal of pathological processes which may affect the 
gland. 
Fig. 162.-This patient had formerly been under the care of Dr. Cushing at 
Baltimore, and it is from his work on the pituitary body that these pictures were 
taken. Patient before the onset of the malady (aged eighteen); at the time of the 
onset (aged twenty-six); after its full development (aged forty). 
One case of a man past middle life was referred to the author 
for operation to make closure of the jaws possible. All the typical 
symptoms of this affection were present in very marked degree, 
but further progress of the unwelcome growth had already been 
checked, presumably by long-continued treatment with pituitary 
extract, and the mechanical difficulty of occlusion had been so 
well overcome by ingenious dental work performed by Dr. Robin 
Adair, of Atlanta, Georgia, that it seemed unnecessary to incur 
the risk and uncertainty of operation upon the jaws. (See Fig. 
162.) 
Hemihypertrophy of the Face.-This condition, in which the 
bones of the face become enlarged upon one side, is presumably 
closely allied to acromegaly, although its true character is not 
fully understood. OSTITIS DEFORMANS 
365 
Leontiasis Ossea.-This form of bony growth affects with more 
or less symmetrical enlargement the facial bones upon both sides, 
particularly the upper part of the face, and has received its name 
on account of the lion-like appearance of the countenance. 
Etiology.-Etiologically there seems to be every reason to believe 
that all of these affections are closely allied, but definite knowledge 
is lacking. 
Symptoms.-In the course of development of hypertrophied 
bone, it may restrict the size of the orbits, the nasal passages, 
or foramina, and by compression of enclosed structures, especially 
when nerve trunks are involved, give rise to painful or other symp- 
toms of nervous disturbance (Fig. 163). 
Fig. 163.-Leontiasis. Skull of a Chinese woman. (U. S. A. Museum, No. 10,620.) 
Treatment.-Surgical treatment is practically unavailing, because 
removal of portions of the hypertrophied bone only gives temporary 
relief and the deformity quickly returns. 
Ostitis Deformans.-Ostitis deformans is a disease of middle 
life or later, manifested by thickening of the skull and long bones, 
marked softening and loss of resistance to pressure. 
Etiology.-Its etiological character is unknown. There is a differ- 
ence of opinion as to whether it is a result of an inflammatory 
cause, trophic disturbance, or syphilis. 
Pathology.-The compact bone becomes absorbed with con- 
fluence of the Haversian canals, and there is new formation of 
uncalcified osseous tissue with accompanying alteration in form. 366 
DISEASES OF BONE 
Symptoms.-The symptoms include broadening of the cranium, 
curvatures of the long bones, pain and discomfort in the affected 
region. 
Treatment.-Until its character is better understood its treat- 
ment must necessarily be only for the relief of such general patho- 
logical states as might be recognized as interfering with bone 
nutrition, and good hygienic care is, of course, always indi- 
cated. 
The removal of all focal infection in such cases should not be 
overlooked. 
DISEASES OF THE PERIOSTEUM. 
Hemorrhage under the Periosteum. Etiology.-This condition 
may be caused by scurvy and other blood diseases, trauma, or 
infectious diseases. 
Pathology.-The formation of a blood clot under the periosteum 
destroys its attachment from the bone over- a more or less exten- 
sive area. If infected, there may be suppuration, necrosis, and the 
results which follow in sequence from these conditions. 
Prognosis and Treatment.-When absorption in natural course is 
sufficient to remove the blood the symptoms subside without 
treatment, but if this does not occur spontaneously then treat- 
ment is required to be directed toward overcoming the disease 
acting as an underlying cause, or to cure pathological results as 
described in consideration of periostitis. 
Periostitis.-Inflammation of the periosteum may be acute 
or chronic. Its forms are simple or non-infective, suppurative, and 
ossifying, or osteoperiostitis. 
Acute Simple Periostitis.-Etiology.-This form is due to trifling 
or traumatic injuries to the periosteum without infection. 
Pathology.-The periosteum becomes swollen and may be 
separated from the underlying bone by subperiosteal hemorrhage 
This is quickly followed by absorption of the blood, proliferation 
of connective tissue, and more or less leukocytic infiltration. 
Through the activity of the phagocytes the blood is removed, the 
cellular products of the inflammatory condition may result in the 
formation of cicatricial tissue which may become calcified or form 
bone by the assistance of the osteoblasts. 
Symptoms.-Pain, tenderness to pressure, and sometimes hemor- 
rhage under the periosteum, which causes more or less separation 
from the bone, are prominent symptoms. DISEASES OF THE PERIOSTEUM 
367 
Prognosis.-The prognosis is good, except when infection takes 
place. 
Treatment.-Usually little assistance is required to hasten 
recovery. Hot fomentations and occasionally, in the more trouble- 
some cases with extensive hemorrhage under the periosteum, inci- 
sion through the overlying tissues down to the bone surface, to be 
followed by suitable antiseptic dressings. 
Purulent Periostitis.-Periostitis due to infection by micro- 
organisms may be circumscribed, confined to a small area, or diffuse, 
when the suppurative process tends to spread over the bone surface 
and separate the periosteal attachments over a more or less consider- 
able area. 
Etiology.-Suppurative periostitis is associated with both ostitis 
and osteomyelitis, being sometimes a cause and sometimes a result 
of these diseases. Its etiological factors are therefore identical 
with those enumerated in description of these affections of bone 
(see p. 368). 
Pathology.-There is more or less marked swelling and cellular 
infiltration with pus formation which tends to separate the perios- 
teum and bone. If sufficient to interfere with circulation and 
nourishment over an extended area of bone surface superficial 
necrosis with exfoliation results. 
Treatment.-The treatment of purulent periostitis requires 
removal or treatment of the cause, relief of the pus by incision 
down to the bone under antiseptic precaution, and cleansing of 
the wound, preferably with tincture of iodin. The application of 
hot gauze wrung out in boric acid solution, 1 to 1000 bichloride 
of mercury or other suitable antiseptic, which may be required 
to check if possible both the danger of more general infection and 
local destruction of the underlying bone. 
Osteoperiostitis. - Osteoperiostitis may result from long-con- 
tinued, not too severe chronic irritation and from constitutional 
diseases, notably syphilis. 
Pathology.-A proliferation of the osteogenetic layer of the 
periosteum takes place, the partial ossification, and finally com- 
plete bone formation with attachment to the underlying bone, 
results in the form of excrescences, exostoses, or osteophytes. 
Treatment.-Treatment consists in removal of the cause and 
when required removal of the superfluous bone. These growths 
are frequently noticeable in the maxillae, sometimes along the 
central division of the palate. Occasionally there are enlarge- 
ments of the buccal side and posterior to the tuberosities and at 368 
DISEASES OF BONE 
other points in the neighborhood of the roots of teeth. Usually 
they are unattended by disturbing symptoms. Occasionally the 
bone growth interferes with some other parts, and its removal is 
required. 
INFLAMMATION OF BONE. 
Inflammation of bone is recognized in two principal forms. 
These are osteitis or ostitis, inflammation of the compact portion 
of the bone, and osteomyelitis, inflammation originating in or 
extending to the medullary structures. 
Clinically it is practically impossible to differentiate between 
these two forms of bone inflammation because almost invariably 
one leads to the other. 
Osteomyelitis.-Osteomyelitis is an infective disease involving 
at first the bone marrow and central or cellular parts of the bone. 
Etiology.-Its causes are pyogenic microorganisms following 
traumatic injury, suppurative forms of periostitis, infection through 
the circulation, infective diseases, dento-alveolar abscess, fracture 
and toxic effects from mineral or other poisons. Quite frequently 
it has been found to be the result of infection from the pneumo- 
coccus, Bacillus typhosus, Bacillus coli communis, tubercle bacilli, 
and other microorganisms. 
Pathology.-Cellular infiltration and proliferation accompany 
changes in the bone marrow. Vascular distention is associated 
with thrombosis, which is followed by coagulation necrosis, lique- 
faction of intercellular substance and the development of purulent 
foci. Coalescence of these tiny abscesses leads to rapid destruction 
of bone. Dead bone is thrown off in the form of a sequestrum, and 
suppurative periostitis conveys the infection to the overlying tissues 
with resulting inflammation and the formation of a sinus for the 
discharge of pus. 
Symptoms and Treatment.-See Necrosis. 
NECROSIS OF THE JAWS. 
Necrosis and caries of bone are sequelae of bone inflammation, 
and since it is these conditions of the maxillary bones that most 
frequently require treatment, the acute, subacute, and chronic 
forms of both, ostitis and osteomyelitis, as well as the symptoms 
and treatment of these associated conditions, will be considered 
together in their relation to necrosis for purposes of simplification 
and clinical directness. NECROSIS OF THE JAWS 
369 
Necrosis and Caries.-Necrosis is death of bone en masse. 
Technically any dead tissue is necrotic, but the term necrosis is 
usually applied to distinguish from a slough, gangrene, or death 
en masse of soft tissue. Caries is molecular destruction of bone. A 
similar condition affecting the soft tissues is called an ulcer. 
Etiology.-Acute or chronic diseases of the periosteum, bone 
marrow, and adjacent bone, and interference with blood supply 
by separation from the underlying bone in purulent periostitis 
are the direct causes of necrosis. 
The factors to which these conditions are due have already 
been described as injury, infection by pathogenic microorganisms, 
including staphylococci and other bacterial forms recognized as 
representative of general disease and the toxic effects of certain 
mineral and other poisons, which are also capable of producing 
the practically inseparable chain of conditions associated with 
bone inflammation. Some of these causes require individual 
recognition and special treatment in order to secure successful 
results from local treatment of the diseased bone. 
The classification of etiological factors on page 370 is presented 
as arranged for clinical convenience and assistance. 
There are some peculiarities of necrosis of jaws the importance 
of which has been impressed upon the author by a long series of 
cases in which very disastrous results might have been averted by 
early recognition of the cause. In some of these, as will be noted, 
the process of bone destruction continued for fifteen years and 
more, with widely distributed ill results through constant absorp- 
tion of toxic products by the general system. The following cases 
are typical forms of necrosis of the jaws, therefore, each has an 
important significance. 
Case I.-This was a child, aged five years, with history of 
trouble with pain, which began many months before coming under 
the author's care. There were swelling and soreness of the mouth 
in the region of the premolar teeth, high temperature, malaise, 
and a slight eruption upon the skin. Her physician diagnosti- 
cated typhoid fever; later the disease was termed some other form 
of fever. Upon examination it was found that large sequestra 
of bone representing the major portion of both upper and lower 
jaws were in a state of exfoliation, and so completely had Nature 
performed her office in this respect that upon removal of the dead 
pieces of bone newly granulated surfaces beneath them were found 
to be perfectly healthy and the child discharged from the hospital 
as practically cured the day following the operation. 370 
DISEASES OF BONE 
Devitalized or infected, or 
Gangrenous tooth pulps. 
Imperfectly filled roots of teeth. 
Fractured roots of teeth. 
Implantation, transplantation, and replantation 
of roots of teeth. 
Dento-alveolar 
abscess 
Chronic pericementitis. 
Pyorrhea alveolaris. 
Pericemental abscess. 
Ulcerative stomatitis. 
Gangrenous stomatitis. 
Gangrenous conditions of the buccal tissues. 
Diseases of the 
teeth and al- 
veolar struc- 
tures 
Inj ury to the periosteum with subsequent infection. 
Compound fractures of the jaw or of teeth, or 
dislocation of roots of teeth. 
External blows, or force causing the jaws to strike 
forcibly together, causing subsequent death and 
infection of and from tooth pulps. 
Traumatism 
Foreign bodies in the tissues. 
Extension of nasal disease. 
Empyema of the maxillary sinus. 
Middle-ear disease, furuncle or other inflammatory affections of the skin and soft 
tissues of the face. 
Surgical operations upon the maxillary bones. 
Exanthemata or eruptive fevers 
Typhoid fever. 
Scarlet fever. 
Measles. 
Smallpox. 
Infectious 
diseases 
Influenza (la grippe). 
Tuberculosis. 
Syphilis. 
Actinomycosis. 
Glanders. 
Leprosy. 
Predisposing conditions 
' Anemia. 
k Chlorosis. 
Blood disorders 
Leukemia. 
Pernicious anemia. 
Scurvy. 
Septicemia. 
Pyemia. 
Mercury. 
Arsenic. 
Phosphorus. 
Lead. 
Corrosive and escharotic 
Acids and alkalies. 
Inorganic poisons 
Toxic agents 
Vegetable poisons in the form of 
drugs may lead to necrosis by 
their direct destructive action 
upon tissue, or secondarily by 
causing depleted conditions to 
the general system, or induc- 
ing diseases of special organs 
which may predispose to bone 
diseases, as may also animal 
poisons, such as bites of veno- 
mous reptiles, stings of insects, 
etc. 
Organic poisons NECROSIS OF THE JAWS 
371 
Case IL-This was the case of a young boy, Harry D., aged 
seven years. Trouble began with toothache, which lasted for 
six months. After extraction of tooth, swelling began in the face. 
The symptoms were fistula with pus discharge at extreme angle 
just below right eye. Depression was marked in that region and 
the lower eyelid was everted. There had been one or two operations 
performed, and his surgeon finally advised the parents to wait 
until all of the dead bone might be forced out through the fistula 
just at the outer angle of the eye. At this point several pieces had 
been removed. It was found that almost the entire upper maxilla 
upon the affected side was necrosed. By carefully removing each 
loosened piece of bone without disturbing underlying structures it 
was possible to leave the molar teeth in course of eruption partly 
embedded in healthful bone structure. Later development proved 
that new bone was formed about these teeth and in that way 
serious deformity was avoided. 
Case III.-Sam. F. K., aged twelve years. Necrosis. Extreme 
pain in lower jaw for about ten days. November, 1905, tempera- 
ture, 102°, followed by swelling in right side. Was opened through 
skin surface below bicuspid region. Later an opening for pus was 
made under chin on left side. Some sequestra of necrosed bone 
were removed from time to time. Present time (March 6, 1906) 
opening from socket of the L. I. C. I. and along jaw from lateral 
to molar on left side, one erupting bicuspid on left side. Fistula 
under chin on left side. Thickened and swollen tissue from right 
inferior to left inferior second molar region. 
There was necrosis of the inferior maxilla from the angle to 
the symphysis. Several previous operations had given no result 
beyond temporarily checking the progress of the disease. The 
fact that several teeth had become devitalized before their pulps 
were gangrenous and were constant sources of reinfection had 
been overlooked. These were removed with the dead bone, but at 
several points in the jaw the enamel caps of developing but still 
deeply embedded permanent teeth were noted, and these with 
much care were preserved. The result in both these cases made 
possible continued development and growth in the affected region. 
This could never have taken place if all of the teeth had been 
destroyed, and in natural course of development one side of the face 
would have been left deeply indented and much deformed. 
The great prevalence of these extensive necroses in growing 
children is undoubtedly because the jaws are so filled with the 
crowns of developing 4eeth that circulation and bone nourishment 372 
DISEASES OF BONE 
is much impaired. Therefore bone infections from any cause easily 
result in extensive destruction. 
Fig. 164 represents a woman who gives a striking example of 
an acute, diffuse, suppurative periostitis and the involvement of 
adjacent tissue from an original infection by putrescent roots in the 
lower jaw. Extensive abscess followed, and on account of illness 
during pregnancy the patient was confined to her bed for several 
months. The prone position favored the spreading out of pus 
under the periosteum. Large numbers of scars from fistuke may 
be noted as low down as the clavicle. The whole submaxillary 
area and the neck from jaws to clavicle at times were filled with 
Fig. 164.-Woman with pus discharging from fistula; in neck, cheek, and at the outer 
portion of lower eyelid from an original abscess of a lower molar tooth. 
pus so that the skin hung down like a pouch. This large abscess 
was continuous with one discharging through the center of the 
cheek and again at the outer angle of the eye. Irrigation through 
any one of the openings forced fluid through all the others. Prompt 
recovery followed removal of dead bone and through drainage. 
Fig. 165 illustrates a type of necrosis quite frequently met with 
when caries of bone extends from the maxillary region until it 
includes either the maxillary sinus or the nose, or both, and the hard 
palate. In syphilitic cases this is quite a common form of necrosis, 
and in those cases the disease usually extends from the nose down 
through the hard palate. One young man, Mr. Harry D., aged 
twenty-five years, had had an accidental blow at the age of twelve. NECROSIS OF THE JAWS 
373 
Discharge from region of incisors had been present ever since. 
Necrosis had gradually destroyed and included the anterior portion 
of the superior maxillary bones including the palatal processes so 
that there was a large opening into the hard palate. He had suffered 
from the toxic effect of continuous suppuration in this region until 
the condition of his palate was very much disordered. He had been 
affected with what he believed to be rheumatism. Opening through 
Fig. 165.-A typical case of necrosis, affecting bony walls of the maxillary sinus, the 
nose and the mouth after removal of necrosed bone. 
the hard palate necrosis in the region of the lateral incisor was found. 
On account of the color, it was determined that this tooth had 
become devitalized years before as a result of traumatism. Upon 
opening it was found filled with pus. A history of trouble with the 
upper jaw following traumatic injury fifteen years before was given. 
He was sent to the author to have an opening in his hard palate 
closed. Examination disclosed the fact that bone destruction was 
yet in progress. Repeated operations had failed to do any good. His 374 
DISEASES OF BONE 
disorder had been diagnosticated as long-continued chronic rheuma- 
tism, but later it proved to be the result of long-continued septic 
intoxication. The opening had extended through the hard palate 
into the nose, as described by the patient through caving in of the 
bone. It was plain at a glance that an upper tooth upon the affected 
side was discolored, and it should have been understood by those 
who saw the case long years before that as a result of the traumatism 
at the time of injury the pulp in that tooth became devitalized 
and subsequently infected. 
Over and over again in the author's practice such teeth have 
been found to be the cause of much long-continued necrosis; because 
of the fact that the crowns of the teeth were not noticeably decayed 
and there was no outward evidence of the tooth being affected 
except slight discoloration, this cause had been overlooked. It 
should be a matter of routine procedure to examine every tooth 
upon the affected side in every such case, not only by throwing 
reflected light from an electric mouth lamp through the teeth, 
but by tests of heat and cold. Whenever there is the slightest 
doubt of the vitality of the pulp of any tooth it should be opened 
and its exact status definitely determined. The loss of an occa- 
sional tooth pulp which it might become necessary to remove in the 
course of such treatment should not be considered for a moment in 
comparison with the serious results that follow the overlooking 
of such a tooth or teeth where extensive necrosis is already in 
progress or when operation of any kind is contemplated in that 
region of the jaws. 
Tuberculosis of Bone.-Tuberculosis of bone is manifested in 
the form of an acute tuberculous osteomyelitis with miliary tubercles 
disseminated through the bone marrow or by chronic tuberculosis 
of the bone, which may begin in the periosteum, bone marrow, 
synarthrosis, epiphyseal disk, or epiphysis. 
Etiology.-The bacilli most frequently reach the bone through 
the circulation, although infection may occur from contiguous 
structures or through the lymphatics. 
Pathology.-Proliferation of fixed connective-tissue cells and 
leukocytic infection leads to the formation of granulation tissue. 
Absorption of the adjacent bone progresses in advance of the tuber- 
culous formation. As a result of the specific poison of the tubercle 
bacillus, changes occur in the newly formed vessels which are 
followed by caseation at or near the center of the diseased area. 
By extension this may lead to perforation of the periosteum and 
cause periosteal tuberculosis, and lead to formation of what is NECROSIS OF THE JAWS 
375 
known as cold abscess. When the hip is affected, the disease is 
known as coxgdgia; when the knee, as white swelling; and when the 
vertebra, as Pott's disease. Large masses of necrotic bone may 
form and by continued bone destruction may affect articular 
surfaces or quickly destroy the usefulness of joints. 
Symptoms, Treatment, and Prognosis.-See Tuberculosis, pp. 102 
to 117. 
Syphilis of Bone.-Syphilis of bone is responsible for many 
widely different lesions. In congenital syphilis the bones at birth 
sometimes show characteristic alterations. Calcification is irregular. 
Syphilitic osteochondritis due to proliferated changes in the peri- 
chondrium and similar abnormalities of the periosteum cause more 
or less marked thickening and irregularity of form. In acquired 
cases bone lesions occur during the tertiary stage. During the 
secondary stage gummata in the periosteum or disturbance in the 
bone marrow, with degenerative and necrotic processes, may 
involve the overlying tissues and induce pyogenic infection. Bone 
destruction may continue until large areas have become necrotic, 
or through chronic diseases of the periosteum there may be osseous 
overgrowth resulting in osteophytic enlargement, irregularities 
of the surface, osteosclerosis, and similar structural alterations. 
The mouth and jaws, which offer unusual opportunities for infec- 
tion through nasal, dental, pharyngeal, aural, and oral diseases, 
are frequently affected by manifestations of this disease in the form 
of necrosis. A very common symptom is an opening through the 
hard palate, which usually occurs from the extension of disease from 
the nose with destruction of the nasal cartilage vomer and the bony 
palate. (See Syphilis, p. 132.) 
Actinomycosis of Bone.-This disease most commonly affects 
the jaws, but the vertebrae, ribs, and sternum may also be attacked. 
Etiology.-It is due to infection by the ray fungus and favored 
by abrasions in the surface of the mucous membrane of the mouth, 
tooth sockets after the extraction of teeth, and by the fact that 
many persons have the habit of carrying a straw in the mouth or 
of using one as a substitute for a toothpick. 
Pathology.-Proliferative and necrotic osseous changes resulting 
from this form of infection progress within the central portion of 
the bone and cause resorption of surrounding osseous structures. 
Subperiosteal involvement frequently causes marked increase in 
the size of the bones. (See Actinomycosis, p. 142.) 
Leprosy of Bone.-Leprosy is sometimes marked by bone inflam- 
mation and necrosis. (See Leprosy, p. 155.) 376 
DISEASES OF BONE 
Glanders.-Glanders usually attacks the periosteum, but may 
involve the bone also. (See Glanders, p. 149.) 
Mercurial Necrosis.-Etiology.-Ptyalism, interstitial gingivitis, 
periostitis,. and necrosis'Were frequent results in the days when 
calomel was extensively used by the laity without proper prescrip- 
tion, especially in malarial districts. The same results are not 
infrequently noted at the present time when mercury has been 
prescribed for syphilis and when by continued repetition of the 
prescription without medical advice excessive doses have been 
too long continued. The inhalation of fumes or dust contain- 
ing mercury by workmen in mirror factories is also said to be a 
cause of chronic poisoning. Miners working in mercury mines 
according to Talbot are usually toothless at the age of thirty-five 
years. 
Pathology.-In acute mercurial poisoning there are violent inflam- 
matory and necrotic lesions of the gastro-intestinal tract. Degenera- 
tions of the renal epithelium and other organs sometimes occur. 
In subacute cases, ptyalism is believed to be due to pathological 
change in the salivary glands, but this is not definitely understood. 
In chronic cases the pericemental tissues in common with overlying 
and surrounding structures undergo degenerative changes which 
render them particularly susceptible to inflammation. 
Mercury is eliminated by active stimulation of all excretory 
organs. When elimination is insufficient both lead and mercury 
accumulate in the system. It is believed that they' form albu- 
minized combinations in the tissues with resultant affection of 
both the central and peripheral nervous systems. Trophic changes 
occur which, assisted by accumulation in the vessels, cause thicken- 
ing of the intima-tunica and result in endarteritis obliterans. When 
the circulation is thus impeded and there is local irritation by 
accumulation in the vessels with weakened general resistance, owing 
to disturbance of the eliminative organs, degenerative changes 
result. 
Symptoms.-In the subacute stage there is an excessive flow 
of saliva, a dark bluish line forms at the borders of the gingivae, 
the gums become swollen and everted, the teeth loosened and 
elongated, and these symptoms are followed by the discharge of 
pus from the alveoli and the formation of pus pockets around the 
teeth. Acute, diffuse, suppurative periostitis with symptoms of 
acute inflammation of overlying tissue is followed by the formation 
of sequestra of bone and complete or partial necrosis. Accom- 
panying the bone destruction there is usually extensive ulceration NECROSIS OF THE JAWS 
377 
and loss of the soft tissues of the mouth which may involve the 
cheek, muscles of the soft palate, or the oral mucous membrane. 
Marked contraction and scar formation is a notable feature in 
chronic ulceration of this character, and closely resembles syphilitic 
ulceration in this respect. 
Diagnosis.-In the early stages differentiation must be made 
from interstial gingivitis from other causes, gangrenous stomatitis, 
acute leukemia, pernicious anemia, and syphilis. The history of 
the case, blood counts, and general physical examination, or the 
Wassermann test, where no clear history may be obtained, usually 
supply the distinctive diagnostic indications. 
Treatment.-Discontinue the administration of mercury and 
avoid exposure to mercury in any form, and treat the same as 
any other form of necrosis. 
Phosphorus Necrosis.-Phosphorus necrosis was a common type 
before employees in large factories were protected from the fumes 
of phosphorus. 
Etiology.-This form of necrosis is due to the contact of phos- 
phorus or its fumes with the periosteum or pericementum of the 
roots of teeth, or infection by microorganisms in a state of weak- 
ened bodily resistance induced by the poisonous effect of the 
phosphorus. The chewing of matches has sometimes been recog- 
nized as a cause. It has seldom been known to affect the mouths 
of persons with sound teeth. Carious teeth and those otherwise 
diseased have most frequently been held responsible for its 
occurrence. 
Pathology.-In phosphorus poisoning there is catarrhal inflam- 
mation of the gastro-intestinal mucous membrane and fatty degen- 
eration which affects the liver, other internal organs, the heart 
muscle, and intima of the bloodvessels. In the chronic forms 
catarrhal inflammation of the respiratory tract paves the way for 
bone infection, and the results are quite similar to bone necrosis 
under other conditions. 
Symptoms.-The only symptoms of phosphorus necrosis which 
might be considered as pathognomonic of this form of necrosis 
have been claimed to be the peculiar pumice-like appearance of 
the dead bone and the fact that the periosteum becomes unusually 
resistant and retains its vitality even though the bone undergoes 
extensive osteoporous necrosis. The author, however, has noted 
the same characteristic quite frequently in necrosis of the jaws, 
where there was no possibility of phosphorus having been an 
etiological factor. 378 
DISEASES OF BONE 
Treatment.-Treatment consists of prevention of exposure to 
phosphorus, assisting the process of its elimination from the system, 
and upbuilding the general health of the individual to increase 
resistance and aid in overcoming the effect of the poison. In other 
respects the treatment of diseased bone is the same as for other 
forms of necrosis. 
Arsenical Necrosis.-Etiology.-This form of necrosis has usually 
been caused by careless application of arsenical paste for the 
devitalization of tooth pulps. Fortunately cocain pressure anes- 
thesia for the removal of pulps has largely done away with danger 
in this respect. 
Pathology.-The powerful escharotic action of the drug in con- 
tact with the pericementum or periosteum of the alveolar struc- 
tures surrounding the teeth, and particularly the bony septum 
between the roots of teeth, excites an acute inflammation which 
destroys the affected bony area. 
Symptoms.-The symptoms include discharge of pus, exfolia- 
tion of small portions of bone, and occasionally the loss of one or 
more teeth that have become devitalized and loosened. The 
extensive necrotic areas, involving the soft tissues of the mouth 
as well as the alveolar process, which have been reported, were 
probably due to infection, since the action of arsenic is more or 
less self-limiting. 
Treatment.-The treatment consists in complete extirpation of 
diseased bone and soft tissue, and the local application of tincture 
of iodin or the hydrated oxide of iron, which it has been claimed 
will neutralize the effect of arsenic in the tissues. 
In all other respects the treatment is the same as for other forms 
of necrosis. 
Pathology.-When a mass of bone, whether large or small, has 
been destroyed through the processes described in connection with 
osteomyelitis and infection from periostitis a line of demarcation 
is formed between the living and dead bone which is quite similar 
to that of gangrene. Where the dead tissue joins the living, phago- 
cytic cells attack the osseous matrix forming the line between the 
dead and living structures, the result of secretory and phagocytic 
action of the leukocytes and osteoclasts is that a portion of dead 
bone becomes separated from the living bone and becomes what is 
known as a sequestrum. The process by which this is accomplished 
is called exfoliation. The newly formed bone surrounding the 
sequestrum is called the involucrum, through which there may be 
little openings called cloacae. Suppurative processes extending to NECROSIS OF THE JAWS 
379 
and through the overlying tissues may form a sinus or sinuses 
for the escape of pus, or the sequestrum may become enclosed 
in masses of fibrous or osseous tissue, which sometimes hold and 
prevent its exfoliation and in this way give rise to chronic condi- 
tions that sometimes persist for many years. Sometimes lique- 
faction of tissue takes place without the formation of a sequestrum, 
there being a continued softening and crumbling of the bone which 
either becomes roughened with more or less excavated areas upon 
the surface or a softened mass within the bone. This we recognize 
as caries. 
Symptoms.-The symptoms of necrosis of the jaws are neces- 
sarily modified by the character of the cause. Traumatic injury 
would be evidenced by inflammation of the periosteum in common 
with overlying injured parts. Infection from an acute dento- 
alveolar abscess would present the predominant symptoms of 
this affection during the early stages. In all the non-traumatic 
or so-called idiopathic cases there are present the symptoms of 
acute infectious diseases. These vary greatly, according to the 
severity of the infection, resistance of the individual, and condi- 
tions governing the actual cause. There may be chills, fever, 
prostration, temperature ranging from 101° to 105° F., or even 
higher, with severe local pain and great prostration. The toxemia 
may be so rapid as to cause delirium, stupor, endocarditis and 
death, or there may be acute local pain with but slight evidence 
of general symptoms and infection, or subacute and chronic perios- 
titis, osteomyelitis, or ostitis may lead to the destruction of large 
areas of bone with almost no serious objective symptoms and com- 
plete absence of pain, until in due course there is formation of pus 
and the final exfoliation of the bone. Tenderness to touch over a 
more or less considerable area which is marked by redness is usually 
an early symptom. 
Caries of bone, being a slower process, is usually unattended by 
painful symptoms other than those incident to acute infections, 
which may be the first cause of the formation of the bone abscess. 
The most common cause of caries in the maxillary bones is dento- 
alveolar abscess, which, having become chronic, proceeds slowly 
with bone disintegration until considerable excavations in the 
bone have been accomplished. 
Diagnosis.-When sequestra of bone have been formed there is 
usually discharge of pus, which by making pressure upon the over- 
lying surface may be seen to exude through several fistulse. Touched 
with a probe or suitable instrument, such bone will be found to 380 
DISEASES OF BONE 
have lost its velvety feeling and is rough. Usually slight motion 
of the sequestrum can be detected. In carious conditions due to 
extensive and long-continued chronic abscesses the external bony 
wall will usually be found to be extremely thin and yielding to 
pressure. It is this characteristic which often serves to indicate 
the existence of a carious area that would not otherwise be sus- 
pected. Surrounding bone, not yet fully disintegrated but with- 
out normal vitality, is also recognized by its rough dead feeling. 
Perhaps in no other part of the body is recognition of the exact 
cause of necrosis so necessary or difficult. The differentiation of 
different diseases and forms of infection through which the local 
disease might have been caused is equally important in all fields 
of practice, but on account of the multiplicity of causes of diseases 
of the teeth, and the great variety through which infection might 
occur, careful distinction is exceedingly necessary. 
Treatment of Necrosis and Caries.-In the acute stages, when 
pain and other symptoms of acute inflammation are present and 
before nature has had an opportunity to complete the process of 
separation between dead and living bone, treatment is limited 
to measures which relieve the pain, check the progress of the 
inflammation, and if possible abort the formation of complete 
necrosis. Sources of infection or irritation must be brought within 
control or at least receive appropriate attention. Incision through 
the overlying tissues and periosteum down to the bone may be 
necessary to check the progress of an acute diffuse suppurative 
periostitis. Painting the surface with tincture of iodin serves the 
double purpose of antisepsis and local aborption. Hot applica- 
tions in the form of capsicum plasters, or similar agents applied 
to the mucous membrane surface immediately over the point of 
greatest tenderness sometimes give relief and facilitate the progress 
of pus toward the surface, and this aids more complete relief. Hot- 
water bags or hot fomentations applied to the face are always 
gratifying and sometimes quite beneficial. Relief of pain by the use 
of hypodermic injections of codeine or morphin or the internal 
administration of suitable remedies is occasionally necessary to 
tide over the period until surgical relief may be given. All the bodily 
eliminative processes should be called into action. Cathartics, 
diuretics, and sudorifics should be administered if required; usually, 
however, the increased activity of the kidneys and sweat glands 
may be more naturally stimulated by free administration of warm 
drinks, hot foot baths, warmth to the surface of the body, etc. 
The bodily temperature should be carefully noted, and the degree NECROSIS OF THE JAWS 
381 
of fever, which in the acute fulminating cases is sometimes high, 
may be taken as an index of the relative virulence of the infection 
and bodily resistance of the individual. Cold sponge baths, spong- 
ing with tepid water followed with alcohol, and high bowel flushing 
offer the most satisfactory means of controlling the fever, which 
after all is only one of nature's means of fighting the infection 
and should not be masked by the use of antipyretics or other drugs, 
the ultimate effect of which is almost invariably bad. 
Nourishment should be in concentrated, highly nourishing, 
easily digested form. When, as sometimes happens, the entire 
digestive tract becomes so disturbed as to make the administra- 
tion of food by stomach inadvisable, then rectal nourishment 
should be given and supplemented by frequent administrations of 
normal salt by rectum slowly, according to the drop method. 
Virulent infection with weakened bodily resistance frequently 
leads to toxemia of serious nature, and ill-advised attempts to 
give surgical relief through opening the vessels to direct entrance of 
infection has been known to result in true septicemia and pyemia. 
In all such cases the effect of general septic infection must be 
combated in addition to local treatment. Hypodermoclysis (the 
administration of the normal salt subcutaneously into the tissues) 
is required in the graver cases of this affection to stimulate depleted 
vital forces. Intravenous administration of normal salt is also 
recommended as giving a more direct and therefore more prompt 
and efficient effect. Transfusion of blood when performed by a 
proper technic and sufficiently safeguarded is undoubtedly the most 
effective means of combating every form of septicemic or pyemic 
condition. 
When actual disintegration of bone has been accomplished the 
treatment briefly outlined is as follows: 
1. Correction of the cause. 
2. Relief of pus. ■ 
3. Sterilization, local antiseptic treatment to prevent extension. 
4. Removal of Dead Bone.-Distinction must be made between 
necrosis and caries in treatment. A sequestrum or sequestra should 
be taken out intact if possible. Carious bone must be removed 
with a surgical or dental engine bur, a chisel, or curette, and all 
roughened bone borders made smooth. This distinction is very 
necessary because an attempt to get out a sequestrum of bone 
with a dental bur would only result in breaking up little particles 
of bone and forcing them into the tissues, thus, leading to continua- 
tion instead of relief of the disease. After the sequestrum has 382 
DISEASES OF BONE 
been removed the bone borders may be smoothed by the use of a 
10 to 25 per cent, solution of sulphuric acid or better still with 
a curette, and all carious bone removed until the smooth velvety 
surface of healthful bone can be recognized. 
5. Packing.-If the cavity in the tissues remaining after the 
dead bone has been dislodged or cut away is of such form or situa- 
tion as to be unfavorable to drainage, then it may be necessary to 
insert a packing. This is best done with gauze, because cotton is 
likely to leave threads behind to continue irritation and infection 
afterward. The gauze should be wrung out in a 2.5 per cent, car- 
bolic acid solution, 1 to 10,000 mercuric bichloride, 10 per cent, 
tincture of iodin, or some similar antiseptic, and sealed in with 
collodion or gutta-percha dissolved in chloroform. Once each day 
this should be changed to avoid infection. 
When the wound cavity can be made sufficiently open and 
saucer-shaped to facilitate natural drainage and prevent lodg- 
ment of disadvantageous agents this should be done, and then no 
packing ought to be used; but the frequent holding in the mouth 
of dioxo gen, or any of the well-known suitable germicidal agents, 
must be depended upon to prevent infection. 
General treatment is often required to overcome the toxic effect 
of the disease. Ovoferrin, other forms of iron, quinine, cod-liver 
oil, and tonics are often valuable. 
Diseases such as syphilis, tuberculosis, actinomycosis, leprosy, 
and glanders must each receive its own special treatment as indi- 
cated in addition to the local treatment. 
FRACTURES OF THE JAWS. 
A fracture may be defined as a break in the continuity of bone 
or cartilage caused by direct force or muscular contraction. 
Varieties of Fractures.-Complete.-1. Simple.-A single fracture 
without division of the overlying soft tissues. 
2. Compound.-Fracture with broken bone surfaces exposed to 
the external air by division of the overlying parts. 
3. Multiple.-Two or more distinct fractures of the same bone. 
4. Comminuted.-A fracture in which the bone is crushed or 
broken into small communicating fragments. 
5. Complicated.-A term usually applied to fracture accom- 
panied by some serious injury of the parts in the region of the 
fracture, as important nerves, bloodvessels, joints, etc. FRACTURES OF THE JAWS 
383 
6. Impacted.-When the fractured fragments of bone are driven 
into each other and more or less embedded. 
Fractures are further described by the following self-explanatory 
terms: Transverse, oblique, longitudinal, dentated, spiral. 
Incomplete Fractures.-Green-stick fracture or partial separation 
of the bone fibers allows the bone to bend, but it is not completely 
broken off. 
Other forms of incomplete fracture are described as: 
Fissured. 
Indented or depressed. 
Punctured. 
Perforating. 
Special Forms of Fracture.-Fractures not invariably or distinctly 
within either of the foregoing classes are: 
Pathological Fractures.-This is due to preexisting disease, as 
from some constitutional condition affecting the bone structure, 
fragilitas ossium, sarcoma, cancer, senile atrophy, etc. 
Subperiosteal Fracture.-Fracture of the bone sometimes occurs 
without separation of the periosteum in cases of infants and very 
young children. 
Gunshot Fracture.-Gunshot fractures necessarily depend upon 
velocity, character of the missile, and the kind of bone at the seat 
of injury. Cancellated structures yield to pressure without exten- 
sive lateral injury. Compact bone structures such as in the lower 
jaw are likely to suffer extensive comminution with fissured frac- 
tures. Splinters of bone may also be forced in different directions 
and the size of the wound materially increased. 
Alveolar Fractures.-This form consists in splitting or fracture of 
the alveolar process not involving other portions of the maxillary 
bones. 
Intra-iiterine Fractures .-The weakened osseous system of the 
offspring of mothers affected by scurvy, syphilis, and struma may 
sometimes suffer fracture before birth. This does not include 
injury by instruments in delivery. 
All fractures are also described as: 
Recent. 
United. 
Old. 
Ununited. 
Etiology.-Superior Maxilla.-The superior maxillae with the 
malar, nasal, palate, lacrimal, ethmoid, and sphenoid bones form 
an almost indivisible complement in the bony structure of the 
upper part of the face, which is greatly exposed to traumatic 
injury. It is, nevertheless, true that these other bones serve to 
protect the maxillae, so that fractures of the upper jaw are com- 
paratively rare. They usually result from more or less unusual 384 
DISEASES OF BONE 
force directly applied, such as the kick of a horse, falling upon 
the face or from some height, runaway, automobile, motor cycle, 
and similar accidents, gunshot injuries of the mouth, and not 
infrequently when the lower jaw is forcibly driven against the 
upper. 
Inferior Maxilla.-The inferior maxilla, because of its exposed 
situation, its size, and shape, is much more subject to fracture than 
the superior maxilla, or, in fact, any other bone of the face. The 
weakest point in a normal lower jaw is generally recognized as 
being slightly anterior to the mental foramen and in an edentulous 
jaw at or in line with the mental foramen. Naturally these are 
the points at which fracture most frequently occurs. Fractures 
in this region are quite common because of exposure or the likeli- 
hood of blows upon the face or neck affecting the side of the jaw, 
and also because in such large numbers of people the first molars 
or bicuspids have been lost with corresponding absorption of the 
alveolar structures to weaken the jaw. At the angle of the jaw 
fracture is also quite frequent. Many cases of fracture in this 
region have been reported from extraction of third molar teeth, 
especially when impacted. Beyond this general characterization 
the exact order of frequency in the occurrence of fractures through 
the symphysis, the ramus, the neck of the condyle, and the coronoid 
processes, situations in which fractures of the mandible may occur, 
is according to the author's experience too uncertain to warrant 
definite statements. 
Symptoms.-Symptoms of fracture of the jaws are: (1) De- 
formity, (2) unnatural mobility, (3) crepitus, (4) loss of function; 
(5) pain, which.may be constant or only on movement of the jaws, 
or the fractured ends of the bone; and (6) in compound cases the 
fractured ends of the bone may project into the mouth through 
the wound in the soft tissues. 
Swelling and other symptoms are dependent upon the extent 
of traumatic injury and infection. 
Diagnosis.-The distortion of facial features may be sufficiently 
indicative without other symptoms. Quite often this is disguised 
by swelling of the overlying soft tissues. When there are teeth 
in the jaws disarrangement of occlusion is usually a marked and 
important symptom. The teeth upon one side of the line of frac- 
ture may be higher or lower than those upon the other, or they 
may be out of alignment in a lingual or buccal direction with 
deformity still more evident. By firmly grasping the bone upon 
each side of the seat of injury unusual motion is usually detected, FRACTURES OF THE JAWS 
385 
and the crackling, scraping sound (crepitus), as the ends of the 
bone are rubbed against each other, completes the diagnosis. 
Fractures of the Superior Maxillae.-Injury sufficient to cause 
fracture in the upper jaw is usually so severe and the bone so 
broken into different portions that diagnosis is quite simple. Never- 
theless, upper jaws have frequently been broken and the fact was 
not discovered until long after union had taken place with marked 
deformity of the dental arches. This has occurred in many instances 
because fracture of the superior maxilla occurred simultaneously 
with that of other bones of the face, the latter masking the maxillary 
fracture and causing it to be overlooked. 
Notwithstanding the frequency of comminuted fractures of the 
upper jaw, an attempt has been made to recognize certain definite 
fracture lines. Thus a transverse fracture has been described by 
Guerin which extends backward along both sides of the upper 
jaw below the malar bones until it includes the pterygoid processes. 
The roof of the mouth, including the teeth, drops down until it 
rests upon the floor of the mouth and is to some extent displaced 
in a backward direction. This form of fracture quite frequently 
occurs from blows upon the face just below the nose. In one of 
the author's cases it was caused by the kick of a mule. Fracture 
closely associated with diastasis of other bones of the face is usually 
evidenced by division through the median palatal suture, and is 
caused by accidents which jar or drive the lower jaw forcibly 
into the upper in such manner as to force the maxillae apart. In 
one of the author's cases there was an opening through the hard 
palate with division of the soft tissues when the bones were forced 
apart and disarticulation of the zygomatical maxillary suture was 
revealed when the infra-orbital outline was followed with the 
finger. The separation between the maxillary bones was also 
evident at the intermaxillary suture and by space between the 
central incisor teeth. In another case, a patient of Dr. G. W. Fox, 
of Milwaukee, an automobile accident had caused similar fracture 
with diastasis of nearly all the facial bones, accompanied also by 
fracture of the malar bones. Force applied against the upper jaw 
obliquely outward or upward upon the side causes splitting of 
the alveolar process and occasionally oblique fractures extending 
deep into the body of the bone. Alveolar fractures are quite 
commonly incidental to extraction of teeth. 
Fractures of the Inferior Maxilla.-Ordinarily fractures of the 
lower jaw present typical and therefore easily recognized symp- 
toms. When caused by falling and striking upon or blows at the 386 
DISEASES OF BONE 
point of the chin, which tend to drive the jaw backward and upward, 
there is displacement of the mandible in a backward direction. 
This may be caused by fracture of one or both condyles or fracture 
of the anterior wall of the external auditory meatus, and in these 
cases occasionally the differentiation is somewhat difficult. Frac- 
tures of the condyloid processes usually occur at the neck. If upon 
one side only, there is dislocation of the chin and jaw, which are 
pulled toward the injured side, chiefly because of the action of the 
internal pterygoid muscle of the opposite side. Unilateral fracture 
Fig. 166.-Radiogram of the jaw of a young woman, one of the author's cases. 
This fracture through the lower jaw resulted from an ill-advised attempt to extract 
an impacted third molar in a dental office. 
of the neck of the condyloid process is distinguished from disloca- 
tion of the jaw, because in these cases the jaw is drawn toward the 
normal side. When both condyloid processes are broken the lower 
jaw is drawn upward and backward and there is more or less loss 
of movement with tendency to necrosis. When the condyles are 
intact, but in being driven backward have caused fracture of the 
anterior wall of the external auditory meatus, the most marked 
symptom is occlusion of the external auditory canal when the jaws 
are closed or the mandible forced backward. 
Fracture of the glenoid cavity, which is necessarily associated FRACTURES OF THE JAWS 
387 
with this condition, may become serious if inflammatory processes 
are excited by infection and lead to permanent ankylosis. There 
is slight depression in front of the external auditory meatus; the 
broken articular surface of the condyle may be pulled forward 
and inward by the external pterygoid muscle, and can be felt 
by drawing the jaw forward and pressing the condyle from within 
outward with a finger placed upon the upper lateral wall of the 
pharynx. Such fractures may sometimes be reduced in this way. 
Fractures at the Symphysis.-Fractures through the symphysis 
are usually vertical and cause comparatively little dislocation. 
With fractures of the coronoid processes the symptoms are usually 
slight except when the jaw is moved extensively. This form of 
Fig. 167.-Fracture of tooth and jaw. The tooth becomes infected in such cases 
and must be removed. (Dunning.) 
fracture is exceedingly rare, and is always accompanied by fracture 
of other bones. Its existence would therefore only be suspected 
under such conditions and when the injury was of such direct char- 
acter as to make such injury possible. Palpation by the fingers 
within the mouth usually leads to discovery. 
Fractures, of the ascending ramus are rare because it is well 
covered with muscles. They can best be felt from within the mouth 
and by passing the finger along the posterior border of the ramus 
externally. 
In most cases fracture of the lower jaw can be distinguished by 
the break in the natural outline, which is felt by passing a finger 
along the lower and posterior border. By all means the most 
perfect diagnostic aid in doubtful conditions are the ar-rays, by 388 
DISEASES OF BONE 
Fig. 168.-Impacted cuspid in line of fracture; a predisposing cause and an obstacle 
to healthy repair of bone. (Dunning.) 
Fig. 169.-Pathological fracture; no history of any trauma, but long history 
of chronic abscesses of jaw. Fracture occurred while patient was eating crust of 
bread. (Dunning.) FRACTURES OF THE JAWS 
389 
which not only the existence of fracture may be established but 
its exact character as well. 
Treatment of Fracture of the Maxillae.-The methods of retain- 
ing fractured lower jaws are as follows: (1) By bandaging alone; 
(2) by ligating teeth upon each side of the fracture as first done 
by Hippocrates and used in one form or another ever since; (3) 
by splints constructed of metal, plaster of Paris, or other suitable 
material laid upon the external surface of the chin, the side of the 
jaw or behind the angle with a few layers of cotton pad to prevent 
irritation and firmly bandaged; (4) by interdental splints, i. e., 
supports placed between the jaws, a method first used by Hayward 
in 1858 and modified and improved by Gunning in 1861; (5) by 
attachments to or upon the teeth of the affected jaw only; (6) by wiring 
the teeth of both jaws together; and (7) by wiring the bones, of which a 
successful case was reported by Buck, 1847. 
In deciding upon the splint or appliance that may be used to hold 
the fractured bony parts in position there are certain important 
principles which must be kept in view to govern selection. These 
in the order of their relative importance are as follows: (1) Perfect 
approximation of the parts; (2) immobility; (3) freedom in taking 
nourishment; (4) facility in keeping the mouth surfaces clean; (5) 
the possibility of frequent observation of the parts; and (6) freedom 
in the use of the jaws, which necessarily implies their not being 
bandaged or bound together by wires. 
In some forms of fractures all of these desirable conditions can 
be secured, and in others this is impossible. It therefore becomes 
necessary to select the kind of splint that will give the greatest 
possible comfort to the patient with the best promise of a good 
result by securing as many of these advantages as may be practi- 
cable. A vast amount of ingenuity has been expended upon differ- 
ent forms of appliances for retaining fractured jaws. An attempt 
at enumerating and describing them would be both impractical 
and unnecessary if the foregoing principles are kept in mind. 
Selection may be made from a few simple, thoroughly practical 
forms, which can be modified so as to be adapted to almost any 
variety that may occur. The illustrations and descriptions are 
therefore confined to these examples. 
First aid in these cases depends largely upon the character .of 
the injury and the condition of the patient at the time treatment 
is begun. Many times the shock attendant upon the accident, 
concussion by injury to the head, or complications make it necessary 
to be content with such temporary measures as may give the best 390 
DISEASES OF BONE 
possible immediate relief with a view to more accurate and effective 
treatment when other conditions are more favorable. In one of 
the author's cases, for example, a man was butted through a fence 
by a bull, and in addition to fracture of the jaw, suffered fractured 
ribs, also with traumatic injury to the lungs, which brought about 
a pneumonia and temporarily endangered his life. In the absence 
of grave general obstacles, the swelling of the parts, with attendant 
pain and soreness in manipulation and difficulty in opening the 
mouth, sometimes renders perfect adjustment at the time impossible. 
In these cases for temporary purposes and to hold the parts during 
the period necessary for the preparation of a proper permanent 
support, an interdental splint is valuable. It is made of modelling 
compound, softened in warm water, molded into proper form, 
placed between the jaws and held there a few minutes until it 
hardens, then removed and trimmed into suitable form with an 
opening in the anterior part, as shown in Fig. 172. It serves an 
excellent purpose by retaining the fractured bone in comfortable 
position when it is properly placed and the jaws are securely 
bandaged, until such time as a permanent substitute may be 
inserted. A few cakes of dentist's modelling compound should be 
part of the equipment of every surgeon's case. 
The author's experience in one instance, however, may serve to 
impress the need of caution in one respect. In this case the model- 
ling compound splint was left in place longer than usual on account 
of the precarious general condition of the patient due to the acci- 
dental injury. Directions were given at the hospital to have the 
mouth freely irrigated through the opening in the anterior part of 
the splint. Upon returning several days later, it was found that 
warm water had been used and the compound softened until both 
shape and usefulness were lost. Irrigation with antiseptic solu- 
tions may be freely given without disturbing the splint, but such 
solutions should always be cold whenever modelling compound is 
the material from which the splint is made. 
Reduction of the Fracture.-Antagonism chiefly due to the digastric, 
geniohyoglossus and mylohyoid muscles upon the one hand, and 
the masseter, temporal, and the pterygoid muscles upon the other, 
when lost by a fracture of the jaw, if the parts are sufficiently 
separated to lose resistance cause more or less marked disarrange- 
ment. Naturally this is greater when the fracture is double or 
comminuted, or when a segment of bone is actually lost. Under 
favorable conditions the manipulation necessary for production 
and proper alignment is accomplished with comparatively little FRACTURES OF TRE JAWS 
391 
pain and without much difficulty. Sometimes, however, the pain, 
tense contraction of the muscles due to irritation, extreme nervous- 
Fig. 170.-a, cast of the mouth of one of the author's patients, showing line of 
fracture through the lower jaw, with typical disarrangement of the occlusion of the 
teeth; b, the same case after treatment. 
Fig. 171.-Fractured lower jaw, with characteristic deformity. 
(After von Bergmann.) 
ness of the patient, and swelling or other unfavorable symptoms 
resulting from injury, make satisfactory adjustment without 392 
DISEASES OF BONE 
general anesthesia practically impossible. In the absence of contra- 
indication, ether should be administered in order that accurate 
satisfactory reduction of the fracture may be accomplished with 
complete muscular relaxation (Figs. 170 and 171). 
Fig. 172.-Gunning's interdental splint, with opening for introducing food 
Fig. 173.-Radiograph of one of the author's patients, a boy twelve years old, 
run over by an automobile. Fracture between the cuspid and lateral incisor teeth 
on the right side, and in the region of the first molar on the left side is shown held 
in fixation by a cast aluminum interdental splint. 
Methods of Fixation.-Transverse, comminuted, or multiple 
fractures of the upper jaw require general support, which may be 
given by binding the lower jaw firmly against the upper if the 
occlusion of the teeth prior to the accident was sufficiently regular. 
The difficulty in administering nourishment, which must be given 
through a tube, passed along the buccal surfaces of and behind 
the molar teeth, through the nose, or in a limited way per rectum, 
is an objection to this method. The old-fashioned interdental 
splint (Fig. 172) made of vulcanized rubber gives the necessary FRACTURES OF THE JAWS 
393 
support, allows nourishment to be taken through the opening in 
the splint, and permits of fairly satisfactory cleansing by irrigation. 
Kingsley s interdental splint (Figs. 175 and 176), as modified mid 
described by Marshall, is made of rubber vulcanized upon an 
Fig. 174.-Modification of the Gunning interstitial splint as used by Dunning for 
edentulous upper jaw, when lower bicuspids and molars are also missing. 
impression of the upper teeth against which the lower jaw has 
been pressed sufficiently to mark the outline of the crowns of 
Fig. 175.--Kingsley's interdental splint. 
their occlusal surfaces. Wires have been embedded into the sides 
and so bent as to pass out around the angles of the mouth and 
extend outside the cheek surfaces. The wires make it possible 
to bind the appliance with elastic or other bands passed over 394 
DISEASES OF BONE 
the head in such manner as to support the fractured upper jaw 
without restricting movement of the lower jaw. It has the addi- 
tional advantage of permitting constant observation, cleansing 
Fig. 17C.- Kingsley's splint applied. 
and local treatment of the parts, as well as freedom in taking food. 
When a sufficient portion of the upper jaw is left firm and immov- 
able, a metal splint cemented to the teeth (Fig. 177) may be employed 
as in the case of the lower jaw (except that it is in reverse position), 
Fig. 177.-Dental splint applied to cast. 
with almost entire absence of discomfort and full functional possi- 
bility. Even though there may be diastasis of facial bones with 
fracture of the malar, the condition is not necessarily a serious one FRACTURES OF THE JAWS 
395 
from the stand-point of retention. In some of the author's cases 
the molding of the parts and adjustment of the bones by pressure 
was sufficient, and only slight support secured by adhesive plaster 
laid upon the surface to make slight tension in the desired direction 
or properly adjusted bandages, and keeping the patient as nearly 
absolutely quiet as possible for a sufficient time, was required. 
Fig. 178.-Cap splint or single arch splint used whenever there are one or more 
sound teeth on either side of the line of fracture. (Dunning.) 
The method of wiring the lower to the upper teeth to secure frac- 
tured jaws was first advised by Dr. Thomas L. Gilmer.1' Dr. 
Gilmer is a strong advocate of this method, and his good results in 
large numbers of difficult fractures seems to warrant his position. 
He says:2 
"In cases of fracture of the ascending ramus, or at any point 
posterior to the third or second molar, if most of the teeth or a 
sufficient number are in the mandible, the best results are obtained 
by wiring the upper teeth to the lower. This may be done with 
Angle's bands, it is true, but it is not so conveniently done, I think, 
as by wiring the upper teeth to the lower teeth. I believe that 
this is a better method of treating fractures in the angles or ascend- 
ing ramus than by drilling through the bone, unless there are 
complications. 
1 Arch. Dent., 1887, p. 388. 
2 International Congress, 1904, ii, 185. 396 
DISEASES OF BONE 
"I discard the use of bandages because that may interfere with 
the circulation and retard recovery." 
He uses a small, very soft annealed German silver wire. 
The objection to fixation of the parts in this way is, that unless 
carefully done there is tendency to loosen the teeth. This, how- 
ever, need not necessarily occur, and is a question of technic rather 
than of method. Nourishment can be taken with the jaws together 
but not so comfortably or so satisfactorily as when the mouth 
can be opened. Moreover, the opportunity to view the inside of 
the mouth, which is prevented, is also important. It is therefore 
advisable to wire the teeth together only when more accurate results 
can thus be secured than by other forms of dental or interdental 
splint. 
It is very natural that there should be some question as to priority 
of invention or application in the use of methods such as Angle's 
for fixation of fractured jaws. But there can be no doubt of the 
fact that Angle, with his well-known ability to bring to perfection 
any appliance which he devises or employs, has done more than 
anyone else toward making treatment of fractured jaws simple and 
effective. The following illustrations of Angle's methods (Figs. 
179, 180 and 181) are given with full credit to the author and 
without prejudice to any others who may have previously employed 
similar but almost certainly less perfect appliances. Naturally, in 
the course of extended practice, whatever the original suggestions 
may have been, one finds one's self making certain modifications 
which appear to be improvements. In this way the author has 
adopted certain modifications of Angle's appliance which have 
seemed in certain cases to be an improvement (Figs. 179, 180 and 
181). Fig. 182 shows Loher's; Fig. 184, Sauer's; Fig. 185, Martin's; 
and Fig. 186, Hammond's splints. These are self-explanatory. 
Dr. J. D. Patterson, of Kansas City, makes a practical sugges- 
tion for the treatment of a fractured edentulous jaw by utilizing 
the plate that has been worn by the patient and adjusting the 
parts to fit the form of the plate. 
Dr. Patterson is also entitled to credit for devising the bridge 
splint attached to teeth upon each side of the fracture, and used 
in the first instance to bridge across a space caused by the loss 
of a section of the lower jaw from gunshot fracture, but adaptable 
also for use in a similar manner for resection. By the use of this 
splint the parts are kept apart and securely in position until such 
time as intervening tissue may be formed and great deformity 
avoided. This method has been of great service in the present war. FRACTURES OF THE JAWS 
397 
He concludes his description of the first use of this splint on 
a patient, the anterior part of whose jaw had been destroyed by a 
shot from a Winchester rifle in 1891, with the following statement: 
Fig. 179.-Splint for fractured lower jaw. (After Angle.) 
Fig. 180.-Splint for fractured lower jaw (After Angle.) 
Fig. 181.-Splint for fractured lower jaw. (After Angle.) 398 
DISEASES OF BONE 
"Upon removal of the splint I was delighted to find that the 
bone had reformed where it had been entirely missing, and the 
Fig. 182.-Loher's splint. 
Fig. 183.-Illustrates one of the author's cases. The subject, a young man, 
suffered severe cranial injuries as well as a fractured upper jaw, from a fall from the 
roof of a shed. His cerebral condition necessarily claimed first attention. Later 
the splint was applied with nuts and screws so adjusted to metal bands cemented 
to his teeth that both fixation and correction could be applied simultaneously. He 
was able to eat comfortably immediately after the splint was applied. FRACTURES OF THE JAWS 
399 
sides were firmly held in their places without any change during 
the four days when I was remodelling the bridge."1 
Fig. 184.-Sauer's splint. 
Fig. 185.-Martin's splint. 
Fig. 186.-Hammond's splint. 
External Dental Splint.-Many forms of splints to be applied 
upon the outside of the face and chin have been devised. These 
1 Western Dent. Jour., 1891, p. 536. 400 
DISEASES OF BONE 
are equally unnecessary and are occasionally required. The splints 
illustrated in Figs. 188 and 189 are an example of splints of this 
character which are valuable because of their simple construction. 
In fracture through the angle of an edentulous lower jaw it is 
sometimes necessary to hold the ramus forward against the body 
Fig. 187.-Gunshot fracture; cap splint in position. (Dunning.)1 
of the mandible, and wiring the bones may sometimes be avoided 
by molding modelling- compound to fit closely around the angle 
of the jaw upon the external surface and by binding this into 
place with a bandage having a few layers of cotton under it to 
protect the skin. 
Fig. 188.-Shape of splint before being fitted 
to chin. (Roberts.) 
Fig. 189.-Splint molded 
to fit chin. (Roberts.) 
Dr. F. A. Green, of Geneva, New York, has devised an appliance 
which combines an external dental splint with an interdental one. 
Its purpose is to give both external and internal fixation to the 
lower jaw without the use of bandages. Description of this splint 
1 Fractures of the Maxilla, Jour. Amer. Med. Assn., Jan. 9, 1915. FRACTURES OF THE JAWS 
401 
with illustration is published in the International Congress, 1904, 
ii, 183, 184. 
Bands or wires which are to be depended upon for securing 
fractured jaws should not be attached to the teeth immediately 
upon each side of the fracture, because as a result of the traumatism 
or subsequent inflammation such teeth are always loosened. 
Attachment should be made to teeth two and sometimes three 
teeth away from the line of bone division. 
Wiring fractured ends of maxillary bones is occasionally necessary 
when approximation and immobility cannot otherwise be secured, 
but this method should be avoided if possible, because opening 
through the tissues and bone for insertion of the wires gives exposure 
to infection, and with the wires in place this disadvantage is con- 
tinued. Incision made through the external surface of the face 
to expose the bone for the purpose of inserting wire gives still 
greater opportunity for infection and makes an unnecessary, often 
unsightly scar. It is practically impossible to pass silver wire as 
generally used through the jaw bones and twist the ends with 
sufficient accuracy to give perfect immobility; consequently there 
is usually more or less motion in segments of jaw thus attached. 
Sometimes this is of little consequence, and union takes place appar- 
ently without interruption, but in many instances it has led to 
delayed or faulty union as well as deformity through disarrange- 
ment of the parts. 
In this connection it must be remembered, however, that there 
are cases in which suturing of the fractured bones cannot be avoided, 
because no splint serves the purpose as well. Fortunately these 
cases are rare, and almost always a dental or interdental splint can 
be used to better advantage. 
The bandages generally used for retention of fractures of the 
jaws are illustrated in Figs. 190 to 193. 
Of these the most commonly used is the Barton bandage. The 
four-tailed bandage is made by splitting a three-inch roll of bandage 
from each end to a point within two or three inches from the center. 
The free ends are then applied as shown in Fig. 190. 
Patients in whom a bandage such as the Barton, which holds 
the jaws firmly together, had been applied while under influence 
of an anesthetic, must be very carefully watched and the nurse 
or attendant instructed to cut the bandage instantly in cases of 
vomiting which otherwise might lead to suffocation. Quite serious 
accidents of this nature have been reported. Usually the appli- 
cation of such bandages during anesthesia may be avoided, and 402 
DISEASES OF BONE 
when this is impossible the likelihood of danger will be reduced 
when opportunity is given for proper preparation of the patient 
Fig. 190.-Four-tailed bandage of chin. 
(Wharton.) 
Fig. 191.--Barton's bandage 
(Wharton.) 
Fig. 192.-Modified Barton's bandage. 
(Wharton.) 
Fig. 193.-Oblique bandage of the 
angle of the jaw. (Wharton.) 
before operation and the postoperative hypodermic injections of 
morphin. But in no case should vigilance be relaxed until the 
period of danger is over. FRACTURES OF THE JAWS 
403 
Cases in which habitual drunkenness or other reasons make 
it impossible to keep the patient's bandages in place have been 
reported by Roe, Marshall, and others. In these the difficulty can 
be overcome by shaving the head and attaching broad strips of 
adhesive plaster or a cap of metal or other material, which may be 
adjusted to the head and the adhesive strips attached without 
the necessity of shaving the head. 
It is unnecessary to describe the manufacture of interdental 
splints, which is understood by all dentists and fully described in 
works upon prosthetic dentistry. It seems advisable, however, 
to call attention to the fact that it is often difficult and sometimes 
quite impossible to secure a correct impression of a fractured jaw. 
This can be overcome by the method of sawing through the plaster 
case secured from such an impression at the line of fracture and 
adjusting the teeth to correct occlusion with a cast made of an 
impression of the opposite jaw. In this way an imperfect impres- 
sion may be converted into a sufficiently perfect one, providing 
the dental arches were originally reasonably regular in outline. 
Once the parts have been firmly secured, the treatment is the 
same as for other wounds. With compound fractures, care must 
be exercised to avoid or overcome the results of infection. Harm- 
less, sufficiently antiseptic mouth washes should be used frequently, 
wound surfaces, if accessible, painted occasionally with tincture 
of iodin, and close observation given to detect, and, if necessary, 
to relieve, formation of pus to prevent necrosis if possible. When, 
by reason of comminution of the parts or otherwise, sequestra of 
bone require removal, this should be done in the same manner as in 
other forms of necrosis. Nourishment ought to be suited to the 
conditions under which it must be taken and as highly nutritive as 
possible. The bowels must be kept open and generally healthful 
conditions must be observed. 
Repair of Fracture.-When a fracture is properly set the result- 
ing hyperemia is followed by the exudation of lymph which solidi- 
fies around the broken fragments and encloses the blood clot and 
periosteum together with such other tissues as may have been dis- 
placed by the traumatism. This becomes vascularized and forms the 
fibrous tissue of the provisional callus during the first week, which 
eventually becomes calcified and forms the permanent callus. The 
latter ensheaths the bone at points of fracture and serves to give 
necessary protection until union may take place by more than 
normal development. In the course of time the callus is absorbed 
and disappears almost entirely, but a slight thickening along the 
line of fracture usually remains. 404 
DISEASES OF BONE 
Length of Time Required for Complete Union.-The period during 
which it is necessary to continue fixation of fractured bones depends: 
(1) Upon the situation of the fracture, which is exposed or subject 
to the action of powerful muscles, requires a longer time for healing 
than when such adverse conditions are not operative; (2) upon 
unfavorable constitutional conditions such as debility from old age, 
long-continued fevers, pregnancy, prolonged lactation, scorbutus, 
tuberculosis, syphilis, rickets, etc.; (3) upon mobility due to imper- 
fect approximation of the parts or insecure fixation, and complica- 
tions such as the interposition of foreign substances, soft tissues 
of the mouth, displaced teeth, suppuration, necrosis, etc. 
The time required for union to take place may vary from two 
weeks and a half, an unusually short time, to several months. 
Ordinarily five or six weeks are required to give a reasonably good 
result. But the judgment of the operator must recognize adverse 
conditions, and in these cases allow the retention appliance to 
remain in position a sufficient time to make the united fragments 
self-sustaining. 
Delayed Union.-Delayed union may persist for months, and 
yet, with improvement of the adverse constitutional or other 
condition, union may take place in natural course. 
Faulty Union.-Under unfavorable conditions there may be no 
perceptible effort at repair, or fibrous union may occur by the 
formation of fibrous tissue between the ends of the bone fragments, 
which through absorption and rounding of angular surfaces by 
more or less continued motion sometimes results in a false joint 
(pseudarthrosis). 
In the treatment of united fracture of this character it is neces- 
sary to remove the intervening fibrous tissue and to freshen the 
bone borders, then they must be brought into contact and held 
securely with a suitable splint or by wiring, as in the case of recent 
fractures. Pathological constitutional states should receive appro- 
priate treatment to favor the process of bone repair. 
Attempts to hold jaw fractures by ligatures or wires around the 
teeth immediately upon each side of the fracture without other 
supporting assistance are almost always ineffective, and should 
not be depended upon as a matter of general practice. Constant 
movement, because of imperfect fixation, is the chief cause of 
both delayed and faulty union. 
Complications of Fracture.-The trauma which caused the bone 
lesion may result in serious injury to other parts, or the bone frag- 
ments may be forced into or against important structures and AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
405 
cause laceration of important vessels, with profuse and even danger- 
ous hemorrhage. Pressure upon a nerve trunk may cause numbness 
or paralysis. Virulent forms of infection may be carried into the 
wound at the time of injury and result in tetanus, septicemia, or 
other infectious diseases. Double fracture of the anterior part 
of the lower jaw by action of the digastric, the mylohyoid, and 
geniohyoglossus muscles allows the part to drop downward and 
backward with consequent difficult breathing or even suffocation. 
Drawing the tongue forward in these cases is not sufficient. Stiff- 
ness of the jaw through injury of the glenoid cavity or fixation 
for a long period of time may lead to complete or partial ankylosis. 
Necrosis from infection or comminuted fragments of bone often 
delay union, and may cause septicemia or pyemia with quite serious 
general results. 
The most frequently troublesome complication, and one which 
is peculiar to the jaws and not found in any other form of fracture, 
consists in abscess and continuance of suppuration from teeth 
devitalized by the traumatism which caused the fracture. These 
teeth are often quite sound, and if not noticeably displaced give 
no outward sign of being affected, and yet, over and over again in 
the author's practice, it has happened that healing processes have 
been delayed or union prevented by this simple cause. Pus from 
the roots of these teeth in which the pulps have become gangrenous 
follows the line of fracture, and no matter what may be done in the 
way of other treatments, the discharge of pus with corresponding 
destruction of bone will be continued almost indefinitely. Such 
teeth should be suspected at once and always sought for in every 
case of faulty union. 
Fractures of the upper jaw very frequently involve the maxillary 
sinus, and when compound or comminuted, one or both antra may 
become infected. If there be no other cause for continuance of 
antral disease such conditions clear up in the course of time, and 
unless necrosis of the bony walls occurs they are not usually followed 
by chronic empyema. 
AFFECTIONS OF THE TEMPOROMANDIBULAR 
ARTICULATION. 
Description.-In the temporomandibular articulation the socket 
is formed partly by the mandibular fossa and partly by the articular 
eminence, and over the latter an approximately confluent surface 406 
DISEASES OF BONE 
for the head of the condyle is formed by the articular disk. The 
two temporomandibular articulations act simultaneously. 
When the mouth is opened the head of the condyle with the 
interarticular disk glides forward upon the articular eminence, 
and when the mouth is closed it slips back into the mandibular 
fossa. The opening and closing of the mouth are consequently 
attended by a sliding of the mandible (a gliding joint). 
In addition to this modified form of hinge movement, the articu- 
lation possesses a second kind of motion, the lateral displacement 
of the mandible in reference to the skull. In this movement one 
condyloid head remains in the mandibular fossa, while the other 
advances upon the articular eminence, a movement which is impos- 
sible when the mouth is opened to its greatest extent. Both the hinge 
and the lateral movements are combined in the act of mastication.1 
Alterations in Form.-As a result of jaw habits the complete or 
partial loss of teeth, irregularity of teeth and other deformities 
of the maxillse, abnormal movement of the mandible results. These, 
the author believes, often have pathological importance. When 
the anterior portion of the alveolar ridges is allowed to come in 
close contact there is more or less disarrangement in the relative 
situations of the condyles, the intra-articular cartilages, and the 
coronoid processes. In this way pressure upon nerve trunks is 
sometimes occasioned and may become an active factor in the 
causation of persistent pain in the distribution of the fifth nerve. 
When from habit or necessity there is unusual sliding backward 
or forward of the mandible or continued lateral movement the 
result as might be expected is bone absorption through which 
there is enlargement of the mandibular fossa. Sometimes this is 
evidenced by more or less reduction of the eminentia articularis and 
occasionally by absorption of the posterior wall of the fossa. In 
one of the author's cases this was very marked through abrasion 
of the anterior teeth and consequent tipping of the anterior part 
of the mandible upward and forward and tipping of the condyloid 
processes upward and backward. Constantly applied, more than 
ordinarily powerful muscles of mastication exercised in the habit 
of clenching the teeth together caused the heads of both condyles 
to work backward and upw'ard. This led to extensive absorption 
of the anterior bony wall of the external auditory meatus and 
compression of the openings of both external auditory meatuses 
during closure of the jaws with attendant more or less perceptible 
deafness. When the jaw was relaxed or the mouth partly opened, 
the deafness was relieved. Changes in the form of the mandibular 
1 Sobotta-McMurrich: Atlas and Text-book of Human Anatomy, i, 118. AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
407 
fossa and in the heads of the articular surfaces of the condyles bear 
an important relation to diseases of the teeth and pericementum, 
particularly interstitial gingivitis or that form which is known as 
pyorrhea alveolaris. It also accounts for much of the difficulty 
experienced with artificial dentures. This form of enlargement 
of the temporomandibular fossa, especially when associated with 
loss of distinct form and particularly changed outline of the 
eminentia articularis, accompanied by the general laxity of liga- 
mentous and muscular attachments which is naturally acquired 
under these conditions, favors dislocation of the mandible in certain 
individuals. There is unlimited clinical evidence that such altera- 
tions in the form and structure of the parts associated in the 
temporomandibular articulation do occur. Cryer, through his 
anatomical studies of dried specimens, has added the final proof by 
calling attention to the more or less frequent evidences of absorp- 
tion that he has found in both the condyloid processes and the 
mandibular fossae. 
Dislocation.-Definition.-Dislocation or luxation is defined as 
displacement of bones at a joint or an organ from its usual situation. 
In the surgical sense the term dislocation is used to describe the 
separation of the articular surfaces of two or more bones entering 
into the formation of a joint. 
Classification.- 
Traumatic.-When caused by injury. 
Spontaneous.-Any dislocation not 
caused by external violence (usually 
pathological). 
Complete.-When the articular sur- 
faces are entirely separated. 
Simple.-When covered by unbroken 
tissues. 
Complicated.-When accompanied by 
serious injury to surrounding parts, such 
as important vessels or nerves, injury 
to the capsule, or fracture of the bones 
at the joint. 
Primitive.-When the articular sur- 
faces retain their first position after 
luxation. 
Recent. 
Single.-When there is one dislocation. 
Unilateral.-When a bone situated in 
such position in the body as to have an 
articular surface upon each side is dis- 
located upon one side. 
Pathological.-When brought about 
by disease resulting in destruction of 
tissues of the joint and displacement by 
muscular action. 
Congenital.-If resulting from prenatal 
defect or malformation. This form of 
dislocation is rare and must not be con- 
founded with injury during delivery. 
Incomplete.-When only partly sepa- 
rated and some point of contact remains. 
Compound.-With an external wound 
leading to the joint cavity. 
Relapsing.-When recurring after a 
previous dislocation, either because of 
insufficient time for repair of the parts 
or through chronic relaxation of the liga- 
ments. 
Consecutive.-When still further move- 
ment allows a new position of the articu- 
lar ends of the bones. 
Ancient. 
Double.-When there is luxation of the 
same joint in both of two similar bones 
upon each side of the body. 
Bilateral.-When a bone having artic- 
ular surfaces upon each side of the body 
is luxated on both sides. Examples of 
these bones are the inferior maxillae, the 
sternum, and the hyoid bone. 408 
DISEASES OF BONE 
Dislocations of the lower jaw are usually intracapsular because 
of the wide articular capsule permitting dislocation without division 
of its surface, and therefore simple dislocation is the most common 
form, although both compound and complicated dislocations some- 
times occur from severe injuries. 
Incomplete Dislocation.-'Through relaxed conditions, one or both 
condyles may lodge upon the intra-articular cartilage over the 
eminentia articular is. 
Unilateral dislocation describes displacement upon one side only. 
The dislocation is bilateral when it occurs upon both sides. 
Forward dislocation is the typical form of dislocation of the 
lower jaw. But in rare instances there is backward dislocation, 
in which the articular process glides over the small tympanic 
tubercle which closes the articular fossa behind and reaches the 
tympanicostylomastoid fossa.1 
Etiology.-If for any reason the head of the condyle when the 
mouth is opened passes over the eminentia articular is to a point 
beyond that from which it can glide backward with normal move- 
ment in closure of the jaw, it may become fixed in this position 
or slide forward over and beyond the articular eminence, to be 
drawn upward and forward in fixed position by contraction of the 
masseter and temporal muscles and stretching of the spheno- 
maxillary and stylomaxillary ligaments. This is a typical form of 
dislocation of the lower jaw. Abnormality in the form of the 
mandibular fossa with unusual muscular and ligamentous relaxa- 
tion to which reference has already been made, would be termed 
predisposing causes. 
The jaws of children are less frequently dislocated than adults, 
because the eminentia articularis is not so marked and the angles 
of the rami are obtuse. On the other hand, dislocation among 
women is much more frequent than among men (according to 
Krbnlein four times more frequent), because of the shallower 
development of the articulation and the greater tendency to con- 
ditions of general health, which predispose to muscular relaxation 
and the greater tendency to nervous jaw habits, which lead to 
pathological changes in the fossa. 
Direct causes are usually immoderate opening of the mouth, 
such as in yawning, laughing, states of excitement, screaming, 
vomiting, the insertion of mouth gags, stretching the mouth open 
for the purpose of performing dental operations of various kinds, 
1 Described by Schlatter, von Bergmann's System of Practical Surgery, i, 672. AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
409 
violence, blows upon the side of the face, which usually lead to 
unilateral dislocation, or upon the chin with the mouth open, which 
by driving it backward and downward cause bilateral dislocation. 
Backward dislocation is caused, according to Thiem,1 by forcibly 
closing the teeth, the action of the temporal muscle forcing the 
jaw backward. Doubtless this would be favored by traumatic 
force at the point of the chin with the jaw' closed. 
Pathology.-When the joint capsule is relaxed or the surrounding 
muscles and ligaments have lost their activity, through paralysis 
or otherwise, dislocation may take place without laceration of the 
synovial membrane. When, however, dislocation occurs under 
normal conditions from some unusual force, there may not only 
be laceration of the capsule, but involvement of the surrounding 
and associated bone and soft tissues. Hemorrhage and inflammatory 
conditions naturally follow with resulting exudate and the forma- 
tion of connective tissue, which in reduced dislocations in the course 
of time render their reduction exceedingly difficult or impossible. 
Through infection the integrity of the glenoid cavity or the condyloid 
processes may be more or less completely destroyed by suppurative 
processes. 
Symptoms.-Forward dislocation of the mandible gives a general 
picture of distress, but the explanation of the symptoms is obvious 
(Fig. 194). 
In bilateral forward dislocation the mouth is widely opened; with 
the lower jaw fixed in this position, the lower teeth project beyond 
the line of the upper, there is abnormal flow of saliva, and a distinct 
depression at the glenoid cavity, in front of the tragus; the head of 
the condyle can be felt beneath the malar bone, and the coronoid 
processes felt from within the mouth are found to be displaced 
forward under the zygoma. Marked muscular contraction may be 
accompanied by pain. The fixed position of the jaw interferes 
with speech and prevents use of the jaws in mastication or other- 
wise. Unilateral dislocation is marked by similar symptoms upon 
one side only with the chin displaced toward the unaffected side. 
As previously noted, this is distinguished from unilateral fracture 
of the neck of the condyle, because in this form of fracture the chin 
and jaw are pulled toward the injured side. In the course of time 
pain ceases to be troublesome, and if the dislocation is not reduced 
a certain amount of free movement is acquired through loosening 
of the capsule. In backward dislocation the teeth of the lower 
1 Von Bergmann's Bulletin, p. 672. 410 
DISEASES OF BONE 
jaw rest behind those of the upper, and the condyloid process can 
be felt beneath the external auditory meatus in front of the mastoid 
process. 
Diagnosis.-The symptoms as described are in most cases recog- 
nized without difficulty. Confusion could only occur through some 
complicating condition or in backward dislocation, and in cases 
of this character the z-rays are a valuable aid in determining the 
exact situation of the parts. 
Fig. 194.-Bilateral dislocation of the lower jaw. (Hamilton.) 
Treatment.-To make reduction of a dislocated lower jaw, stand 
in front of the seated patient, and, with thumbs well wrapped for 
protection, placed upon the lower molar teeth upon each side of the 
dislocated jaw, make pressure downward and slightly backward, at 
the same time lifting the chin upward with the other fingers. In 
more obstinate cases pieces of wood or cork may be placed between 
the molar teeth, and standing behind the patient, whose head rests 
against the operator's chest, with hands elapsed under the chin, 
force is exerted to draw it upward. It is sometimes necessary to 
give a general anesthetic to cause muscular relaxation. In irre- 
ducible or chronic cases the removal of the coronoid processes or 
operations upon ligaments have been recommended, but conditions 
calling for such radical treatment are exceedingly rare, and the AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
411 
results undoubtedly more or less uncertain. In unilateral dislocation 
the treatment above described is applied to the affected side and 
simultaneously an additional effort to force the chin toward the 
median line. Backward dislocations are reduced by forcibly opening 
the mouth or by pressing the lower jaw backward, then downward 
and forward, under anesthesia. The after-treatment in all forms of 
dislocation of the mandible is to limit or control its movement, to 
prevent tendency to recurrence until after the parts have had 
opportunity to recover. Usually this requires ten days and some- 
times longer. Food should therefore be such as to require slight 
movement of the jaw, if any, and highly nourishing in character. 
Recurrent dislocations are often very troublesome (Fig. 195). 
Fig. 195.-Reduction of dislocation of lower jaw. 
Chronic Dislocation of the Jaw.-C. Riley1 reports the case of 
a young woman whose jaw became constantly dislocated when 
talking and laughing after having been dislocated for the first 
time in a dentist's chair. She was relieved by an appliance which 
is illustrated (Fig. 196). It is described as follows: 
"A piece of German silver wire was bent so as to fit across the 
top and sides of the head and extend down toward the zygoma and 
over the joint on each side. On the inner side of each end there 
was riveted a plate about three-quarters inch in diameter, which was 
padded with piano felt and covered 'with kid. The wire was bent so 
as to make firm pressure over and slightly below the joints. This 
acted in retaining reduction, enabled her to eat solid food in a short 
time, and ultimately to do away with the apparatus." 
Imperfect dislocation or subluxation of the lower jaw Marshall2 
describes as a condition in which the condyle partially slips from 
the glenoid fossa in a forward direction, and in front of the inter- 
1 Am. Jour. Orthop. Surg., April, 1908. 
2 Injuries and Surgical Diseases of the Face, p. 254. 412 
DISEASES OF BONE 
articular cartilage, when the mouth is opened. Upon closing the 
mouth the condyle goes back again to its place with a clicking, 
snapping sound. Sometimes it catches for a moment when the 
mouth is widely extended and causes anxiety on the part of the 
patient for fear that the jaw is dislocated. 
Etiology.-The pathology consists in alterations of the man- 
dibular fossa and relaxation of the surrounding ligaments as pre- 
viously described. 
Fig. 196.-Riley's appliance for chronic dislocation of the lower jaw 
Treatment.-No treatment is required except in rare instances 
when reduction cannot be accomplished by the patient without 
assistance. If very annoying, temporary fixation of the parts may 
assist in stiffening the parts surrounding the articulation and 
decrease the likelihood of its recurrence. 
Arthritis.-The temporomandibular articulation is subject to 
the same inflammatory affections as other joints. Inflammations 
limited to distinct parts are described as chondritis, when affecting 
the cartilage; synovitis, the synovial membrane; parasynovitis, the 
joint capsule and ligaments; and panarthrosis when all parts are 
involved. 
These terms are of little clinical value, because in acute inflam- 
mations almost invariably all of these structures are involved 
together. In rare instances, however, some one of them may be 
affected by a low-grade chronic inflammation without necessarily 
involving the associated parts. Surgical affections usually begin 
in the synovial sac as synovitis. 
The temporomandibular articulation is not as frequently exposed 
to traumatic and other injuries as many other joints in the body, 
and inflammations beginning in the joint cavity are comparatively AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
413 
rare, and further, because it is the results of such inflammations 
that the surgeon is chiefly called upon to treat. For the sake of 
brevity and practical advantage the pathological conditions leading 
thereto will be described in relation to their effect in limiting the 
free movement of the joint. 
Synovitis.-Classification.- 
Primary. 
Acute. 
Secondary. 
Chronic. 
Etiology.-Causes are traumatic injuries, affections of the syno- 
vial membrane or articular cartilages, foreign bodies in the joint, 
and inflammatory process due to the foregoing causes or bacterial 
or chemical irritants in the circulation. The general causes include 
diseases due to-faulty metabolism, rheumatism, gout, and infec- 
tious diseases, such as influenza, pneumonia, typhoid and scarlet 
fevers, gonorrhea, syphilis, etc. Neuropathic influences manifest 
themselves as causal factors in spinal and other nerve affections. 
Pathology.-The disease may be monarticular (affecting one 
joint) or polyarticular (affecting more than one joint). Its first 
manifestations are usually in the synovial membrane. As a result 
there may be a decrease of serous secretion with exudate having 
a tendency to coagulate-dry synovitis (synovitis sicca). In acute 
synovitis there is usually more or less effusion. If this becomes 
infected it is known as purulent synovitis and in chronic synovitis 
in the absence of pus the serous effusion is called hydrarthrosis. Such 
effusions naturally cause distention of the synovial membrane, with 
such changes in the structures of the joint as their character would 
indicate. 
Symptoms.-The symptoms consist in more or less loss of motility, 
pain, and swelling. In chronic forms there may be deformity, as in 
arthritis deformans, complete ossification of the joint, as in osteo- 
arthritis, or the destructive processes of caries and necrosis. 
Treatment.-Treatment must be so directed as to overcome the 
cause and relieve the local symptoms, with a view to prevent 
stiffening of the joint. With reference to the lower jaw this is 
as described in treatment of temporary ankylosis, page 415. 
Ankylosis of the Jaws.-While the following classifications are 
applicable to ankylosis of the temporomandibular articulation in 
common with the other joints, the following distinctions require 
special consideration in this region: 
Classification.- 
Temporary. 
Fibrous. 
Unilateral. 
Permanent. 
Bony or true ankylosis. 
Bilateral. 414 
DISEASES OF BONE 
Murphy1 states that ankylosis is a generic term and does not 
represent a pathological entity. His classification of ankylosis 
and the types of arthritis which lead to ankylosis are as follows: 
Capsular 
Peri-articular 
Extracapsular 
' Tendinous. 
Tendovaginal. 
_ Muscular. 
Ankylosis, true 
and false 
Articular 
Synovial. 
Cartilaginous. 
Osseous. 
(a) Primary hematogenous fibrous arthriti 
(b) Dry fibrous arthritis non-traumatic. 
(c) Traumatic fibrous arthritis 
With fracture into the joint. 
Without fracture (contusion) 
Cryptogenetic. 
Typhoid. 
Scarlatina. 
Pyemia. 
Gonorrhea. 
Arthritis 
(d) Suppurative 
Hematogenous 
Metastatic 
Traumatic. 
Osteitis 
Tuberculous. 
Osteomyelitic (infective.) 
Extension 
Peri-arthritis (phlegmon). 
Panarthritis. 
(e) Ossifying arthritis (primary) 
(/) Static adhesive. 
Temporary Ankylosis.-Etiology.-Temporary ankylosis is due 
to inflammatory conditions of the tissues surrounding the temporo- 
mandibular articulation, which may be in the nature of an acute 
synovitis or stiffness and contracture of the surrounding muscles, 
spasmodic muscular contraction due to direct irritation of the 
third division or of the trigeminal nerve, which, however, must 
not be confounded with the trismus of tetanus; parotitis or inflam- 
mations of other glands in this region, both salivary and lymphatic; 
tumors, traumatic injuries; and infections of any kind which may 
affect the joint structures or surrounding parts without creating 
permanent injury. 
Pathology.-The most frequent causes of temporary ankylosis 
are malposition and delayed eruption' of the third molar teeth 
with attendant inflammatory processes and dento-alveolar abscess 
in the same region. As the mandible develops, unless the third 
molars are allowed to progress upward in the natural course of 
eruption, it quite frequently happens, as the growth of the roots 
proceeds, that the extension finally reaches the inferior dental 
canal. This occasions more or less direct pressure upon the third 
1 Jour. Am. Med. Assn., May 20 and 27, and June, 1905. AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
415 
division of the fifth nerve, and in this way irritation may occur 
which can be a factor in causing muscular spasm or in leading to 
pain which may give rise to inflammatory processes, especially 
when supplemented by infection. 
Dento-alveolar abscess and other infections, tumors, and swell- 
ings which restrict or obstruct jaw movement do not differ in 
their pathological manifestations from similar conditions in other 
parts. 
The pathology of acute synovitis has already been described 
(p. 413). 
Symptoms.-The symptoms are usually those of acute inflam- 
matory conditions when the restricted movement of the mandible 
appears to be merely incidental to other troublesome symptoms. 
Prognosis-The prognosis in these cases is good, providing relief 
can be given before permanent changes in the tissues have been 
allowed to take place. Usually the symptom of jaw stiffness dis- 
appears in the course of time, but occasionally efforts to open the 
mouth forcibly must be continued for a considerable period to 
prevent the formation of adhesions. 
Treatment.-Treatment consists ' of applications to reduce the 
swelling, removal, or prevention of local infection and separation 
of the jaws when necessary with mouth gags or movement otherwise 
enforced if possible. When impacted third molars are the cause, and 
there is infection in the surrounding and overlying gum and cheek 
tissues, good judgment must be exercised in deciding between 
immediate removal of the impacted molar, through which complete 
relief might be expected, or palliative treatment for the control of 
the acute infectious condition before exposing the individual to 
general infection by allowing the pus microorganisms directly to 
enter vessels which must be unavoidably lacerated in removal of 
the tooth. A number of deaths have been reported from this 
cause. When the presence of pus in considerable quantity seems 
to indicate danger in this direction it is usually the part of wisdom 
to force the mouth open with suitable mouth gags, even though 
an anesthetic may be required on account of the acute pain. They 
should be kept apart with corks between the teeth so as to permit 
proper cleansing and treatment of the inflamed tissues in the angle 
of the jaw. 
When the acute infectious symptoms have sufficiently subsided, 
removal of the impacted tooth may be safely performed. Even 
after removal it is sometimes necessary to continue the processes 
of more or less forcible openings of the jaws in order to prevent 416 
DISEASES OF BONE 
adhesions in and around the joint which might lead to more or 
less permanent ankylosis. If there is synovitis, with marked 
evidence of effusion, which necessitates relief by division of the 
synovial capsule, this should only be done as a last resort and 
under the most careful aseptic precautions to prevent carrying 
infection into the joint. Of course, when pus has already formed 
in this situation its free evacuation is demanded. 
Fibrous Ankylosis.-Fibrous, false, or pseudo-ankylosis as noted 
by Park is more properly a contracture. 
Etiology.-Fibrous, or false, ankylosis is caused by the formation 
of fibrous tissue within the joint intra-articular or extra-articular, 
cicatricial or fibrous bands constricting the ligaments or muscles 
concerned in the movement of the joint, and the structures 
immediately surrounding it. These may be the result of synovitis 
and arthritis due to syphilitic or other destructive process following 
infectious diseases, extensive burns, ulcerative processes within the 
mouth, as ulcerative stomatitis, necrosis of the jaws, gangrena oris, 
and similar affections. 
Pathology.-Intra-articular adhesions are the residt of synovitis 
and arthritis in which the exudate has become organized and has 
caused the formation of fibrous tissue within the joint or the 
formation of osteophytes which interfere with free movement. In 
extra-articular conditions the cicatricial and fibrous bands are 
formed in the course of healing of extensive injuries, ulcerations, 
and gangrenous or inflammatory processes which mechanically bind 
the parts. These may be in the ligaments surrounding the joint 
or in the muscles of mastication or both. 
Symptoms and Diagnosis.-The symptoms consist in fixation of 
the jaw, but this is usually susceptible of slight motion, which 
serves to distinguish it from true or bony ankylosis, for in such 
cases movement is impossible. 
Arrested development of the lower jaw with marked recession of 
the chin is a notable feature when fixation of the jaw has occurred 
at an early period of life. It is not always possible to determine 
whether the ankylosis is unilateral or bilateral, but in the author's 
experience the center of the chin being more or less noticeably 
upon one side of the central facial line1 indicates that the jaw has 
been drawn toward the affected side and that loss of development 
has been more marked on that side. Therefore it is fair to assume 
that the affection is chiefly unilateral, for it must be remembered 
1 An imaginary line, referred to elsewhere, taken from the central portion of the 
forehead perpendicularly down through nose and chin. AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
417 
that although the lesion that caused the ankylosis may originally 
have been confined to the temporomandibular articulation upon 
one side, fixation of the jaws during a long period of time might be 
expected to cause more or less permanent impairment upon the 
opposite side. In all of the author's cases, four of which are referred 
to in the following descriptions, this simple diagnostic feature has 
served to point the way to successful diagnosis. 
Prognosis.-The prognosis in these cases depends entirely upon 
the successful continuance of the effort to keep the jaws open. 
The contraction of scar tissue following such operations continues 
for a very long period of time, and it is not sufficient to continue 
extension during the healing of the wound only. The muscles 
must be stretched by forcing the jaws open, and this treatment 
continued for a period of time sufficiently long to make certain the 
permanency of the result. 
Treatment.-When the fibers or cicatricial bands which hold the 
jaw in fixed position are confined to one side and are so situated 
that ankylosis would persist even though the jaw were free at the 
articulation. 
Such cases may be treated by severing the restricting bands of 
tissue from within the mouth; continued separation of the jaws 
by the use of a mouth gag until the necessary freedom of movement 
has been secured; continuance of this movement and prevention 
of reformation of the adhesive-tissue bands and contracting muscular 
factors by keeping the mouth permanently and continuously open 
and the jaw in free movement until there appears to be no likelihood 
of recurrence of fixation. The author has had many satisfactory 
results in the treatment of unilateral fibrous ankylosis by the 
intra-oral operation as described in the following cases from his 
own practice. 
The history of such treatment as generally practised has been 
unsatisfactory, but chiefly so for the reason that the proper measures 
for continuous jaw movement have not usually been instituted. 
When this has been done there has been failure to continue for a 
sufficiently long period. Nevertheless in spite of every care in the 
effort to continue the free movement of the jaws, it may be impos- 
sible to overcome the tendency to restricted motion. This is indi- 
cated by the complete history of the child shown in Fig. 200 and 
again in Fig. 202. The development of the molar teeth in this case 
led to conditions which caused recurrence of the jaw fixation, long 
after complete success seemed to have been assured. 
Figs. 197 and 198 illustrate a little girl, aged two and one-half 418 
DISEASES OF BONE 
years, with ankylosis from birth. No instruments were used in 
delivery, but the mother was a number of hours in labor and there 
was without doubt some injury to the jaw by reason of this fact. 
From this case and other similar ones that the author has seen it 
seems to him fairly certain that ankylosis of this character is brought 
about by backward dislocation of the jaw through some traumatic 
injury during labor. It is interesting to note by way of emphasizing 
the value of the simple diagnostic signs, that eighteen different 
medical and surgical practitioners had examined this child without 
being able to determine whether the affection was unilateral, 
bilateral, fibrous, or bony. Diagnosis was made of fibrous ankylosis 
Fig. 197.-Child, aged two and one- 
half years, with ankylosis of the lower 
jaw from the day of birth. The reced- 
ing chin shows the typical arrested de- 
velopment of the mandible. 
Fig. 198.-Same child as shown in 
Fig. 197. The chin is drawn to the left, 
the side that was found to be affected by 
fibrous ankylosis. 
because there was slight but distinct movement of the jaw upon 
manipulation. The chin, as will be noted, is upon one side of the 
central facial line. Therefore it was believed to be unilateral. At 
the time of operation this proved to be correct. The child was given 
a general anesthetic, and with complete relaxation a thin, flat 
instrument was passed between the teeth. By continued application 
of steady force it was then possible to slip an ordinary mouth gag, 
with the flanges filed down so as to leave two flat surfaces to slide 
between the teeth, in through the space caused by the overbite of 
the upper jaw projecting beyond the undeveloped lower jaw. This 
permitted the passage of the blade of a knife and a blunt instrument 
to be used as a director through which the most prominent fibrous AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
419 
bands were located and then severed. With each incision there was 
a noticeable improvement in opening the jaw, and with continued 
pressure it was finally possible to pass a finger into the mouth 
between the teeth. With this as a guide the knife could follow until 
all of the restricting bands of tissue were cut and the jaw opened to 
its full extent. Every movement indicated without question that 
there was no serious obstruction upon the opposite side. The teeth 
should first be protected by a metal or other plate, to prevent injury 
from the gag. 
Postoperative Treatment.-It must be recognized: (1) That the 
jaw must be kept continuously open or in free movement for a 
long period of time; otherwise there will be recurrence and a 
condition probably worse than before the operation. (2) Unless 
the jaws are kept widely open both day and night, the healing 
process during the sleeping hours will more than overcome what 
might be accomplished during the daytime. (3) That any kind 
of an appliance which a young chilfl would be likely to fear would 
cause so much disturbance and difficulty, perhaps fighting and 
struggling in efforts to keep it between the jaws, that it would be 
unreasonable to expect parents to carry on such methods regularly 
and continuously for a sufficiently long period of time. 
To meet these requirements the author employs a very simple 
expedient which has been useful in many similar and large numbers 
of other kinds of cases in which it was necessary to keep the jaws 
open. The device consists of a series of rubber corks, to which for 
safety several inches of string, ligature, or cord have been firmly 
attached to prevent accident in case one might slip into the throat 
and be swallowed. The smallest size of these can be readily slipped 
between the teeth and gradually forced backward without fright- 
ening, giving pain or other serious inconvenience to the child. A 
larger size can then be inserted on the opposite side of the mouth 
and gradually forced back in the same way. Continuing from one 
side to the other the fourth or fifth larger cork can finally be placed 
between the teeth. Any reasonably disciplined child can be induced 
to keep a cork of that kind constantly in the mouth, for it gives 
practically no inconvenience. The little girl whose case is described 
used to amuse herself and play with her dolls with the cork between 
the teeth without any trouble whatever, and slept with the jaws in 
the same situation. Thus they were kept continuously apart for 
many months, and even now, after a lapse of several years, the 
mother continues to stretch the parts occasionally in this way. 
Improvement in the shape of the face and the lower jaw with 420 
DISEASES OF BONE 
almost complete free movement has been the result. Figs. 199 and 
200 are pictures of the same child, shown in Figs. 197 and 198, with 
the cork in place as described, and after operation. 
Fig. 199.-Child shown in Figs. 197 
and 198, with cork between the jaws as 
described. 
Fig. 200.-Result of operation for 
fibrous ankylosis. Same child as in 
Figs. 197 and 198. 
Fig. 201. - Shows the scar of the external 
operation for ankylosis about three weeks after 
operation. The hair that was shaved above the 
flap will almost entirely cover the defect when 
grown again, and the scar will be much less notice- 
able in all respects. 
Fig. 202.-Same girl shown in Fig. 201 
after operation. Previously there was 
almost complete fixation of the jaws. AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
421 
The eruption of the molar teeth backward, toward the angle of 
this typically short mandible, created conditions which brought 
Fig. 203.--Unilateral fibrous ankylosis; 
chin drawn toward the affected side. 
Fig. 204.-Same girl shown in Fig. 203, 
attempting to open her mouth. 
Fig. 205.-Picture of the same girl as in Figs. 203 and 204, opening her mouth after 
operation. 
about a more or less gradual limitation of movement until finally, 
about the age of thirteen years, the ankylosis was again complete. 
An attempt was again made to force the jaws apart under anesthesia, 422 
DISEASES OF BONE 
but it was found impossible to do this without serious injury to the 
teeth. It therefore became necessary to do the external operation 
according to Murphy's method, the result of which is shown in 
Figs. 201 and 202. 
Figs. 203, 204 and 205 show a little girl for whom the intra-oral 
operation was performed for unilateral fibrous ankylosis, resulting 
from aural disease. It will be noticed that beginning at a later 
period there is not the same amount of recession of the chin, because 
the lower jaw has developed normally until the beginning of the 
Fig. 206.-Skiagraph of a case of fibrous ankylosis. The same one illustrated in 
Figs. 203, 204 and 205. 
trouble. The diagnosis of unilateral affection was made from the 
fact that the chin was upon one side of the central line, and it was 
found to be correct, for free movement was secured immediately 
upon separation of the restrictions upon the affected side. Fig. 206 
is a skiagraph of the case illustrated in Figs. 203, 204 and 205. 
Bony Ankylosis.--Etiology.--Bony ankylosis results from a 
distinctive type of arthritis, which may be due to any one of the 
diseases that may cause the latter affection, particularly such as 
are accompanied by suppurative processes. It may also be brought 
about by calcific changes such as occur in osteo-arthritis or result AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
423 
from traumatic injuries which may destroy the integrity of the 
parts and lead to infection. Roe believes that bony ankylosis 
resulting from such injuries is always accompanied by fracture. 
In the author's experience a quite common cause of both true and 
false ankylosis is the extension of suppurative aural diseases. 
The case illustrated in Fig. 207 with bilateral ankylosis began 
after extensive suppuration, which affected the ear upon one side 
and later upon the other. Others of the author's cases have given 
a similar history. 
Fig. 207.-Bilateral bony ankylosis. 
Symptoms.-Absolute immobility of the lower jaw is the dominant 
symptom. In cases where the affection has begun at birth, infancy, 
or early childhood there is arrested development of the lower jaw, 
which remains approximately the size that it was at the period of 
onset of the affection. There is corresponding recession of the chin 
and lack of development of the lower part of the face, with marked 
projection of the upper jaw. This is fortunate for the patients, as 
it enables them to pass food through the mouth and to secure 
sufficient nourishment without movement of the mandible. Con- 
trary to expectation, the general health and appearance of these 
individuals is usually fairly good. Figs. 208 and 209 are radiographs 
of adults with bony ankylosis. 
Prognosis.-In operations for the relief of bony ankylosis the 
chief danger lies in asphyxia. Usually the cases that prove trouble- 424 
DISEASES OF BONE 
some in this respect are also those in which there has been difficult 
breathing before operation was performed, and from this history 
Fig. 208.--Radiograph of an adult with bony ankylosis. 
Fig. -209.-Radiograph of an adult with bony ankylosis. 
the operator may be on guard. Safety depends upon readiness 
to meet the situation both during and after the operation. The AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
425 
result necessarily depends very largely upon the character of the 
cause and the actual condition of the ankylosis. If operation 
upon the condyles can give sufficient movement without restriction 
from anterior attachments, then a good permanent result may 
be expected. If such bands exist and the condition is unilateral, 
there will be sufficient force in mastication from the muscles of the 
unaffected side to overcome disadvantage of the loss of function- 
ating power upon the side from which a section of the jaw has been 
resected. When, however, the ankylosis is bilateral and of such 
character as to make it impossible to give relief by operating upon 
the condyles, resection according to the Esmarch operation upon 
both sides leaves little or no muscular strength for use of the jaw 
in mastication. If such patients are well nourished and getting on 
comfortably without operation, it is the author's belief that they 
should be left undisturbed, for bilateral Esmarch operation ought 
not to be performed except in rare cases of urgent necessity. 
Treatment.-The purpose of all methods of treatment of bony 
ankylosis is to establish a pseudarthrosis. Among the various 
operations devised for this purpose are the following: Removal of a 
segment from the body of the jaw near the angle, already referred to 
as Esmarch's operation; division of the ascending ramus, as recom- 
mended by Dieffenbach; separation of the jaw by cutting with 
forceijs used from within the mouth anterior to the cicatricial band 
causing fixation as recommended by Rizzoli; many variations of the 
three preceding operations, as suggested by Elliot and Cabot, of 
Boston, Whitehead, of Manchester, and others; removal of wedge- 
shaped sections from the ramus and the insertion of gauze or gutta- 
percha tissue, muscle, or other tissue or skin to prevent reuniting 
of the parts, as recommended by Mclllhenny and Gluck, of Berlin, 
who implanted a cutaneous wedge with attachment to the bony 
surfaces to prevent union; excision of the head and neck of the 
condyle, first performed by Humphrey in 1856; and removal of a 
section of the jaw in front of the fibrous bands. 
Excision of a section from the neck of the condyle without removal 
of the head and then insertion of a flap of tissue. This operation 
was perfected by the late Dr. John B. Murphy.1 Modifications of 
his method are now generally followed with much success by many 
operators is illustrated in Figs. 210-213. The incision is L-shaped, 
the perpendicular portion comes down to the upper border of zygoma 
and then extends forward for one-half to three-quarters inch, 
1 Practical Medicine, Series 11, 1915. 426 
DISEASES OF BONE 
Fig. 210.-The Gigli saw used to divide the mandible. 
Fig. 211.-The gap left after the exsection, with the curved periosteotomes still 
in situ. 
Figs. 210 and 211.-Arthroplasty for intra-articular ankylosis of jaw. (Murphy.) AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
427 
Fig. 212.-The temporal fascia and fat flap freed and prepared for insertion. 
Fig. 213.-The temporal fascia and fat flap secured in its interposing position by 
sutures. 
Figs. 212 and 213.-Arthroplasty for intra-articular ankylosis of jaw. (Murphy.) 428 
DISEASES OF BONE 
making the longitudinal portion. This incision leaves a very slight 
scar, and gives better access than does the perpendicular incision, 
because in some of the cases, the ankylosis extends forward on the 
zygoma from the glenoid to the coronoid process. The perpendicular 
incision is for securing the fat and fascia of the temporal muscle. 
Fig. 214.-Arthroplasty for intra-articular ankylosis of jaw. (Murphy.) A, B, 
Dr. Murphy's periosteotome, side and back view (somewhat reduced); C, D, bone- 
cutting forceps or nippers, side and front view (somewhat reduced); E, the interdental 
block designed by Dr. Murphy to maintain the desired spread of the jaws. It is 
made of wood, and since it is wedge-shaped the degree nf opening can easily be 
regulated by withdrawing or pushing in the block. 
For dividing the ankylosis, the chisel is more satisfactory than the 
bur. The greatest caution is required in the use of the chisel, or 
the bur, because the brain is separated by a very thin plate of bone 
only. AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
429 
After the incision the edges of the wound are retracted, the lower 
lip being displaced down over the lower border of the zygoma, to 
give a good exposure of the joint. Then the tissues are separated 
with a special curved periosteotome all around the anterior surface 
of the line of union and further separated with a similar instrument 
around the posterior surface. When the bone is laid bare, the 
instruments are passed .behind the neck of the bone, one from each 
side, when they are in place they completely encircle the neck, 
holding the soft parts retracted so the articulation is fully exposed. 
The insertion of these instruments and their retention during 
excision form the key to the success and safety of the operation. 
Injury to the internal maxillary artery, which closely hugs the neck, 
is. thus avoided. The chisel or bur then divides the bone on the level 
of the tubercle, without endeavoring to remove the articular surface 
of the head of the bone, as there is danger of penetrating the base of 
the skull when an effort is made to excavate all of the head. If bony 
ankylosis is present, one-third inch of the neck is excised, so one can 
put the tip of the finger between the divided fragments across the 
space over the inner margin of the neck at the base of the zygoma. 
This must be done carefully, and ample bone removed, so as to 
admit the interposing flap. The periosteum should be left attached 
to the bone that is removed. The deeper fragments of bone Qan be 
taken out with a small rongeur. If one desires, as soon as the peri- 
osteotomes have been passed behind the neck of the bone, a small 
and full-curved aneurysm needle may be used to carry a silk 
thread around the neck to act as the carrier for the Gigli saw; this 
method is rapid and effective. The difficulty of inserting the saw 
is slight, but the acute angulation which necessarily occurs, occa- 
sionally causes it to break, giving some inconvenience. On the whole, 
it is not handled as easily as the chisel. As soon as the bone is com- 
pletely divided, the mouth can be opened readily by the anesthetist. 
The interposing flap should now be prepared. The perpendicular 
incision is elongated up, say for one and one-half inches over the 
temporal muscle, about three-quarters inch wide and one and one- 
half inches long, leaving the base attached to upper margin of 
the zygoma. This is freed from above down, folded down over 
zygoma and packed into the bony gap, from which a portion of the 
neck has been removed. At its anterior and posterior basal angles 
it is securely tacked, with a few catgut sutures, to the fascia and 
periosteum, so as to retain it in position. Then the skin is accu- 
rately closed with horsehair, dusted with bismuth subiodide and 
sealed with collodion gauze. No other dressing needs to be applied. 430 
DISEASES OF BONE 
No special effort should be made at this time to spread the jaws, 
as it is important the lower jaw should remain steadied on the well 
side in order that the wooden block inserted on the diseased side may 
maintain the wide separation of the molar teeth, until the inter- 
posing flap has healed in. This block also prevents compression 
and necrosis of the flap. 
Babcock transplants fat from some other portion of the body into 
the space between the ends of the bone. This saves the necessity for 
the perpendicular incision. Dr. Morris I. Shamberg, of New York, 
recently exhibited a very successful result, although he placed no 
tissue between the bone ends in that case. The author has found 
it easier to insert the flap of fascia as described by Murphy, and 
although Murphy's instruments, as shown in Fig. 214, would 
undoubtedly facilitate the accomplishment of the operation, he has 
found little difficulty in securing the desired results with quite 
simple instruments, devised to meet the operative requirements. 
Roe's description of the operation for excision of the head and 
neck of the condyle in the report of one of his cases is valuable. 
He says:1 
"I made an incision opposite the neck of the condyle, beginning 
just below the zygoma and extending downward one and one-half 
inches. The anterior border of the parotid gland was next retracted 
backward, exposing the masseter muscle. With the blunt-pointed 
dissector I separated the fascia and fibers of the masseter muscle 
and periosteum about opposite the middle of the skin incison for- 
ward, dilating this opening with forceps until I could introduce my 
two index fingers. Through this opening I made a subperiosteal 
excision with a chisel of the mass of callus, including the condyle 
and neck, and found that the bridge of bone connected the outer 
surface of the head and neck of the condyloid process with the 
outer surfaces and lower border of the posterior portion of zygoma, 
and was about one-third of an inch in thickness and three-quarters 
in width. There was no union between the articular surfaces, and 
an apparent absence of the interarticular fibrocartilage. After 
clearing the lower border of the zygoma and making smooth the 
excised border of the ramus, I was able to pass my index finger freely 
between the ramus and glenoid fossa, and could spread the mandible 
sufficiently to demonstrate that it was free upon that side, except 
for its muscular attachments. After carefully flushing with water 
to remove any chips of bone, I brought together the separated 
1 National Dental Association, 1902, pp. 92 to 94, AFFECTIONS OF TEMPOROMANDIBULAR ARTICULATION 
431 
fibers of the masseter muscle and fascia with catgut sutures, after- 
ward closing the skin wound with Halstead's subcuticular suture, 
using silkworm gut. (Gregg has recommended closing the wound 
without drainage.) The same procedure was repeated upon the 
left side, and almost precisely the same condition of the articu- 
lation was found. As soon as the section through the neck of 
the condyle was complete, the mandible dropped a little distance. 
When I had completed the excision, and before closing the wound, 
I placed an ordinary mouth gag between the teeth and opened the 
mouth to about the normal extent, and then by grasping the 
mandible I made some lateral manipulations, after which the wound 
was closed. 
"There was no special interference with respiration during either 
operation, and the patient made a rapid and uninterrupted recovery 
from each. The wound healed by primary union, and in each case 
the sutures were removed on the eighth day. He was allowed to 
open his mouth as freely as the bandages would permit, and ten 
days after the second operation, when he left for his home, he could 
voluntarily separate the anterior teeth to the extent of one inch, 
and was learning to masticate solid food. Three weeks later he could 
open his mouth one and one-fourth inches. There was paralysis of 
the muscles supplied by the malar and infra-orbital branches of the 
temporofacial division of the seventh nerve, from which he gradually 
and almost completely recovered in two months. He has actively 
exercised the muscles connected with the mandible, and at the 
present time can open his mouth one and one-quarter inches, can 
close it with about as much force as the ordinary person, and has 
good lateral motion." 
In describing other cases, Roe calls attention to one in which 
a tracheotomy was necessary to overcome arrested respiration 
when the mouth was opened after the jaw had been freed from its 
attachments. He reports the case of another patient who died 
from arrested respiration almost without warning after he had 
been returned to his room in the hospital apparently in good 
condition. In this case local anesthesia was used because of the 
danger apprehended from a general anesthetic. Dr. Wayne Bab- 
cock, of Philadelphia, also reports one case in which death occurred 
quite unexpectedly after the patient had been returned from the 
operating room. 
Roe believed that through absence of development of the man- 
dible in these individuals the hyoid bone is not raised to its proper 
position, and that it is displaced backward and downward, causing 432 
DISEASES OF BONE 
displacement of the organs dependent upon it. Thus it leaves 
very little pharyngeal space, and when the mandible is freed from 
its attachment and drops to some extent, the base of the tongue 
and the posterior surface of the larynx lie in apposition to the 
posterior pharyngeal wall. Thus respiration is difficult or impos- 
sible. 
Esmarch's Operation.-An incision about two inches in length is 
made along the lower border of the jaw. The bone is exposed, the 
periosteum divided, and a wedge of bone with its base below removed 
from the body of the jaw anterior to the masseter muscle and in 
front of the contracted tissues, bleeding checked, and the wound 
closed. Passive movements must be begun as soon after the opera- 
tion as practicable and continued regularly. Corks between the 
teeth to keep the mouth open as widely as possible should be 
employed as already outlined for fibrous ankylosis. It is only under 
very rare conditions that this operation might be required. 
Postoperative Treatment.-The jaw must be firmly secured to 
prevent its dropping and causing suffocation until such time as the 
patient may have quite recovered from the anesthetic and has had 
some opportunity to become accustomed to new conditions in 
respiration. At a later period and before adhesions have had oppor- 
tunity to become sufficiently resistant, motion of the jaw should be 
instituted and continued until a permanent result is secured. In 
other respects the treatment of these patients is the same as for 
other operations subject to more than ordinary care in adminis- 
tering nourishment under the difficult conditions that are im- 
posed. 
Arthrodesis.-This term is applied to the intentional production 
of ankylosis in a joint previously healthy or nearly so with the inten- 
tion to stiffen and enhance its usefulness. This is usually required 
in cases of infantile paralysis with loss of control of the extremities. 
It is also in a measure applicable to cases of too free movement 
of the condyle in the temporomandibular fossa from habit, relaxed 
conditions of the ligaments and muscles, when temporary immo- 
bility of the jaws is secured or other methods of fixation for the 
purpose of gaining a measure of stiffness in motion, and it is 
undoubtedly upon this principle that the various expedients for 
jumping the bite are enabled to operate successfully. 
In other parts arthrodesis is sometimes brought about by opening 
into the joint itself to stiffen more firmly than might be expected 
from less heroic methods. 433 
RESECTIONS OF THE JAWS 
RESECTIONS OF THE JAWS. 
The purposes of resection of the maxillae are for removal of the 
malignant growths, correction of deformities, and, as already 
described, the formation of a false joint in treatment of ankylosis. 
In addition to this, large sections of bone involving the entire 
thickness of the body of the jaw are sometimes removed as sequestra 
in the treatment of necrosis. 
Resections of the Lower Jaw.-The several forms of resection 
of the lower jaw are as follows: 
Temporary, when the jaw is resected to facilitate the perform- 
ance of some operation in the mouth or pharynx and immediately 
closed as illustrated in Fig. 215. 
Fig. 215.--Temporary resection of the inferior maxilla. (After Sedillot.) 
Partial, without complete division of the jaw. 
Complete, when the jaw is completely divided. 
Disarticulation, when the articular portion is removed. 
Partial Resection.-Resections involving the alveolar process 
or part of the body of the jaw can under normal conditions be 
performed without an external incision. Provision must be made 
against the inspiration of blood, as with other mouth operations. 
The patient is placed in a recumbent position with the shoulders 
raised by a pad or sand-bag sufficiently to tip the head as far back 
as possible when turned as it should be toward the side away from 
that which is to be operated upon. The lips and angle of the mouth 
are held out of the way with a retractor, a gauze sponge made into 
a roll and clasped with a forceps placed along the inside of the jaw 434 
DISEASES OF BONE 
under the tongue. In this way the field of operation may be satis- 
factorily exposed and the flow of blood kept within bounds. Bone 
shears or bone-cutting forceps sometimes facilitate removal of the 
bone, or a chisel may be used. But there seems to be no reasonable 
doubt of the fact that in these cases a surgical engine bur, or bone- 
cutting burs for the dental engine, as described (p. 80), will effect 
the necessary removal more rapidly with less hemorrhage, because 
the torsion of the vessels by the rotary motion of the bur favors 
their contraction and lessens the flow of blood. A properly 
manipulated bur leaves a smooth bone surface, which favors healing 
processes. If resection be made for any purpose other than 
malignant growths, and when the periosteum is not actually involved 
in disease which necessitates its removal, or in cases where it is not 
desirable to have pseudo-arthrosis, this membrane should be care- 
fully preserved to as great an extent as possible, in order that bone 
may again be restored with a maximum of functional usefulness 
and minimum of deformity. 
In the performance of all such operations within the mouth 
it should be remembered that both control of hemorrhage and 
proper care of the wound surface to promote healing processes 
may depend upon the satisfactory retention of a packing. The 
outline of the wound cavity should therefore be clearly defined, 
and so formed as to facilitate both the insertion and the retention 
of such a packing. It is the author's practice to use plain sterile 
gauze in the form of a long, narrow packing strip, with all the 
frayed edges of the gauze so folded that there will be no likelihood 
of shreds becoming detached and clinging to the wound surface to 
give trouble after its removal. This is wrung out in 2.5 per cent, 
carbolic or 1 to 10,000 bichloride of mercury. Any other suitable 
antiseptic will do as well. When the wound cavity is almost filled 
a small portion of the end of the packing is saturated with collodion, 
packed into position, and the surface again sealed with collodion. 
All such packings, especially when inserted during anesthesia, 
should have a piece of ligature attached which can be carried out 
around the corner of the mouth and fixed upon the surface of the 
cheek with a small piece of adhesive plaster. In this way the danger 
that the packing may become dislodged and be swallowed during 
sleep is avoided, and removal is easily accomplished by drawing it 
out with the ligature. It is sometimes advisable to leave such a 
packing in the mouth forty-eight hours after the operation, but 
later packings should be changed daily. Once or twice a day the 
buccal mucous membrane surfaces of lips, cheeks, tongue and palate RESECTIONS OF THE JAWS 
435 
as well as the tooth surfaces, should be cleansed with applicators 
dipped in dioxogen, and instructions given to have such patients 
hold in their mouths 2.5 per cent, carbolic acid or other mouth wash 
used alternately with the dioxogen once each hour during the day. 
Complete Resection.-Complete resections of the lower jaw may 
be performed from within the mouth, as described for partial 
resections, or by skin incisions along the lower border of the jaw 
or through the central portion of the chin and lower lip or both, or 
the vertical incision may extend up to but not include the lip 
border, according to the situation and character of the affection 
of jaw that is to be resected. When large segments have to be 
removed the external incision is by all means more satisfactory. 
Not only can the operation be performed with less fear of hemor- 
rhage, but there is a tendency in any event, when intrabuccal 
resection is performed, for secretions of the mouth to lodge and 
form a pouch in the situation of the wound. The almost invariable 
result of this is an opening through the external surface, which is 
quite likely to cause as much or more scar and deformity as a 
properly made skin incision. Treves1 emphasizes Heath's sug- 
gestion that it is not wise to cut completely through one section 
before the other is begun; that by cutting almost through the jaw 
at one point, and again nearly through the other, the steadiness 
thus retained facilitates rapid work and prevents the irritation of 
the rubbing of the ends of the bone, which all who have performed 
this operation know to be exceedingly annoying. The excision can 
be completed by rapidly completing each cut (Figs. 216 and 217). 
When a neoplasm is the cause of the resection the structures 
connected with the bone must be removed, including the peri- 
osteum, but under other conditions the periosteum should be pre- 
served with the greatest possible care. When the lower lip and 
bone are divided in the medial line for the removal of a section of 
the jaw in that region, there is danger of suffocation if the tongue 
is allowed to fall back and close the entrance to the larynx when 
the genioglossal and geniohyoid muscles are divided. In anticipa- 
tion of this a ligature should be passed through the fleshy portion 
of the tongue so that it may be drawn upward and forward and 
held in that position. Most surgeons prefer the Gigli wire saw 
for performing the resection. The author prefers engine burs, as 
already stated. Whatever the instrument may be, however, it 
is desirable to avoid splitting or chipping the bone and to have 
1 Treves: Operative Surgery, ii, 291. 436 
DISEASES OF BONE 
smooth, clean-cut surfaces. Hemorrhage may be controlled by 
packing or ligating vessels that may be persistent. 
Fig. 216.-Outline of the incision for resection of the lower jaw. 
Retention of the Divided Fragments.-It is important to prepare 
the retention appliance in advance of the operation when this 
can be done and its need foreseen. If there are sound teeth in 
Fig. 217.-Resection of the lower jaw. 
the jaw at each side of the resected portion, crowns may be fitted 
in advance and a piece of bridge-work constructed which can RESECTIONS OF THE JAWS 
437 
be permanently cemented into place as soon as recovery has pro- 
gressed sufficiently to allow its insertion. This will serve to fixate 
the parts with the additional support of bandages until the jaw 
may become secure. The author has usually found it advisable 
to have bridge-work for this purpose made removable. Crowns are 
first attached to teeth beyond the line of the proposed resection, 
other crowns are made to telescope over these, and the body of 
the bridge is made of vulcanite. The advantage of this form of 
bridge splint is that it gives greater cleanliness over a necessarily 
uneven and changing surface than fixed bridge-work as ordinarily 
constructed, and that it can be altered from time to time as the 
jaw fills in. A modification of the Angle band splints may be 
employed with additional nuts so placed that by turning them 
force may be applied in extension to prevent drawing together 
of the ends of the bone by muscular action when the section has 
been removed, as well as to retain a proper alignment. When 
it is not practicable to hold the parts by either of the foregoing 
methods, crowns upon the upper and lower teeth with flanges out- 
side the line of occlusion of the upper teeth are arranged that when 
the jaws are closed the flange will pass along the buccal side of the 
upper teeth and force the lower teeth into proper alignment, thus 
securing adjustment. This is a modification of the plan first 
adopted by the Berlin dentists Sauer and Siiersin. The purpose 
of this is to overcome the tendency of the attached section of the 
lower jaw to be drawn inward by cicatricial and muscular action. 
Dr. Martin, the well-known dentist of Lyon, has originated many 
ingenious appliances of this character. One of these, shown in Fig. 
218, is an artificial denture fitted to the lower jaw and behind 
to a plate which rests against the palatine surface of the upper jaw. 
It is adjusted so as to allow movement of the mandible, and flanges 
are attached to each plate in such position as to slide past each 
other and to permit the flange from the upper plate to be held upon 
the inside of the one attached to the lower when the mouth is closed, 
and thus apply the necessary retention of correct position. Figs. 
219 and 220 are also Martin's devices for resected jaws. 
Another of Martin's valuable suggestions, termed by him a 
"prothese immediate," was published in 1889. It is the use of 
gutta-percha fashioned to occupy the resected segment of the jaw 
and firmly attached to the remaining portions. This material is 
easily molded into the required form and serves to hold the parts 
during the healing processes. Afterward a permanent appliance 
containing teeth arid firmly attached to the bone segments by 438 
DISEASES OF BONE 
screws are made removable if necessary. It is used to supply the 
place of the artificial fixture (Fig. 221). 
Bull reports the successful use of Martin's plan in the case of 
a girl, aged eighteen years, in whom it has given satisfactory services 
Fig. 218.-Martin's artificial denture for the support of a resected jaw. 
for eight or more years. A temporary splint was used immediately 
after the operation, and a permanent splint inserted a few weeks 
later which the girl was able to remove, cleanse, and reinsert without 
difficulty. The advantage of metal splints when adaptable is 
obvious. 
Fig. 219.-Martin's plate for 
resected jaw. 
Fig. 220.-One of Martin's appliances for a 
resected lower jaw, with tubes for irrigation pur- 
poses attached. 
Bonnecken, Partsch, and Stoppany have undertaken to supply 
this need, as is shown by their artificial jaw splints illustrated 
in Figs. 222, 223 and 224. The purposes of their construction 
are sufficiently plain without detailed explanation except that RESECTIONS OF THE JAWS 
439 
Stoppany's splint, which is made of aluminum, is designed to hold 
the soft parts of the chin in position and to prevent the deformity 
Iig. 221.-Martin's artificial jaw. 
Fig. 222.-Bonnecken's artificial jaw. 
wmcn is iiKeiy to occur witn otner lorms oi support wmcn no not 
have this feature. 440 
DISEASES OF BONE 
Fig. 223.-Partsch's artificial jaw. 
Fig. 224.- Stoppany's artificial jaw. RESECTIONS OF THE JAWS 
441 
Disarticulation.-In removal of one-half of the lower jaw the 
position of the patient is as previously described. A vertical 
incision is made through the tissues of the chin in middle line 
without division of the lip, and incision along the lower border of 
the jaw to the angle and upward behind the posterior margin of 
the ascending ramus. Where the incision crosses the facial artery 
only the skin is divided, the artery is exposed by dissection and 
divided between two ligatures. The skin and external muscles 
are separated together in the flap, the surface of the bone being 
followed closely. The mental and masseteric arteries and small 
vessels which are divided can be easily controlled. If there are 
teeth in the jaw an incisor is extracted and the jaw d.ivided through 
its socket at or near the median line. The muscles are stripped 
from the inner side of the jaw by following the bone surface closely 
upon the external surface. The geniohyoid, geniohyoglossus, and 
digastric muscles are detached. The anterior portion of the jaw 
is gradually drawn downward and outward, the mylohyoid and 
ultimately the internal pterygoid muscles are dissected free. The 
inferior dental artery and nerve are exposed, the artery secured 
and divided. By drawing the bone outward and keeping close to 
its surface, injury and sublingual and submaxillary glands may be 
avoided. By depression of the jaw the tendon of the temporal 
muscle may be detached from the coronoid processes and the con- 
dyle exposed. The external pterygoid muscle is next divided, the 
capsule of the joint opened and the bone cut free from the internal 
lateral, stylomaxillary, and pterygomaxillary ligaments, and the 
bone removed (Fig. 225). Treves warns against laceration of the 
internal maxillary artery by contact with the neck of the bone if 
it be twisted or rotated in removal. Anyone who has opened 
the internal maxillary in this situation, as happened in one of the 
author's cases, will not need a second warning to be careful in this 
respect. Tracheotomy is seldom necessary in these cases for one 
who is accustomed to operate in this field. Removal of the entire 
loiver jaw is credited to Blandin in 1848 as the first surgeon to 
succeed in its performance, and is identical with disarticulation and 
removal of one-half, as already described, except that the vertical 
incision through the chin and lower lip is unnecessary. The 
longer time required for the operation and increased loss of blood 
necessarily involve greater shock with correspondingly increased 
danger. 
Prognosis and General Consideration of Results.-Entirely apart 
from the question of mortality, which is necessarily subject to the 442 
DISEASES OF BONE 
conditions under which the operations for resection of the lower 
jaw must be performed and which in most cases can be success- 
fully controlled, the author's experience with these cases leads to 
the belief that prognosis is usually unfavorable and that a word 
of caution is demanded. 
He cannot help feeling that a surgeon ought to be at least reason- 
ably sure of permanent benefit before subjecting a patient to the 
Fig. 225.-Resection of inferior maxilla. (Farabeuf.) 
postoperative disadvantages of these operations. It seems as 
though prolongation of life that is to be continually made miserable 
is a questionable benefit, as when a detached ramus is drawn inward 
to irritate the tongue, interfere with speech, deglutition, and of 
course mastication, and have the added discomfort of dribbling 
saliva and deformity. 
Prosthetic assistance along the lines suggested by the illustra- 
tions sometimes gives much satisfaction, but in the vast majority RESECTIONS OF THE JAWS 
443 
of such cases continued movement causes loosening of crowns or 
even of teeth, and removable appliances are so subject to change 
in the form of the jaw structures that permanent comfort is often 
an impossibility. 
Pictures of misery such as these cases present are not soon 
forgotten, especially when recurrent growth of the. neoplasm gives 
evidence of the futility of the suffering. 
That through misguided judgment many lives are lost which 
might have been saved had more radical operations been performed 
before advancing malignant disease rendered surgical relief una- 
vailing is only too true, but, on the other hand, many jaws have 
been resected when the affection was benign. 
The author was once called upon to make necessary preoperative 
preparations for a splint. He saw the case for the first time as the 
patient was about to be taken to the operating room for complete 
resection of almost the entire side of the horizontal portion of the 
mandible, and noted that the condition was, in fact, a simple 
dento-alveolar abscess, not a sarcoma as previously diagnosticated. 
Later in the operating room he was able to prove that it was only 
necessary to extract a devitalized lower first molar and do a small 
curettement to effect a cure. This example is, of course, unusual, 
but it nevertheless points the way to great need of caution. 
Resection of the Upper Jaw.-Definition.-This term is usually 
understood to mean the removal of the superior maxilla upon one 
side, although equally applicable when both superior maxillae are 
removed. It is also used to describe partial removal of this bone. 
Surgically this should not be confounded with removal of the bone, 
even though included almost in its entirety in one or more sequestra 
of necrosis, because such a sequestrum does not require excision, it 
having already separated from the living bone except for the attach- 
ments of soft tissues. When properly performed, removal of 
sequestra is a comparatively simple operation with slight danger of 
serious damage, and can be accomplished from within the mouth 
without external incision. In actual resection of the superior maxilla 
for malignant growths, however, the surgical problems, especially 
with regard to hemorrhage and shock, are of very serious character, 
and require a high degree of surgical skill at the time of operation, 
as for the preoperative and postoperative steps, in order to avoid 
disaster. 
Forms of Resection.- 
Partial. 
Complete. 
Temporary or 
Osteoplastic. 444 
DISEASES OF BONE 
Partial resection is, as a rule, easily performed through the mouth. 
The position of the patient and the instrumentation are the same 
as described for resection of the lower jaw. Hemorrhage in these 
cases can, as a rule, be readily controlled by packing or the ligation 
of small vessels at the wound surface. 
Complete Resection of the Upper Jaw.-The principal differences 
between the various operations for complete resection of the superior 
maxilla are in the lines of external incision for exposure of the parts. 
Figs. 226, 227, 228 and 229 are self-explanatory, and indicate the 
most commonly used method of gaining access to the bony field of 
operation. Of these, Velpeau's and Langenbeck's are objectionable 
because of insufficient exposure of the parts and division of the 
branches of the facial nerve with corresponding postoperative 
deformity. Weber's modification of Diffenbach's incision is gener- 
ally accepted to be in all respects the most advantageous and gives 
Velpeau's. 
Langenbeck's. 
Weber's. 
Kocher's. 
Figs. 226, 227, 228 and 229.-Lines of incisions for resection of upper jaw, 
complete freedom in uncovering the bone surfaces. It avoids the 
division of important nerves and follows lines which make the scar 
as little noticeable as possible. 
Surgical Steps.-After the soft parts have been dissected from 
the bone, the bleeding vessels clamped, and capillary hemorrhage 
checked by dry gauze applied with pressure, or gauze wrung out 
of hot water, the periosteum is forced back from the floor of the 
orbital cavity as far as the sphenomaxillary fissure, and the eye- 
ball is protected with a flat instrument and gently forced out of 
the way. A curved needle connected with the Gigli wire saw is 
passed into the fissure and out at the malar fossa. With this the 
malar bone is divided. The articulation of the upper jaw with 
the nasal and frontal bones is then cut- with bone shears. In 
division of the hard palate the Gigli saw passed through the nose, 
behind through the palate, and out through the mouth may be RESECTIONS OF THE JAWS 
445 
used, or a long fissure bur in the dental or surgical engine may be 
substituted with increased rapidity and facility in many ways. 
Fig. 230.-Division of bone in resection of jaw. (Von Bergmann.) 
Fig. 231.-Resection of superior maxilla. (Farabeuf.) 446 
DISEASES OF BONE 
The jaw is then loosened, grasped with bone forceps, and twisted 
out. A large gauze pad should be at hand quickly to pack the 
wound and check the force of hemorrhage (Figs. 230 and 231). 
Osteoplastic Resections.-Osteoplastic resections of portions of 
the upper jaw for temporary purposes are usually performed by 
freeing a sufficient portion of the proposed section to admit of its 
being forced apart from the body of the bone. This is done in 
such a manner as to allow of its being turned back in a flap with the 
overlying tissues. It is then replaced without complete destruc- 
tion of the surrounding periosteum. Without going into detailed 
description of the several operations for this purpose, such as 
devised by Langenbeck for exposing the base of the skull through 
the mouth, the various procedures for reaching the Gasserian 
ganglion as outlined on pages 303 and 305, and other less justifi- 
able operations for removal of tumors in this way, it is sufficient 
to say that the external incisions for these resections are such as 
to permit satisfactory exposure of the division of the bone which is 
to be resected. Closure of the skin surfaces in all the operations 
upon the jaws requiring external incision should be accomplished 
with care to avoid as far as possible unsightly scars. Exact coapta- 
tion with fine silk or horsehair sutures is required, or the sub- 
cuticular suture may be placed to give the perfect approximation 
that is desired. When there is extreme exhaustion immediately 
following the operation, sutures may be rapidly inserted which will 
hold the tissues in fairly good approximation, and after there has 
been recovery from shock at a later period, more perfect adjust- 
ment can be accomplished in the parts that are most notice- 
able. 
Resections for Cosmetic Purposes to Correct Deformities of the Jaws.- 
Much that has been done in a surgical way in this direction has 
been ill-advised. The author has seen a number of cases in which 
resections of the lower jaw have been made to correct prognathism 
in which, although the surgical steps have been skilfully performed, 
the defective condition might better have been corrected by ortho- 
dontic procedures. The surgeons in these cases had evidently not 
realized that it was the upper jaw' that needed widening and exten- 
sion, not the lower jaw that needed reduction, and that nasal, facial 
and other results were associated with the contracted upper jaw 
which would also have been improved by treatment of the maxilhe 
instead of the mandible. There are, however, conditions of mal- 
formation and imperfect occlusal relation of the jaws which call 
for surgical interference. This may be of such nature as to bring RESECTIONS OF THE JAWS 
447 
about complete readjustment, or for the purpose of facilitating 
treatment in correction of orthodontic procedures. 
Figs. 232 and 233.-Casts of the face of a young man, for whom the author 
removed a section from one'side of the lower jaw, as shown in Fig. 234. This 
picture is shown through the courtesy of Dr. Joseph Eby, of Atlanta, Ga., who made 
the cast. 
Fig. 232 
Fig. 233 
Fig. 234.-Drawing showing the deformity of the jaws of the young man, a cast 
of whose face is shown in Figs. 232 and 233. The dotted line indicates where the 
second bicuspid tooth and a section of bone completely through the jaw was removed 
by the use of a hand engine bur. 448 
DISEASES OF BONE 
For example when the mandible is so much longer by actual 
measurement from the angle on each side to the symphysis, with 
facial deformity such as is shown in Fig. 232, the operation 
illustrated in Fig. 234 is indicated. The author's method in the 
treatment of such cases is to place casts of the jaws upon an articula- 
tion, cut out a section from the plaster cast corresponding to the 
Fig. 235.-Shows drawing of the jaws as they were in the cast illustrated in Figs. 
232 and 234 after removal of a second bicuspid tooth and complete resection of the 
jaw,, the approximation of the bone ends and fixation with an appliance attached 
with metal bands cemented to the teeth and adjusted by a nut tightened upon a 
thread cut in the bar of the appliance. In most cases the metal band shown attached 
to the molar next to the point of excision would be better attached one tooth farther 
back. The situation of the bands must necessarily be determined by the condition 
of the case. 
bone to be removed. When this adjustment is perfected, a splint 
with bands to be cemented to the teeth, and suitably adjusted nuts 
and screws is prepared. This is cemented to the teeth twenty-four 
hours before the bone excision is performed. When the section of 
the jaw has been removed the bone ends are brought together and 
held in perfect apposition by tightening the nuts on the appliance. RESECTIONS OF THE JAWS 
449 
Let no one who values his peace of mind ever cut through a jaw 
without first having made provision for its retention if conditions 
make such preparation possible. 
Section to Correct Unilateral Shortness of the Mandible.-When the 
deformity is exactly opposite to that illustrated in Fig. 232, as when 
there has been contraction due to necrosis, accidental or surgical 
injury, or maldevelopment from other causes, through which one 
side of the mandible is shorter than the other with the chin drawn 
to one side as shown in Fig. 237, a similar appliance is arranged to 
make extension instead of contraction after the jaw has been 
resected as shown in Fig. 236. Intra-oral separation is made 
Fig. 236.-Illustration of an appliance which acts as a splint when the mandible 
is divided. It is also capable of exerting pressure when the nuts are turned to give 
extension and thereby lengthens the jaw. An increased length of one-half inch more 
on one side may thus be secured with comparatively little difficulty by an intrabuccal 
operation. If one inch or more be required then bone grafting through an external 
incision is required. 
preferably between the cuspid and first bicuspid, or between the 
bicuspids, with care to avoid the mental foramen and its vessels. 
The author uses a fine straight saw which can be passed between the 
teeth, and by retracting the lips can usually be made to divide the 
jaw-bone through the septum which separates the roots, without 
serious injury to the pericementum. 
Beyond this the division is completed with dental engine burs, 
until a fracture of the undivided part of the section may be accom- 
plished. This leaves at least a portion of the periostium intact. 
By turning the nuts on the appliance the pressure thus exerted may 450 
DISEASES OF BONE 
be made to extend the mandible from one-third to one-half inch. 
The appliance serves as a splint to support the divided bones until 
bone repair has assured the permanence of the result (Fig. 237). 
There should be no external scar in these cases. 
Fig. 237.-Photograph of a young man whose jaw was very much one-sided, 
with a markedly receding chin, for whom the operation illustrated in Fig. 236 was 
performed. Approximately one-half inch was gained on the left side of the mandible 
by this method with corresponding improvement in his appearance. 
Figs. 238 and 239.-Radiographs, showing tumor and successful bone graft. The 
tumor was removed and a section of rib grafted into the jaw by Dr. Judd, of the 
Mayo Clinic. 
Fig. 238 
Fig. 239 
If conditions are unfavorable for the intra-oral operation, as when 
greater extension of the jaw is required, bone grafting must be re- 
sorted to. Dr. Fred H. Albee, of New York, by the use of his wonder- 
fully accurate bone-cutting instruments removes a section of bone RESECTIONS OF THE JAWS 
451 
from the tibia and grafts it between the ends of the divided mandible. 
The section removed is cut in such form as to favor its retention 
and mortised into correspondingly cut receptacles in the jaw-bone. 
Dr. Judd, of the Mayo Clinic, at Rochester, Minn., has reported 
a very successful case in which he grafted a section of rib to replace 
bone lost in the excision of a tumor from the lower jaw. 
The external operation should be performed with care not to 
enter the buccal cavity. Freedom from infection is absolutely 
essential to successful bone grafting. The bone is handled entirely 
with instruments, even gloved hands are not allowed in contact 
with the graft. An autograft is by albmeans preferable to bone taken 
from another individual, and animal grafts are usually useless. 
The protection of the periosteal covering is also essential to the 
best success. 
In deciding between these types of operation the author's experi- 
ence in the following case may be of interest. The retention of the 
bone segments following an operation to restore the jaw of a young 
girl that was badly contracted from necrosis, was found to be 
exceedingly difficult and discouraging because of the absence of 
lower back teeth on that side. Nevertheless, by ligation of the 
lower to the upper teeth, sufficient retention was secured to give an 
improvement of approximately one-half inch. Later this patient 
went to the late Dr. Murphy who undertook to graft bone through 
an external opening. The result was loss of the graft from necrosis, 
a bad scar following the slow healing of a very persistent fistula 
through which the buccal fluids and pus discharged. The skill of 
this surgeon was world renowned, therefore the warning against this 
treatment except under favorable conditions is the more entitled 
to consideration. 
Bilateral Resection for the Reduction of Prognathous Lower Jaws.- 
Blair and Angle have perfected a method of performing a submucous 
periosteal operation for the removal of a section upon each side of 
the jaw, and fixation by the aid of a splint covering the crowns, 
buccal and lingual surfaces of the teeth, made in three sections 
and cemented before the operation so that they may be fastened 
together immediately upon removal of the bone segments. 
Blair believes that the jaw should also be wired near the lower 
border to give additional security. Babcock cuts through the 
rami of the jaw, slides the body back, and fastens it in this position. 
Harsha cuts sections from the angle on each side, and thus accom- 
plishes the necessary shortening. 
The author has seen one of Babcock's cases in which the result 452 
DISEASES OF BONE 
was perfect insofar as retraction was concerned, and Harsha's 
models and illustrations leave no doubt as to the success of his 
method in this respect; but in both of these cases it appeared that 
better results could probably have been attained by enlargement of 
the upper jaw instead of shortening the lower, and with a distinct 
benefit to respiration and health by such expansion. 
Malocclusion with the Molars in Contact and a Wide Separation 
between the Anterior Teeth.-This defect which not only affects the 
facial appearance, but the speech also, is often very marked. Cor- 
rection in young children is best accomplished by orthodontic 
procedures, the use of a skull cap, with chin attachment, or inter- 
maxillary rubbers attached to appliances adjusted to the teeth to 
hold and regulate the pressure, will often work wonders in these 
cases. A large variety of appliances and methods for this purpose 
have been devised by many orthodontists. 
In adults surgical treatment may be required. The deformity 
may then be corrected by the extraction of a bicuspid tooth on each 
side, the removal of a V-shaped section from the jaw, forcing the 
chin upward to make a green-stick fracture of the lower border of 
the jaw, and holding the parts with an appliance similar to the one 
shown in Fig. 235. The likelihood of shortening the jaw is an objec- 
tion to the operation. Except for the external scar, the author 
believes that this might be accomplished more successfully by cutting 
through the lower border of the jaw, after making an incision through 
the skin, separating the intervening tissues and the periosteum, to 
avoid mouth infection, then forcing the anterior teeth into contact and 
holding them in position with interdental ligatures from jaw to jaw. 
The Surgical Correction of Mandibular Deformities Due to Tumor 
Growths.-When the outline of the lower jaw has been deformed by 
tumor growth, much may be done by careful separation of the 
overlying periosteum, and the removal of the redundant bone struc- 
tures sufficiently to restore symmetrical outlines. The periosteum 
is then replaced. Notwithstanding the unavoidable oral infectious 
influences the results in such cases are usually gratifying. 
Preservation of the periosteum, and of the form of the outline 
of the jaw is important in these cases (Figs. 259 and 291, pp. 496 
and 526). 
Receding Chin.-Receding chin may be due to malposition of the 
mandible to attested mandibular development or to a combination 
of both. Jumping the bite, by orthodontic processes whereby the 
occlusal relation of the jaws is changed in such manner as to bring 
the mandible forward, is generally and successfully accomplished RESECTIONS OF THE JAWS 
453 
for children. Steadily applied pressure with appliances adjusted 
to the teeth may also stimulate growth. The jaw may be length- 
ened by bone grafting or the chin may be made more prominent 
by transplanting fat, or cartilage to give it an appearance of more 
harmonious prominence. The author does not believe in the use of 
paraffin injection. when surgical transplantation of tissue may be 
made to serve the purpose. 
Operative Dangers and Methods of Avoiding Them.- Hemorrhage.- 
Ligation of the external carotid is usually required, and, as a rule, 
is sufficient to avoid dangerous loss of blood. In more or less rare 
instances compression of the common carotid with temporary liga- 
ture or clamp may be required. Because of the effect upon the brain, 
permanent ligation of this vessel should be avoided. Dawbarn 
recommends reduction of the flow of blood by temporary bands made 
of small rubber tubing tied close to the shoulders and the thighs 
and drawn sufficiently to impede but not completely suppress cir- 
culation in the extremities. Crile says: "Permanent closure of the 
common carotid, and on account of the high percentage of cerebral 
softening in the cancer period of life, should be avoided. Permanent 
closure of the external carotid, while it is not attended by the risk, 
carries with it approximately 2 per cent, mortality rate from wash- 
ing away of the thrombus of the ligatured stump, causing cerebral 
embolism." 
A very large element of danger lies in the inspiration of blood or 
the secondary effects of inspiration, diseases of the air passages 
due to wound infection, bronchitis, and affections of the lungs, 
which are said to have been responsible for more than one-half 
of the deaths following this operation. 
The Rose position reduces the likelihood of blood being inspired, 
but this position is not suitable for the performance of the opera- 
tion. With the shoulders raised and the head tipped back as 
previously described (page 78), practically the same effect is 
secured as with the Rose position, with the head hanging over the 
end of the table but with the parts in more favorable position for 
operation. Crile, Warren, and others prefer the patient with head 
raised, and body in a semirecumbent position or in a sitting position. 
Crile uses his pneumatic suit to overcome the effect of the raised 
position of the body. A still safer plan is to follow the method of 
Bennet as modified by Crile, who passes two rubber tubes through 
the nose into the pharynx to a point opposite the epiglottis, and then 
packs the pharynx with gauze. A T-tube is attached at the nasal 
entrance and the vapor of the anesthetic is given through the tube. 454 
DISEASES OF BONE 
In this way there is absolute certainty of preventing blood from 
reaching either the lungs or the stomach. 
The performance of a prophylactic tracheotomy is not required 
when these precautions are taken, and is objectionable for many 
reasons, but chiefly because the patient cannot expel mucus and 
secretions, the effect of which upon the pharynx and lungs is a 
serious menace. Martin reports 28 per cent, of deaths from this 
cause. 
Crile has called attention to the necessity of the sparing use of 
anesthetics, and in grave cases favors the use of nitrous oxide and 
oxygen followed by ether in the smallest possible quantity con- 
sistent with avoidance of shock. 
When the pharynx is not packed with gauze it must be 
remembered that complete abolishment of the reflexes increases the 
danger of blood inspiration. Sufficient insensibility to pain and 
unconsciousness can be maintained while the reflexes are yet 
sufficiently active to cause the blood to be swallowed instead of 
allowing it to enter the bronchi and lungs. All other considerations 
pertaining to preparation of the patient for grave operation as well 
as avoidance of unnecessary loss of time in its performance should 
be considered imperative. 
Shock and Collapse.-In these extensive operations prevention of 
shock and collapse may be effectively accomplished. The impor- 
tant shock-producing factors are: The number and intensity 
of .surgical contacts, as forcible retraction, vigorous and repeated 
sponging, blunt dissection, tearing, etc.; loss of blood; mismanaged 
anesthesia; and the duration of the operation. The principal 
factors causing collapse are: Interference with the trunk and 
certain branches and terminals of the vagus, excessive hemorrhage, 
air emboli, and anesthetic accidents. 
The Removal of Both Superior Maxillae.-The steps in removal of 
both superior maxillae are identical with those already described 
for unilateral resection, except that division of the palate may not 
be required. It would seem that this operation could never be 
justifiable under any circumstances, yet it was performed for the 
first time by Heyf elder in 1841,1 and has been done since then by 
a number of surgeons. 
Postoperative Treatment.-The author prefers dry sterile gauze 
laid over the skin surface and held in position with strips of adhesive 
plaster. Dusting powders he has almost entirely discarded because 
after their immediate effect is over the powder becomes clogged 
1 Von Bergmann: System of Practical Surgery, i, 730. RESECTIONS OF THE JAWS 
455 
about the stitches and renders their being kept clean more difficult; 
the dry gauze, on the other hand, absorbs moisture. If there 
should be infection or secretions of the mouth which work through 
to the skin surface at any points, they are easily and directly con- 
trolled by touching occasionally with cotton-wrapped applicators 
dipped in dioxogen. Gauze packing within the mouth should be 
as directed (page 434), and the same treatment of the mouth 
followed with regard to the use of antiseptic and cleansing solu- 
tions. Rectal nourishment must be continued until such time as 
it may be possible to give liquids satisfactorily by mouth. With 
care to avoid infection this may usually be done almost from the 
beginning, but is sometimes a matter of serious difficulty. When 
the wound is healed deformity may, to a considerable extent, be 
Fig. 240.-Appliance made by Dr. Jernigan in case of removal to the left upper 
maxilla. 
overcome and usefulness of the mouth restored by an artificial 
denture, which in the hands of a skilful dentist can be made of 
vulcanite and sometimes with metal. Fig. 240 shows an appli- 
ance made by Dr. Geo. F. Jernigan, of New York, which was 
successfully worn for several years. It decreased both deformity 
and discomfort in a considerable measure, for a man in whose case 
the upper maxilla on the left side had been completely removed. 
Prognosis and General Consideration.-Mortality reports vary 
considerably, as may be seen by the following table: 
Number of oases. 
Y ears. 
Mortality rate. 
Reported by 
606 
1827 to 1873 
18.4 per cent. 
Rabe. 
158 
1870 to 1897 
21.5 
IC 
Kronlein. 
108 
Recent years 
30.0 
cc 
Butlin. 
230 
Recent years 
14.0 
Bryant.1 
12 (personal) 
Recent years 
16.0 
cc 
F. S. Eve. 
20.8 
cc 
Kronlein. 
1 Joseph Bryant: Ann. Surg., May, 1908. 456 
DISEASES OF BONE 
It will be seen from the foregoing table that the results of these 
operations are determined by a wide range of conditions not only 
pertaining to the technic of the operation, but to those also under 
which they are performed. In this relation the character and 
effect of neoplasms is of vital importance. This feature is dis- 
cussed in consideration of tumors (p. 486). 
Exposure of Arteries.-In view of the fact that it may become 
necessary to expose the carotids, the lingual, or the facial arteries 
to control hemorrhage in emergency incidental to operations upon 
the mouth and jaws; as a preoperative safeguard in extensive 
operations; for temporary occlusion by provisional ligation or 
the use of Crile's clamps; and excision of a section for the purpose 
of cutting off the circulation of certain parts to check the progress 
of inoperable cancers of the tongue, face, and jaws, as recom- 
mended by Dawbarn, the following brief description is given 
without attempt to include the ligation of the facial vessels not 
directly connected with the operative field. 
The Common Carotid.-This vessel divides at the level of the 
thyroid prominence, and may be exposed by an incision of 10 
cm. in length along the anterior border of the sternomastoid at 
its central portion, with the sternomastoid drawn outward and the 
other muscles inward. The artery is recognized by its pulsation. 
The sheath is opened and the suture passed with an aneurysm 
or artery needle from within outward, with care to avoid the 
descendens noni. The internal jugular must be carefully avoided 
and retracted. 
The External Carotid.-Exposure of this artery may be effected 
by an incision from the angle of the jaw to the level of the cricoid 
cartilage along the anterior border of the sternomastoid. This 
muscle must be retracted outward. The posterior belly of the 
digastric and the hypoglossal nerve are avoided. The artery will 
be found opposite to the tip of the great cornu of the hyoid, and 
the superior laryngeal nerve which passes behind the vessel must 
also be carefully avoided. 
The Internal Carotid.-This artery may be exposed at the point 
where it lies to the outside and back of the external carotid through 
the same incision by which the external carotid is exposed. The 
external branch is drawn inward and the digastric upward with 
care in passing the needle to avoid the jugular and the vagus. 
The Lingual Artery.-An incision is made 2 cm. above the hyoid 
parallel with it from the middle line almost to the angle of the 
jaw. The submaxillary gland thus exposed is retracted, the fascia 
divided, and the posterior border of the mylohyoid exposed. The RESECTION OF THE JAWS 
457 
digastric tendon is then drawn upward and the hypoglossal nerve 
brought into view with the artery line behind it. The hyoglossus 
must be divided by a short incision to reach the vessel. Injury 
to the nerve must be avoided. 
Fig. 241 
Figs. 241 and 242.-Surgical anatomy of the neck; ligation of the carotid, lingual 
and facial arteries. (Bernard and Huette.) 
Fig. 242 
The Facial Artery.-This is easily exposed at the margin of the 
lower jaw in front of the angle, or it may be tied lower down through 
similar incision to that used for the exposure of the external carotid 
(Figs. 241 and 242). CHAPTER VII. 
DISEASES OF THE GLANDS. 
DISEASES OF THE SALIVARY GLANDS. 
The Pathological Indications of Saliva.-During recent years 
Michaels and Kirk have done much to bring about an understanding 
of the possibilities of saliva as a valuable means of diagnosis. In 
opposition to the theories of these writers it has been urged that the 
so-called saliva of the mouth is, after all, a mixed secretion of saliva, 
bacteria, food products, ferments, etc.; that saliva, moreover, is a 
secretion and not an excretion, and that therefore its indications 
would not be diagnostic of pathological states as are the urinary 
and other excretions. Nevertheless, colorimetric and qualitative 
examination of saliva is gradually receiving recognition as means of 
detecting certain expressions of disease. 
More recently Roger,1 Simon,2 Le Roy,3 Fenwick,4 and other 
investigators have given valuable evidence that saliva- has an 
important pathological relation to general as well as local affections. 
Congenital Defects of the Salivary Glands.-Anomalous develop- 
ment is infrequent, but a sufficient number of cases have been 
reported to indicate that such anomalies must be borne in mind, 
as they sometimes are an important factor in diagnosis. Mis- 
placed or absent salivary glands have been reported. Gruber 
found both submaxillary glands absent in one case, and in another 
the parotid gland appeared in the situation of the accessory parotid 
at the posterior border of the buccal cavity. Turner reports a 
case in which the submaxillary glands were found on the dorsal 
surface of the mylohyoid close to the sublingual glands instead of 
the digastric triangle. The orifices of Wharton's and Steno's 
ducts, frequently vary. Occasionally there is atresia of these 
ducts or the openings may be exceedingly small or double instead 
of single. Cases of congenital salivary fistula have been reported 
by Gherini, Roser, and Konig.5 
1 Roger: Soc. de Biol., 1907. 
2 Simon: Jour, de Physiol, et de Pathol., March, 1907. 
3 Le Roy: New York Med. Jour., March 7, 1908. 
4 Fenwick: Pract. Med. Series, 1908, vol. vi, General Surgery, p. 133. 
6 Kiittner: Von Bergmann's System of Practical Surgery, p. 607. DISEASES OF THE SALIVARY GLANDS 
459 
Symptoms.-The symptoms are usually indicated by alterations 
in the anatomical appearance. With congenital absence of an 
opening through the duct, ranula may result, or unusual situations 
of the orifices may lead to exposure and irritation, thus causing 
pathological disturbance, displacement, or interference with nerves, 
bloodvessels, or other structure. 
Treatment.-In the rare instances when treatment is required, 
the therapeutic and surgical methods necessarily are indicated by 
existing symptoms. 
Injuries of the Salivary Glands.-The sublingual and submaxil- 
lary glands are so situated as to be more or less protected from 
traumatic injury. The parotids and their ducts, however, are 
more exposed to trauma, hence it naturally follows that these 
structures most frequently require treatment. 
Etiology.-The injury may be surgical, or be caused by stab or 
gunshot wounds or accidental laceration of the glands by foreign 
substances forced through the floor of the mouth or external sur- 
faces, and traumatism, particularly in the parotid region. 
Prognosis.-Favorable in the absence of serious complication by 
infection or extensive tissue destruction. 
Treatment.-Clean surgical wounds heal readily and require no 
special treatment other than careful suturing of the deep and 
superficial structures to favor immediate union and to prevent 
the formation of salivary fistula. In other injuries the chief diffi- 
culties lie in the forcing of infection into the substance of the gland 
and the destruction of tissue which makes accurate closure diffi- 
cult and therefore favors the formation of fistula. If temporarily 
unavoidable, this can be corrected at a later operation. Fixation 
of the jaws for several days by a bandage which should also be 
so adjusted as to make firm pressure over the gland, is of aid in 
preventing the formation of fistula; food which unduly excites 
salivary secretion should be restricted to give sufficient time for 
healing processes to take place. 
Injuries of the Ducts.-Under unusual conditions the ducts of 
any of the salivary glands may suffer traumatic injury. Steno's 
duct, extending from the parotid gland to a point close to the region 
of the second molar tooth in line with the lobule of the ear, and 
the angle of the vermilion border of the upper lip, is much more 
exposed than the other ducts. It lies across the region of the face 
most subject to injury. It is an important factor in the selection 
of many surgical operations requiring incision through the cheek; 
even with the greatest care it cannot always be avoided. Vertical 460 
DISEASES OF THE GLANDS 
wounds of the face are likely to cause its complete division. Severe 
blows upon the cheek have been known to cause its rupture without 
division of the overlying tissues. 
Symptoms.-Flow of saliva from the duct into the wound may 
be distinguished when hemorrhage is checked. A sound passed 
through the orifice of the duct within the mouth appears at the 
point of injury. 
Treatment.-The ends, of the divided duct should be carefully 
approximated and fixed with fine catgut sutures which should 
not enter the lumen of the duct. Closure of the wound so as to 
favor exact approximation usually gives prompt and perfect union. 
In the absence of such care or when perfect coaptation is not 
possible, salivary fistula usually results. Salivary secretion must 
be checked by fixation of the lower jaw and compression of the 
gland with a bandage as previously described. 
Salivary Fistula.-Salivary fistula is an abnormal opening through 
which saliva reaches the surface. 
Varieties.-The principal varieties are salivary gland fistulse and 
salivary duct fistula?. 
External fistula, which is the only one requiring surgical treat- 
ment, is chiefly confined to the parotid gland and the duct of 
Steno. 
Etiology.-Traumatic injury is the most frequent etiological 
factor, but fistulse may also result from abscess or ulcerative pro- 
cesses due to pyogenic microorganisms or infectious diseases, such 
as tuberculosis and syphilis, or from tissue destruction by carcinoma. 
The origin may be within the gland or result from involvement of 
the glandular structure during the progress of disease from sur- 
rounding tissues. Fistula? may also be congenital. 
Symptoms.-Whether the fistula be connected with the gland or 
its duct, the characteristic symptom is discharge of saliva which 
appears through an opening upon the external surface. The saliva 
is annoying and usually causes more or less excoriation of the skin 
surface. If the flow is slight and of a watery character, a fistula 
of the gland is indicated because only a portion of the glandular 
secretion is drained. When the flow is abundant, the probability 
is strongly in favor of a fistula of the duct. Fistula anterior to the 
margin of the masseter is usually one of the duct. If the fistula 
is connected with Steno's duct, a sound may sometimes be passed 
for a considerable distance, but this is usually impossible in fistula 
of the gland. DISEASES OF THE SALIVARY GLANDS 
461 
Differential Diagnosis.- 
DUCT. 
Excessive flow of saliva. 
Opening sometimes anterior to mar- 
gin of the masseter. 
Probe can be passed into the tract for 
a considerable distance. 
GLAND. 
Moderate amount of saliva. 
Rarely so far forward as the anterior 
margin of the masseter. 
Probe penetration only a short dis- 
tance. 
Treatment.-Salivary Gland Fistula-This form may sometimes 
be closed by repeated cauterization with nitrate of silver or the 
galvanocautery, and such treatment is recommended as a first 
step. If unsuccessful, the borders of the wound should be fresh- 
ened, the parts brought into immediate contact if possible, and 
carefully sutured. Pressure with a bandage, restriction of salivary 
flow by dieting, and fixation of the jaws must be continued during 
several days to permit union of the parts. 
Salivary Duct Fistula.- Temporary duct fistula should be given 
opportunity to heal spontaneously, and efforts should be made 
to preserve the integrity of the duct. 
Permanent duct fistula may be treated by: (1) Restriction of 
the normal outflow of saliva through the duct. (2) The establish- 
ment of an internal opening with closure of the external one. (3) 
Obliteration or removal of the gland. 
Of these, the simplest and most practical is the establishment of 
an internal opening and closure of the external fistula. Exposure 
at the duct, excision of the scar, and closure by fine catgut sutures, 
as recommended by Nicoladoni, without recurrence of occlusion 
of the duct, are possible, and obliteration of the gland may be accom- 
plished by compression, ligation of the central end of the duct, or 
removal of a part or all of the gland. The former method, however, 
appears too difficult and uncertain, and the latter, it is generally 
admitted, should only be attempted as a last resort. The establish- 
ment of an internal opening and closure of the external fistula may be 
accomplished by single puncture with a trocar to establish flow of 
saliva into the mouth. This opening must be maintained until 
healing processes have been completed, afterward closure of the 
external fistula may take place spontaneously or be accomplished 
by plastic operation. 
In spite of efforts to preserve a single opening its closure is 
always a menace. A far better and simpler method, accordingly 
is to pass a suture behind the point of occlusion of the duct, to 
tie the suture loosely and allow it to remain until the two open- 
ings are permanently established. When, as frequently, the buccal 462 
DISEASES OF THE GLANDS 
portion of the duct is occluded, the suture may be passed by a curved 
needle in the mouth; but when the masseteric division of the duct 
is affected, it is better to make two openings with a trocar through the 
external fistula and to pass the two ends 
of a wire to form a loop, the ends being 
loosely twisted within the mouth, as 
shown in Fig. 243. This is better than 
silk or other suture material, because it 
does not absorb secretion and is not likely 
to cause infection; moreover, such a loose 
wire loop is moved sufficiently by mus- 
cular activity to prevent the openings 
from closing. 
Foreign Bodies. - Etiology. - Both 
Wharton's and Steno's ducts are occa- 
sionally invaded by foreign bodies such 
as fish-bones, toothbrush bristles, splin- 
ters of wood from toothpicks, fruit 
seeds, and other objects sufficiently 
small to enter the orifices of the ducts; 
projectiles may sometimes be driven into 
and lodged within the gland structure. 
Symptoms.-There may be sharp pain at the moment of entrance, 
followed by swelling, more general pain continues, and other 
distressing symptoms are occasioned by occlusion of the duct 
and interference with normal salivary excretion. The distressing 
symptoms may disappear and recur from time to time until the 
foreign body is removed. Sometimes little discomfort is felt until 
in the course of time the body becomes surrounded by deposits 
of salivary calculus, and in this way leads to the formation of 
salivary stone. If the foreign body is not forced out by inflamma- 
tory processes or removed, symptoms of chronic inflammation 
develop with discharge of pus within the gland, and as a result 
local and general symptoms of serious character may develop. 
Diagnosis.-If the object cannot be seen or felt from the surface 
it may be located by passing a probe into the duct. When this 
is impracticable, on account of the swelling of acute inflammation, 
the presence of such a body can best be determined by a radiograph. 
Treatment.-Remove the foreign body. If superficially situated 
its extraction is easily accomplished, especially if pressure can be 
applied to force it out of the duct. When this is impossible, an 
incision is required for its exposure. Care must be exercised during 
Fig. 243.-Operation for sali- 
vary duct fistula according to 
Deguise. (Duplay-Reclus.) DISEASES OF THE SALIVARY GLANDS 
463 
healing of the wound to prevent occlusion of the duct. Other treat- 
ment must be directed toward relief of inflammation and abscess 
if such conditions be present. 
Salivary Stones; Sialolithiasis.-The formation of salivary stones 
occurs somewhat rarely and affects the salivary glands and their 
ducts in approximately the following order:1 
Wharton s duct 
o ii 
Submaxillary gland 
61.4 per cent. 
Steno's duct 
Parotid gland 
20.4 per cent. 
Sublingual glands 
and ducts 
18.2 per cent. 
Concretions within the salivary glands are found most frequently 
in middle life and among men more often than women, although 
children may occasionally be affected, and a congenital case has 
been reported by Burdel. 
Etiology.-A small particle of calculus from about the necks of 
teeth may find entrance into the duct of a gland and act as a foreign 
body or become the nucleus for the formation of a salivary stone. 
Other foreign substances may act in a similar manner. The presence 
of masses of bacteria in the interior of these concretions of lime 
salts, however, demonstrates that in the large majority of cases 
bacteria are the primary causes. 
Symptoms.-Salivary stones are principally composed of phos- 
phate and carbonate of calcium, and vary greatly in size, form, 
color, and number. Usually they are single and somewhat elon- 
gated, especially if situated in the ducts. Those within the glands 
are much more irregular. They vary in size from tiny grains of 
sand to stones weighing 20 grams or more. The symptoms are 
those of foreign bodies, such as dilatation of the duct, inflammation, 
ulceration, and suppuration, abscesses, salivary fistula, etc. The 
history usually shows more or less gradually increasing disturbance, 
with appearance and disappearance of acute symptoms, due to 
salivary stasis and infection. These are sometimes very painful. 
Chronic discharge of pus (pyorrhea salivalis) from the duct is 
sometimes almost the only noticeable symptom. 
1 Statistics of Czygan, Buchwald and Wenzel, and Kiittner. Von Bergmann's 
System of Practical Surgery, i, 619. 464 
DISEASES OF THE GLANDS 
Diagnosis.-If situated in the duct, the stone can usually be 
felt with the finger or a probe. Usually the fistulous tract is suffi- 
ciently clear to be followed into the gland also. When this cannot 
be done the sublingual gland may be palpated with one finger in the 
floor of the mouth and the other upon the outside, and the hard 
mass thus distinguished. When the stone cannot be felt with a 
probe, a radiograph must be relied upon. Ludwig's angina, phleg- 
monous angina, alveolar periostitis, dento-alveolar abscess, lymph 
nodes, inflammatory tumors, tuberculosis, syphilis, and actinomy- 
cosis must be differentiated in diagnosis. These may be recognized 
by their special diagnostic indications, and the demonstration of the 
salivary stone either with a probe or the Roentgen rays completes 
the diagnosis. 
Treatment.-Whenever possible, salivary stones should be 
removed through the mouth. When situated deep within the 
parotid or submaxillary glands or when they have an external 
fistula in direct communication with its surrounding abscesses, 
external removal is indicated. After-treatment of the wound 
demands the use of antiseptic mouth washes and close observa- 
tion. Timely interference is sometimes necessary to prevent 
occlusion of the duct and the formation of a salivary fistula. 
Sialodochitis; Inflammation of the Excretory Ducts.-Etiology.- 
In addition to the inflammatory results of irritation and obstruction 
by foreign bodies and salivary stones, an inflammation of the ducts 
of salivary glands due to other local irritations and infection some- 
times occurs. 
Such inflammation rarely affects Wharton's duct, but does occa- 
sionally create serious disturbance in connection with the duct 
of the parotid gland. The most common cause undoubtedly is 
the presence of worn sharp or jagged borders of tooth crowns, 
and the jaw-biting habit referred to elsewhere (p. 316). How easily 
such a simple etiological factor may be overlooked and how serious 
its consequences may be illustrated by a description of one of the 
author's cases. 
Symptoms.-A woman of middle age, unmarried, gave a history 
of having had serious swelling in the region of the left parotid, 
which had appeared and disappeared for a number of years. Her 
family history gave no indications of hereditary taint. Her personal 
history gave nothing which might be accounted as an etiological 
factor except marked neurotic tendency. 
Symptoms of the attacks are those of acute parotitis, the gland 
became enormously swollen; she suffered greatly from pain, ina- DISEASES OF THE SALIVARY GLANDS 
465 
bility to move her lower jaw, and therefore to take nourishment 
comfortably, and the dread of impending developments of yet 
graver conditions. The attacks lasted for two or more weeks, and 
during this time she became very exhausted; later they gradually 
subsided. 
Diagnosis.-Many physicians and surgeons whom she consulted 
during these years had been unable to recognize a definite cause 
for her trouble. Mumps, syphilis, actinomycosis, neoplasms, 
traumatic injuries, and general diseases of the glandular system 
were readily excluded by the symptoms and history of the case. 
From constant brooding over her troubles in anticipation of other 
attacks, her nervous state, as evidenced by trigeminal pain, a 
morbid view of her condition and other subjects, had become 
noticeable in marked degree. 
Upon examination of her mouth it was found that abrasion of 
the occlusal surfaces of her molars and second bicuspids had brought 
them in contact in such a manner as to favor cheek biting at a 
point close to the opening of Steno's duct. It was easily demon- 
strated that during periods of pain or unusual nervousness she had 
been in the habit of grinding her teeth. The injury of the tissues 
of the cheek had caused infection, followed by inflammation and 
occlusion of the duct. The other symptoms were thus easily and 
simply accounted for. 
Treatment.-One of her surgeons, Dr. C. A. Wheaton, of St. 
Paul, by whom she was referred to the author, had wisely refused 
to perform the operation for removal of the gland in the absence 
of positive indications of its necessity. A cure was promptly 
effected by rounding the buccal cusps and buccoocclusal borders 
of these teeth; afterward she was referred to a dentist. The pulps 
of teeth which were suspected of having caused pain were removed; 
in two, pulp stones were found. Thus the trigeminal neuralgia, 
which was undoubtedly an exciting factor, was accounted for and 
also relieved. 
Acute Primary Inflammations of the Salivary Glands (Sialo- 
adenitis Acuta).-Etiology.-Acute primary non-specific inflam- 
mations of the salivary glands may result from traumatic injury, 
direct infection, and similar causes. It is generally agreed that 
in most cases bacteria gain entrance from the mouth and the oral 
cavity. 
Symptoms.-The symptoms are swelling and pain, which with 
other signs of inflammation may vary in degree according to the 
nature of the cause. 466 
DISEASES OF THE GLANDS 
Treatment.-The treatment consists of disinfection of the local 
wound, if any, and of the buccal cavity, hot fomentations and 
soothing applications for relief of the inflammations, evacuation 
of pus if suppuration occurs, and general treatment appropriate 
to all inflammatory conditions. 
Mumps.-Etiology.-The exact character of the infection which 
causes mumps is not yet established. I. C. Erb1 claims to have 
isolated a microorganism which occurred most frequently in the 
form of diplococcus and occasionally in small chains. It was non- 
pyogenic and when injected in Steno's duct in monkeys and dogs 
caused a non-suppurative parotitis; occasionally it caused orchitis. 
This he believes to be the actual cause, but verification is 
required. 
Symptoms.-The incubation period of approximately fourteen 
days is followed by stomatitis during a short prodromal stage. 
The first symptom usually noticed is swelling in the region of one 
or both parotid glands. This is most frequently unilateral and upon 
the left side. As the swelling increases, the skin surface becomes 
tightly drawn, hot, and sensitive to the touch. The edema may 
be comparatively slight and limited in extent, or may spread as 
far as the clavicle. The sublingual and submaxillary glands may 
be involved with corresponding alteration of the symptoms. 
Fever.-The rise in temperature is usually slight, but may become 
serious as a result of complications which sometimes arise during 
the progress of the disease. In the absence of such complicating 
conditions the fever disappears at the end of about seven days, 
and this is followed by subsidence of all symptoms in the course of 
two or three weeks. 
Pain.-Pain may be a notable feature and radiating and severe 
in character, or may cause slight discomfort according to the extent 
of the swelling and the tendency of the glands to break down and 
form abscesses. 
Metastasis.-In adults there is often marked tendency to metas- 
tatic involvement of other glands, particularly the testes, ovaries, 
and other generative organs. Swellings of these organs occur with 
pain, tenderness, and occasional abscess formation. 
Complications.-Orchitis.-Through metastasis there may be a 
very tender swelling of one or both testes, which may subside 
gradually under treatment or result in suppuration. The epididymis 
and seminal cord are generally unaffected. In treatment the parts 
1 Arch. Int. Med.. September, 1909, after Practical Medicine Series, Pediatrics, 
1900, vii, 68. DISEASES OF THE SALIVARY GLANDS 
467 
are elevated and local applications employed to relieve the inflam- 
mation and pain. 
Other complications are cystitis, nephritis, and affections of the 
eye and ear. 
Prognosis.-In young children mumps usually runs its course 
with comparatively little tendency to complications. In older 
persons, especially when orchitis has occurred, the prognosis is 
much more grave. Atrophy of the testicles follows orchitis, accord- 
ing to Kocher, in about one-third of the cases. This may be complete 
or partial, and may affect both testes with resulting impotency. 
Treatment.-The treatment should be in the nature of careful 
and regularly continued disinfection of the mouth by keeping the 
teeth clean, and the use of suitable antiseptic mouth washes. 
Local applications of heat or cold are indicated, if necessary to 
relieve distress. Patients should be kept warm and quiet (prefer- 
ably in bed) and given nourishing, easily digested liquid diet; the 
bowels and kidneys should be carefully regulated. 
The formation of abscesses may require treatment, or it may be 
necessary to relieve pain by the use of hot applications and opiates, 
to open and give direct relief as with other suppurative conditions. 
Infantile Sialoadenitis.--This is a form of acute primary inflam- 
mation of the sublingual and submaxillary glands without involve- 
ment of the parotid, which sometimes affects nursing infants during 
the first weeks of life. 
Etiology.-The etiology is not known, but, as suggested by Hen- 
ning, the disease is presumably due to some puerperal condition 
of the mother. 
Symptoms.-The glands swell rapidly and pus is discharged 
through the excretory ducts. 
Prognosis.-The prognosis is favorable, if the general health of 
the infant is sufficient to withstand the effect of the sore mouth 
and infection. 
Treatment.-The mouth should be kept clean. If suppuration is 
extensive, an incision is made and drainage given as in surgical 
treatment for the relief of other forms of abscesses. 
Acute Secondary Inflammation of the Salivary Glands.-Etiology. 
-The causes of secondary sialoadenitis are both local and general. 
Local Causes.-Local causes are the secondary results of inflam- 
mation attendant upon foreign bodies, stones, traumatic injuries, 
and similar factors, or infection from lymph nodes, mercurial or 
other forms of stomatitis, diseased roots of teeth, and the inflam- 
matory conditions incident to malerupting third molars. 468 
DISEASES OF THE GLANDS 
General Causes.-Such inflammations arise secondarily as com- 
plications of infectious diseases, such as scarlet fever, pneumonia, 
smallpox, measles, typhus fever, pyemia, septicemia, and similar 
affections; they also occur from carcinoma and subsequent to 
surgical operations through infection and general reduction of 
constitutional resistance, as from severe abdominal operations. 
Symptoms.-The swelling usually appears in the parotid region 
and closely resembles that of mumps; in cases of virulent infection, 
however, it progresses much more rapidly and to greater extent, 
with corresponding alteration in the appearance of the skin, which 
becomes discolored and the vascular structures extensively dilated. 
The fever is high and there is much more likelihood of abscess 
formation and tissue destruction. Jaw movement is limited or 
completely checked. Hearing is more or less affected. In rare 
instances the facial nerve may be involved, but this is unusual. 
If the swelling does not recede to a noticeable degree after four 
or five days, suppuration is indicated even though the presence of 
pus may not be revealed by palpation on account of the tensity 
of tissues surrounding the parotid gland. 
Diagnosis.-Mumps usually can be excluded by history of a 
previous attack, and in the absence of clear testimony upon this 
point the fact that the inflammation of the glands is secondary 
makes it possible in most cases to recognize the disease that pre- 
ceded it. Occasionally the cause is hidden and differentiation from 
phlegmon of the neck and diseases of the jaw and lymph nodes is 
difficult. 
Prognosis.-The prognosis is much more serious than in the 
case of primary sialoadenitis, but it necessarily varies with the 
nature of the cause. 
Treatment.-Oral Prophylaxis.-Oral prophylaxis is a first 
essential. If the jaws can be opened sufficiently the necks and 
crowns of all teeth should be cleaned and disinfected. Mouth 
washes should be used, preferably dioxogen, alternately' once each 
hour with some one of the agreeable reliable antiseptic mouth 
washes. When the jaws are more or less fixed, cotton wrapped 
upon a toothpick or probe may be passed under the lips and cheek, 
or between the anterior teeth, and if possible over and around the 
tongue. 
Twice daily tincture of iodin, 10 per cent, solution, should be 
used in this way, and dioxogen frequently. 
Efforts to Abort the Inflammation.-Hot fomentation or cold 
applications to the surface, bathing, and gentle massage with 30 DISEASES OF THE SALIVARY GLANDS 
469 
per cent, alcohol, hot-water bags and other means of preventing 
the progress of the inflammation should be employed. Pain may 
require hypodermic injections of morphin, or iodin for its relief. 
Surgical Treatment.-When an abscess is formed it must be 
opened and drained. The external incision is made in such a manner 
as to avoid important nerve structures, and blunt dissection is 
used to open the gland until the pus is reached. The removal of 
the necrotic tissue and suitable drainage is required, as in the 
treatment of other abscesses. 
The original source of infection must receive treatment to prevent 
recurrence of the trouble. 
General Treatment.-Aid should be given to the eliminative 
organs to keep up their activity, and supportive measures should 
be directed toward building up resistance by increase of bodily 
strength. 
Chronic Inflammations of the Salivary Glands.-Etiology.-Long- 
continued and slowly progressive swelling sometimes affect these 
glands, particularly the submaxillary. No definite cause appears. 
The author's experience, however, leads him to believe that it is 
sometimes a result of infection from some chronic mouth affection. 
Syphilis, tuberculosis, and tumors are commonly excluded as 
factors in these cases. 
Symptoms.-The gland is more or less enlarged, slightly indurated, 
the overlying tissue is very slightly or not at all adherent, and the 
tumor more or less movable. 
Treatment.-The treatment comprises correction of the cause, 
relief of the inflammatory symptoms, and removal of the gland 
if absolutely required, but not otherwise. 
Chronic Secondary Inflammations.-Etiology.-Chronic enlarge- 
ments of the salivary glands commonly result from the intoxica- 
tions of mineral and other poisons, such as mercury, lead, copper, 
iodin, opium, etc. In uremia and similar affections such glandular 
conditions also occur. 
Symptoms.-The disease shows itself in chronic enlargements, 
with more or less induration of the glands. 
Treatment.-Removal of the cause is usually sufficient. When 
chronic changes have progressed too far the glands may become 
a menace and require removal. 
Ptyalism; Sialorrhea or Hypersecretion.-Etiology.-Inflamma- 
tions of the mouth are the most common causes. It is a prominent 
symptom of mercurial, phosphorus, and copper poisoning; it may 
also be caused by certain drugs, such as the iodin preparations. 470 
DISEASES OF THE GLANDS 
jaborandi, etc. It is a symptom of certain diseases which involve 
the nervous system, either primarily or secondarily, such as hydro- 
phobia, hysteria, trifacial and other forms of neuritis, and is a 
distressing feature of facial paralysis. 
Symptoms.-The one dominant symptom is an excessive flow 
of saliva. 
Treatment.-The cause should be corrected whenever possible. 
Astringent drugs are more or less recommended, but in the author's 
experience have usually failed to give permanent relief when the 
causative factor was beyond control. 
Aptyalism; Xerostoma, Dry Mouth.-Etiology.-Its exact cause 
is not understood, but it is believed to be due to diabetes. 
Symptoms.-Insufficient saliva secretion causes excessive dryness 
of the mouth. 
Treatment.-The treatment must necessarily be empirical until 
its causes are better understood. The distressing dryness may 
be relieved by soothing local applications and correction of general 
conditions of health. 
Bilateral Parotid Tumors.-Bilateral enlargements is more or less 
rare, although unilateral parotid tumor is not uncommon. The 
latter are commonly mixed tumors, tubercular glands, parotid 
cysts, or the results of infection parotid. Gordon B. New, of the 
Mayo Clinic, gives the following classification of bilateral parotid 
tumors: 
1. Recurrent bilateral parotid tumors. 
2. Syphilitic bilateral parotid tumors. 
3. Tuberculous bilateral parotid tumors. 
4. Bilateral parotid tumors associated with leukemia. 
5. Mikulicz's disease. 
6. Bilateral parotid tumors due probably to a local infection. 
A number of cases have been reported in which bilateral swelling 
of the parotid glands of intermittent character was apparently due 
to certain kinds of food. The swelling may last an hour or two and 
quickly subside. Friedberg's suggestion that spasmodic closure 
of the ducts is brought on by the stimulation of foods, appears to 
be the most satisfactory way of accounting for this affection. The 
diagnosis of the syphilitic and tubercular types, as well as those due 
to local infection and the treatment thereof must be largely deter- 
mined in the same manner as for other forms of these affections. 
Their association with lymphatic leukemia and Mikulicz's disease, 
however, points to a wide field of investigation as yet too unsettled 
to warrant definite etiological conclusions. DISEASES OF THE SALIVARY GLANDS 
471 
Mikulicz's Disease.-Etiology.-Nothing is known of the cause 
and nature of this affection. 
Symptoms.-The symptoms are a uniform swelling occurring 
usually in middle life and progressing slowly, the distinctive feature 
of which is the symmetrical enlargement of the glands of the head, 
particularly the salivary glands. Both parotids, the submaxillary, 
sublingual, and lacrimal glands are involved, as may also be the 
palatine and labial glands. The parotids may become as large 
as a moderate-sized apple, with proportionate enlargement of the 
other glands. All of these glands may not be affected, but there 
Fig. 244.-Symmetrical affection of the lacrimal and salivary glands: a, the enlarged 
sublingual glands. (After Mikulicz.) 
must be a sufficient number of them to give the symmetrical effect 
in order that the case may be correctly diagnosticated as Mikulicz's 
disease. As might be expected, the adjoining lymphatics are also 
frequently involved (Fig. 244). 
The disease does not spread beyond the gland capsule, and the 
tumor is therefore movable under the skin. Its consistency may 
vary, but there is no fluctuation and there are no inflammatory 
symptoms, such as pain or unusual tenderness. Osler describes 
one case in which there was enlargement of the spleen, and states 
that blood examination is negative. Movement of the jaw is 
interfered with, but it is not painful. The mucous membrane of 472 
DISEASES OF THE GLANDS 
Fig. 245.-Bilateral parotid tumor associated 
with lymphatic leukemia. (After New.) 
Fig. 246.-Mikulicz's disease. (After New.) 
Fig. 247.-Mikulicz's disease. (After New.) 
Fig. 248.-Mikulicz's disease. (After New.) DISEASES OF THE SALIVARY GLANDS 
473 
the mouth suffers unusual dryness through imperfect function of 
the diseased glands. Interstitial gingivitis with marked loosening 
of the teeth has been described in some cases, but whether infection 
from this cause is an etiological factor or the condition of the teeth 
a result of the disease is not fully understood. 
Diagnosis.-Diagnosis depends upon the symmetrical and uniform 
enlargement of the affected glands, the absence of inflammatory 
symptoms, and exclusion of malignant growths. 
Prognosis.-The disease is not directly dangerous to life. Its 
course is variable, sometimes remaining stationary and occasion- 
ally receding after intercurrent febrile diseases or as a result of 
treatment. With regard to cure, the prognosis is doubtful. 
Treatment.-Arsenic and potassium iodide are much recom- 
mended, and when these or similar remedies fail, surgical removal 
of the gland may be performed. This, however, should be avoided 
except in cases where such procedure is warranted by marked 
disfigurement. 
The following diseases may primarily or secondarily affect the 
salivary glands as they do other structures of the body. Further 
description is given in detail under their respective headings as 
indicated. 
Actinomycosis.-(See page 181.) 
Tuberculosis.-(See page 102.) 
Syphilis.-(See page 117.) 
Ranula.-(See page 492.) 
Cysts.-Cysts of the Salivary Ducts.-(See page 490.) 
Cysts of the Salivary Glands.-(See page 490.) 
Tumors of the Salivary Glands.-(See page 471.) 
Adult Epithelial Tumors.-Adenomata (page 510) occasionally 
occur but are very rare. 
Embryonic Epithelial Tumors.-(See page 501.) 
Epitheliomata (page 534) are the most frequent. 
Encephaloid (page 536) are rare. 
Adult Connective-tissue Tumors.-Chondromata.-(See page 516.) 
Fibromata.-(See page 518.) 
Myomata (page 520) are found occasionally. 
Angioma (page 521) are rare, and the diagnosis is often ques- 
tionable. 
Lymphangioma.-(See page 523.) 
Lipoma.-(See page 515.) 
Myxoma.-(See page 526.) The existence of pure myxoma of 
these glands is questionable, for most of them are mixed tumors. 474 
DISEASES OF THE GLANDS 
Embryonic Connective-tissue Tumors (page 527) are rare. 
Mixed Tumor (page 529) is the most frequent parotid neoplasm, 
and most of these are endotheliomata. 
Symptoms and Treatment.-Symptoms and treatment of these 
growths do not differ materially in salivary glands from other 
situations of the body, and are therefore described under their 
several subjects as indicated. 
DISEASES OF THE LYMPH GLANDS OR LYMPH NODES 
OF THE MOUTH AND ASSOCIATED PARTS. 
Adenoids; Adenoid Vegetations, Pharyngeal Adenoids, Pharyn- 
geal Tonsils, Epipharyngeal Tonsils, Postnasal Adenoids, Hyper- 
trophy. - Definition. - Adenoids are hypertrophied lymph glands 
which normally exist in the epipharyngeal space. They are 
usually found on the superior and posterior walls of the epi- 
pharynx. 
Etiology.-Practically all the factors leading to chronic irritation 
and inflammation in the nasal and pharyngeal regions may be 
grouped as causes of adenoids. 
Ballenger believes their chief cause to be irritation of the epi- 
pharynx during attacks of exanthematous fever, and calls attention 
to the fact that lymphatic structures of children become enlarged 
or hypertrophied in response to bacterial stimulation more markedly 
than the same structures in adults under similar conditions. He 
holds that as the exanthematous fevers occur chiefly in early child- 
hood there is a special susceptibility to adenoids during this period 
of life. It must, however, be remembered in this connection that 
adenoids, which may occur at any period of life but are usually found 
between the ages of five and sixteen years, affect large numbers of 
children whose histories contain no record of previous attacks of 
any of the exanthemata. Moreover, the common association of 
adenoid vegetations with other developmental abnormalities or 
defects and their frequent existence in members of the same family 
which, while the use of the term hereditary may be unwarranted, 
shows at least a predisposition that is undoubtedly inherited. In 
some cases at least there is an underlying developmental tendency, 
and upon this foundation any factor leading to chronic diseases of 
nasopharyngeal structures may act as direct causes. 
Hypertrophy of the Tonsils.-In rare cases this affection is con- 
genital, infants having been born with enlarged tonsils. Usually, 
however, it begins about the second year of life, and continues DISEASES OF LYMPH NODES OF THE MOUTH 
475 
until young adulthood, after which there is gradual tendency to 
reduction in size. 
While many predisposing factors are recognized and the close 
relation of this process to other glandular influences upon develop- 
ment is beginning to be understood, the essential underlying 
cause has not yet been definitely proved. Many disease processes 
may lead to tonsillar enlargement, as in acute lingual tonsillitis. 
The association of unhealthful nasal, buccal, and pharyngeal 
tissues occurs so frequently that their pathological relation appears 
to be beyond question. 
Symptoms of Adenoids and Enlarged Tonsils.-Adenoids and 
enlarged tonsils are found together in the same individuals in a 
large majority of cases. The important features when contem- 
plated in their relation to pathological conditions of the mouth, 
pertain chiefly to the general involvement of pathological and 
developmental conditions. This includes diseases of the mouth, 
nose, pharynx, throat, the sinuses of the head, the form of the 
dental arches, palate, and face, and their direct or indirect effect 
upon more remote parts or the organism as a whole. Any of these 
affections may be primary or secondary causes of both adenoids 
and hypertrophy of the tonsils as well as other diseases of the nose 
and throat, or the pathological influence may be exerted in a reverse 
direction. Knowledge of the symptomatology of these affections 
is therefore necessary for the oral surgeon. It is frequently a 
method of much importance properly to decide whether the treat- 
ment of adenoids and tonsils should precede correction of the mouth 
affection or this order be reversed. 
Treatment.-It is the author's belief that the treatment of intra- 
nasal and pharyngeal diseases should be referred to those who 
specialize in nose and throat, and that the indiscriminate attempts 
at removal of adenoids and enlarged tonsils by those whose special 
training does not fit them for the attainment of the best results in 
this direction is pernicious in its tendency. 
For this reason no attempt will be made to describe these opera- 
tions in detail in this work. 
Serious and absolutely unnecessary hemorrhage, imperfect 
operations that caused continuance rather than relief of disease, 
and injuries to nerves or the tissues of the faucial pillars and the 
soft palate that have led such patients to apply to the author for 
operation for relief of speech defects, the same as cleft-palate cases, 
are results that have frequently come under his observation when 
unskilled operations have been undertaken to remove adenoids 
and tonsils. Fig. 249.-Drawing of the palate of a young woman, aged twenty years, whose 
faucial pillars were injured in the course of a tonsil operation, shows shortening and 
deflection of the palate, fluids escaped through the nose in swallowing and speech 
very imperfect. 
Fig. 250.-Same case after operation. DISEASES OF LYMPH NODES OF THE MOUTH 
477 
Examples of such postoperative defects are shown in Figs. 249- 
253. Fig. 249, which is a drawing illustrating the case of a young 
woman, aged twenty years, whose faucial pillars upon one side were 
injured in the course of an ill-advised tonsillectomy. She suffered 
Fig. 251.-Atresia of the palatopharyngeal opening resulting from imperfect 
tonsil and adenoid removal. Case of a boy, aged nine years. The soft palate was 
adherent to the posterior wall of the pharynx on the right side, a very slight 
opening being left upon the left side. A number of attempts to correct the 
trouble resulted in failure. Among these the ill-advised, though sometimes 
recommended attempt to transplant mucous membrane to cover the raw posterior 
surface of the palate. Such efforts in these cases are useless. Mucous membrane 
does not transplant well, the tissues are always distorted when the incisions 
are made so that perfect co-aptation is impossible, and there is always infection to 
attack the transplanted tissue. During several years of enforced mouth-breathing, 
nasal disease had become marked, the nares narrow and the septum deflected. As a 
first step the maxillse were separated, the nares thus enlarged; the deflected septum 
relieved and more healthful nasal conditions secured. Following this an operation 
was performed as shown in the illustration, with complete relief. 
great distress through imperfect speech, fluids came through her 
nose in deglutition, and her nervous condition became serious in 
many respects. Fig. 250 shows the author's operation for correction 
of defects of this character through which the patient was enabled 478 
DISEASES OF THE GLANDS 
to drink water, and speak without difficulty after operative treat- 
ment. 
Fig. 251 presents another form of ill-result from careless or unskil- 
ful adenoid and tonsil removal in which there is adhesion of the soft 
palate to the posterior wall of the pharynx. This boy, nine years 
old, had the soft palate on one side adherent to the posterior pharyn- 
geal wall, as a result of adenoid and tonsil operations four years 
previously. During this time an attempt had been made to free 
the palate, and transplant mucous membrane to prevent the tissues 
Fig. 252-The same case as in Fig. 251, in course of correction after the ligature 
is tied. The usefulness of the parts in swallowing and speech was completely 
restored. 
from uniting. At this operation he was under an anesthetic nearly 
all of one day and almost died, but the original condition remained. 
Attempts to stretch the parts had only made him more in terror 
of doctors and doctors' offices, and did no good whatever. Nasal 
disease, quite marked deafness, defective speech, and both palatal 
and nasal defects all combined to make his condition very serious. 
As a first step, his maxilke were separated to enlarge the nares and 
facilitate more healthful pharyngeal conditions. This gave marked 
improvement in respiration, better general health, arid a more DISEASES OF LYMPH NODES OF THE MOUTH 
479 
healthful condition of the local tissues and secretions, after which 
the operation illustrated in Fig. 252, was performed with complete 
success. 
In these cases cutting the palate free from the pharynged wall 
only results in their reuniting again with additional scar contraction. 
The loop suture causes pressure, absorption, and the tendency is 
toward progressive increase of the nasopharyngeal opening, instead 
of its becoming smaller as would otherwise occur. Fig. 253 indicates 
Fig. 253-Illustration of the contracted nasopharyngeal opening of a child, 
aged six years, resulting from a tonsil operation. The soft palate on both sides 
in this case is adherent to the pharyngeal wall. The small opening just under the 
uvula is shown. 
the condition of almost complete stenosis of the nasal pharyngeal 
passage of a child, aged six years. This little fellow is a twin, ever 
so much smaller, bent-shouldered, more markedly nervous, and 
generally ill developed than his brother. The difference is undoubt- 
edly due to the atresia of the palate and its consequences, all of 
which were caused by the removal of adenoids and tonsils in an 
unskilful manner. Fig. 253 shows the operation which was per- 
formed by which benefit was given to enable him to improve in 
both health and speech. 480 
DISEASES OF THE GLANDS 
Suprahyoid Median Phlegmon. - Etiology. - This affection is 
obviously due to some form of infection and is undoubtedly closely 
allied to Ludwig's angina. 
Symptoms.-In typical cases the patient keeps the mouth open, 
salivation and deglutition are impossible, respiration is interfered 
with. A swelling will be found in the suprahyoid region in the 
mouth, an elevation of the floor which lifts up the edematous 
tongue. In some cases the condition can only be discovered by 
bimanual palpation, one finger in the mouth, the other under the 
chin. 
Treatment.-Prompt treatment is required. An incision should 
be made from the tip of the chin nearly to the hyoid. Incision 
in the mouth is advisable only when the collection protrudes more 
into that cavity. There is no occasion to wait for formation of pus, 
the appearance of the swelling together with its rapid extension 
both attest the gravity of the condition. Lejars1 cites a case showing 
the dangers of delay: "A man, aged sixty-five years, apparently 
in vigorous health, had a swelling such as had been described; as 
the fever was slight and the general condition good, some days 
passed with nothing done but lavage, etc., then a short intrabuccal 
incision evacuated a little blood. However, there was some relief, 
and again for some days nothing more was done, the swelling grew 
larger and the whole region was thick and swollen. The actual 
cautery was used and some pus and turbid serum evacuated. There 
was improvement for forty-eight hours, then the swelling rapidly 
extended laterally; this time heroic measures were undertaken, the 
region was freely opened and punctured with the cautery, but it 
was too late." 
Lymphadenitis; Lymphangitis.-These terms denote inflamma- 
tion of the lymph node. 
Etiology.-Practically every form of infection affects the lymph 
nodes because of their unusual susceptibility to the influence of 
bacteria or their toxic products. Tuberculosis, syphilis, bubonic 
plague, leprosy, actinomycosis, glanders, diphtheria, scarlet, 
typhoid, and other fevers, and infectious diseases give rise to ade- 
nitis, which may be apparent in the lymph channels of the neck or 
other regions. Infection from disease of the mouth is, of course, 
an important factor in this relation. This is emphasized by Coplin2 
as follows: 
"Cervical tuberculous lymphadenitis is clearly the result of 
1 Semaine Med., November 10, 1909. 
2 Manual of Pathology, pp. 445 and 446. DISEASES OF LYMPH NODES OF THE MOUTH 
481 
infection from the oral and pharyngeal cavities. Halle found 
that in 3161 children with enlarged cervical glands, 2334 had 
carious teeth; and of these, 1646 corresponded in location with the 
enlarged glands. Odenthal, among 987 children, found decayed 
teeth in 429; 424 of these had enlarged lymph nodes. Halle demon- 
strated that if cavities in the teeth of dogs be packed with Prussian 
blue and cemented, the pigment may, in from two to three days, be 
present in the nearest lymph nodes. Dieulafoy and others have 
shown that tonsils-frequently without evidence of tuberculosis- 
may contain the bacillus, and that the organism often is present in 
adenoids." 
Symptoms.-Inflammation of a lymph node may be acute or 
chronic. In acute cases the node becomes swollen, tense, and 
tender. On account of the obstruction to the passage of fluid the 
swelling may extend to other tissues of the area drained, thus 
giving rise to a paralymphadenitis. The course may be fulminating 
and pass more or less rapidly to suppuration until the gland 
becomes a necrotic mass (bubo), or chronic changes may take 
place with induration that may persist for months or years without 
noticeable change. 
Treatment.-The treatment must, of course, be governed by 
the nature of the cause. If due to mouth infection, the buccal 
secretions must be disinfected and the local disease properly treated. 
Tuberculosis, syphilis, and general infections require measures 
appropriate to the general treatment of such diseases. 
In the absence of entirely evident sources of infection in the 
mouth, such as extensive dental caries, discharging dental abscesses, 
extensive diseases of the mucous membrane, and similar affections, 
care should be taken to test the responsiveness of all the teeth upon 
the affected side to heat and cold in order to determine whether 
by any chance there may be a devitalized tooth. Without giving 
outward evidence of disease or noticeable symptoms of pain, such 
teeth have been frequently known to be the source of extensive 
infection which is the more to be feared because the real cause is 
apt to be overlooked. 
Another valuable method of examination for the same purpose 
is to test the color of teeth by the use of a small electric mouth 
lamp. This usually reveals difference in translucency between 
devitalized teeth and those having living pulps. If a tooth be 
found in a devitalized condition, its history must be carefully 
studied to learn whether the pulp has been previously extracted 
and the roots properly filled or not. 482 
DISEASES OF THE GLANDS 
Many times the only satisfactory method is to have a dentist 
open the root canals and thoroughly cleanse and fill them as a 
matter of precaution. 
Interstitial gingivitis, especially in the form of pyorrhea alveo- 
laris, with chronic discharge of pus from pockets about the necks 
of the teeth, is a relatively frequent cause, and in many cases easily 
overlooked in superficial examination of the mouth. Discharges 
from beneath gum surfaces surrounding the crowns and necks of 
partially erupted teeth are also a cause that might readily be 
overlooked. Adenoids and enlarged tonsils are sources of infection 
constantly under the observation of dentists as well as other 
practitioners. 
When a chain of lymph nodes is involved, and it is evident that 
the infection has extensively invaded the cervical lymphatics, 
the removal of such glands by complete dissection is called for 
(see page 549). The modern tendency, however, is to treat these 
nodes individually if there is no evidence of extensive invasion 
and when operation can be performed sufficiently early to enucleate 
and remove the particular node that is affected without extir- 
pation of the entire chain en masse. The arrays appear to exert a 
valuable influence in the treatment of these cases. 
"Hodgkin's Disease, Lymphadema, Lymphadenoma, Lympho- 
sarcoma, Progressive Lymphadenoid Hyperplasia, Malignant 
Lymphoma, Simple Adenia, Pseudoleukemia, Malignant Lymph- 
adenoma.-These and other more or less synonymous terms have 
been applied to a peculiar form of lymphoid change in which one 
or more of the lymphadenoid tissues of the body are involved, 
including not only the lymph nodes, the spleen, and the tonsils, 
but even the lymphoid tissues of the various mucosa. Without 
doubt a number of conditions have been included in this group. 
Careful study by modern methods, particularly the investigations 
by Reed, Simmons, and Longcope, render it possible to recognize a 
fairly definite anatomical picture, which is distinct from neoplasms 
affecting the lymph nodes and not due to any form of infection 
with which we are at present familiar."1 
Etiology.-Dr. John L. Yates, of Milwaukee, with Dr. C. H. 
Bunting,2 of Madison, isolated and definitely identified an organism 
which, in February, 1912, they named B. hodgkini. Bunting has 
been able to cultivate it from all fresh affected tissue, wherein the 
1 Coplin: Manual of Pathology, p. 448. 
2 J. L. Yates and C. H. Bunting: Johns Hopkins Hosp. Bull., vol. xxvi, No. 297. DISEASES OF LYMPH NODES OF THE MOUTH 
483 
histological diagnosis was positive, or where the blood picture of the 
patient was characteristic unless that tissue had been contaminated, 
or had recently been actively treated by the z-rays. Yates1 defines 
a group of the closely related affections of which Hodgkin's disease 
may be taken as a most characteristic example as, 
"A non-communicable infectious granulomatous process due to 
B. hodgkini (or to similar, but as yet undifferentiated micro- 
organisms), protein in the resultant local (tissue) and general 
reactions, and therefore in clinical manifestations. He differentiates 
these groups in the following manner: 
Group 1. Type, Hodgkin's disease. 
Group 2. Type, lymphosarcoma. 
Group 3. Type, lymphatic leukemia, pseudoleukemia, chloroma. 
Group 4. Type, chloroma, Banti's disease. 
Group 5. Type, chronic hypertrophic arthritis. 
Group 6. Type, elephantiasis-like cellulitis. 
Group 7. Type, mycosis fungoides. 
The common factors in these diseases, as we have observed them, 
are in brief as follows: 
1. The presence (or history) of a primary focal inflammatory 
lesion, usually, but not necessarily, in the upper part of the digestive 
or of the respiratory tract (teeth, tonsils, adenoid tissue, sinuses, 
bronchi). 
2. Progressive enlargement of the lymph nodes, with or without 
accessory extranodal tumors. 
3. Chronic course, with late moderate secondary anemia and with 
the constant development of a fever, usually of an irregularly inter- 
mittent character, exceptionally of the Murchison type. 
4. Eventual fatal termination within a relatively brief period of 
years (two to five). 
5. The occurrence during the course of the disease of either the 
blood picture described by Bunting as the primary blood picture 
of Hodgkin's disease, or of a leukemic blood picture. 
6. The occurrence of a primary lesion in the germinal centers 
leading to an early loss of architecture in the lymph nodes through 
an extensive proliferation of diverse cells but with common factors 
in the picture. 
7. The constant occurrence in the lesions (nodal and extranodal) 
of organisms of the diphtheroid type. 
1 J. L. Yates: Johns Hopkins Hosp. Bull., November, 1915, vol. xxv, No. 280. 
Colorado Medicine, February, 1916. 484 
DISEASES OF THE GLANDS 
Symptoms.-Usually the enlargement of cervical lymph nodes 
first appears, and clusters of these become prominent in a short 
time. They may be in more or less isolated masses or completely 
surround the neck. The axillary and inguinal glands next follow. 
Internal nodes may also be involved. The spleen, thymus and 
thyroid bodies, liver, pancreas and suprarenal capsule may become 
involved. In rare cases lymphoid growths occur in the central 
nervous system (Figs. 254 and 255). 
Fig. 254.-Hodgkin's disease. (After 
Brewer.) 
Fig. 255.-Hodgkin's disease. 
Treatment.-First, elimination of the portal or portals of entry 
of the infection (inflamed tonsils, teeth, accessory sinuses, derma- 
titis; bronchitis, enterocolitis, etc.); second, wide extirpation of all 
eradicable involved tissue; third, improved general health through 
hygienic measures, present by radiation, immune serum, and medi- 
cation any extension of the disease, and to repeat these treatments 
at intervals of a few months. DISEASES OF LYMPH NODES OF THE MOUTH 
485 
Prognosis.-Yates1 believes that by early diagnosis, and prompt 
radical treatment at least some cases can be cured, and the disease 
need not necessarily terminate fatally. 
Tumors of the Lymph Nodes.-Lymphangiomas; Localized Lym- 
phatic Dilatation.-These comprise macroglossia or lymphatic 
enlargements of the tongue and macrocheilia. 
Varieties.-Lymphatic nevi, small areas of colorless dilated lym- 
phatics, cavernous lymphangiomas, irregular compressible tumors 
made up of masses of dilated lymph vessel or a coalescence of several 
dilated vessels, and cystic hydroma, commonly called hydrocele of 
the neck. 
Etiology.-The etiology is obscure. The Filaria sanguinis hominis 
is credited with being the cause of certain forms of these affections. 
Other forms, such as macroglossia, lymphatic enlargement of the 
tongue (page 611), and macrocheilia, lymphatic enlargement of the 
lips, are congenital affections due to lymphatic obstruction. 
For further description and treatment see page 646. 
Other Tumors.-Osteomata, chondromata, and endothelioma 
occasionally but rarely involve lymph nodes. Both sarcoma and 
carcinoma may affect the lymph nodes as primary or secondary 
affections. (The important position of the lymph nodes of the neck 
in relation to malignant growths of the mouth is fully described 
in consideration of these affections on pages 543, 549 and 551.) 
1 J. L. Yates and C. H. Bunting: Jour. Am. Med. Assn., March 10, 1917, pp. 
747-751. CHAPTER VIII. 
TUMORS. 
According to strict definition a tumor is a swelling. Etymology 
warrants the use of the word tumor in this sense, and in the past 
it has been somewhat generally applied to designate any abnormal 
swelling, including those of inflammatory character now termed 
infectious granulomas as well as other circumscribed newgrowths 
of tissue. At present its meaning is restricted so that the term 
tumor is only used to denote neoplasms and cysts. 
NEOPLASM. 
"Neoplasm is a morbid growth characterized by a tendency to 
persist or increase in size independently of changes in the metabo- 
lism of contiguous or systematic structures and performing no 
useful function."1 
"Circumscribed enlargement of a part due to the presence of 
morbid growth."2 
Etiology.-The vague attribution of tumors to humors of the 
body and of the blood in the past as well as many more recent 
explanations, are being rapidly displaced in the light of newer 
research. Experimentation by inoculation of mice and other 
animals and closer study of tumors in human beings is rapidly 
leading to a time when the etiology of malignant growths may be 
definitely determined. At present, ■ however, there is no known 
cause or generally accepted theory with regard to their origin. 
Virchow's demonstration of his law, that "The cellular element 
of the tumor are derived from preexisting cells of the organism," 
and Muller's Law, that "The tissue that forms the tumor has its 
type in the tissues of the organism either adult or embryonic," are 
generally recognized as fundamental. With these in view it may 
be stated that the following are the only theories worthy of 
consideration: 
Heredity.-The many cases that have, from time to time, been 
reported in which blood relations have been affected by neoplasms 
1 Coplin: Manual of Pathology, p. 308 
2 Dunglison's Medical Dictionary. NEOPLASM 
487 
of similar character lends color to the belief that there may be an 
inherited tissue predisposition to malignant growths. Beyond this 
there is no evidence to prove direct heredity. 
Parasitic Influence.-According to germ theories that have been 
advanced, the formation of malignant neoplasms may be due to 
an animal parasite belonging to the protozoa or a vegetable organ- 
ism belonging to the blastomycetes. Although neither of these 
explanations of tumor causation are fully accepted, the trend of 
modern clinical pathological and experimental research appears to 
point in this direction. In support of the belief that parasites 
of some kind are responsible for neoplasms the following charac- 
teristic features of such growths may be noted. 
Local Infectivity.-Local infectivity or extension of cancer from 
one part to another when there is contact of the surfaces is fre- 
quently observed. By instruments and otherwise the disease has 
also been extended. Metastasis is generally recognized as equivalent 
to an inoculation. 
Inoculation Experiments.-The "Jensen mouse tumor" has been 
transplanted thousands of times. Immunity between species, and 
natural, as well as acquired immunity which have been demon- 
strated in the course of experimentation are not unlike the same 
conditions in infectious granulomas. 
Microscopic Findings.-Gaylord and others have shown the 
actual presence of parasites in cancerous growths, but microscopic 
findings which have been reported favorable to the recognition of 
a definite cancer parasite are not generally accepted. Secondary 
invasions of bacteria into tumor growths frequently occur and 
confuse the findings in this respect. 
Embryonal Theory.-The embryonal or Cohnheim's theory pre- 
supposes an anomalous embryonic development leading to the 
inclusion or misplacement of portions of the original blastodermic 
layer in the midst of tissues derived from a different layer of the 
embryo-the so-called embryonic rests. 
Certain forms of tumor, notably ovarian, parotid, and dermoid, 
seem to bear out the truth of this theoretical explanation, but 
others do not, and it does not explain the proliferation of the 
embryonal rests. 
Irritation and Trauma.-Whatever the true cause may be, the 
fact remains that, clinically, tumors are found to appear so fre- 
quently in the sites of previous traumatic injuries and tissues 
subjected to long-continued irritation or chronic inflammation that 
every surgeon must be convinced of the important relation of such 
factors. 488 
TUMORS 
Classification.--In the absence of full knowledge of the etiology 
of tumors the various classifications that have from time to time 
been presented by authors, founded, as they have been, upon not 
fully justified theories of origin, character, and development, are 
unwarranted in the opinion of the more recent writers on path- 
ology, notably Coplin and Stengel. Based upon Muller's law, 
"The tissue that forms the tumor has its type in the tissues of the 
organism, either adult or embryonic." Coplin suggests the ten- 
tative classification, according to the resemblance of tumors to 
normal tissues shown on p. 489. 
Pathology.-Most tumors live at the expense of the organism 
and add nothing to its development or nutrition. A few possible 
exceptions are noted in attempts at milk formation in cancer of 
the breast, biliary pigment formed in carcinoma of the liver and 
glycogen found occasionally in large quantities in some tumors. 
These are assumed to be functional attempts. The disturbance of 
general health is explained as being possibly due to interference 
with organic function, secondary inflammatory changes, and the 
absorption of noxious products, but all of these features will be to 
some extent matters of conjecture until the true etiology of tumors 
is understood. 
Primary tumors are original growths. Secondary tumors are 
metastatic extensions. 
Tumor enlargement or extension takes place by (a) Interstitial, 
by proliferation of its cells uniformly within the tumor, (b) Dis- 
semination, which may be (1) growth by infiltration or extension 
of the tumor in surrounding tissue, usually the lymph spaces and 
without a sharply defined border; (2) by metastasis. 
Metastasis.-The transplantation of a tumor from one part of 
the body to another may take place through lymphatic or venous 
channels and extend for considerable distance along the lines of 
their distribution. Tumor cells may be carried as emboli along the 
lymphatic or venous channels, to result in a secondary growth in 
some new location, or a tumor may spread over membranous 
surfaces such as the peritoneum, pleura, and occasionally mucous 
membrane surfaces to form new foci at various points. 
Benign tumors have been known to recur after removal, as in 
cases of nasal polypi and keloids of the skin, or to cause primary 
tumors or metastasis as in adenomas, chondromas, and leiomy- 
omas. 
Pigmentation results from hemorrhage within the tumor and dis- 
integration of the blood-coloring matter, or may be due to pigment- NEOPLASM 
489 
producing cells, as in a chloroma, melanotic sarcoma, etc. It is 
also claimed to be due to certain bacteria when tumors are ulcerated. 
Tumors.-Those in italics are malignant. 
Papilloma 
Skin warts. 
Villous warts. 
Intracystic warts. 
Acinous. 
Adult (typi- 
cal benign) 
Adenoma 
Neuroma1 
Tubular. 
Ganglionic neuroma. 
Glioma 
Myelinic neuroma. 
Amyelinic neuroma. 
Epithelial 
(epiblast 
and hypo- 
blast) 
Squamous. 
Tubulated. 
Cylindric. 
Epithelioma 
Embryonic 
{atypical, 
malignant) 
j Carcinoma 
( or Cancer 
Scirrhus. 
Encephaloid 
(.Colloid, 
Mucoid, 
Melanotic). 
Glandular 
Simple. 
Fibrous. 
Lipoma 
Chondroma 
Osteoma 
Eburnated. 
Compact. 
Spongy. 
Simple 
Hard. 
Soft. 
Tumors 
Neoplasms 
Adult (typi- 
cal or be- 
nign) 
Fibroma 
Myoma 
Angioma 
Lympho- 
ma (?) 
Myxoma 
Sarcoma 
Fibroma molluscum. 
Keloid. 
Leiomyoma (unstriped). 
Rhabdomyoma (striped). 
Hemangioma 
(blood- 
vessels) 
Simple. 
Cavernous. 
Plexiform. 
Connec- 
tive tissue 
(meso- 
blast) 
Lymphangioma 
(lymph vessels). 
Large. 
Small. 
Spindle-cell 
Round-cell 
Large. 
Small. 
Embryonic 
{atypical 
malignant) 
Myeloid. 
Mixed-cell. 
Alveolar. 
Melanotic, cystic, etc. 
M ixed Teratoma 
(both epithelial and connective tissue") 
(1) Retention (occluded excretory ducts). 
(2) Exudation (accumulations in closed cavities). 
(3) Cystomas (new formation). 
(4) Extravasation (those forming from extravasations). 
(5) Dermoid (congenital and due to inversion of the cutis and to imper- 
fectly closed fetal clefts). 
(6) Parasitic (due to animal parasites). 
(7) Cysts resulting from necrotic and degenerative changes. 
1 Coplin: Manual of Pathology, p. 366. 490 
TUMORS 
Diagnosis.-In a general way the clinical distinctions between 
benign and malignant growths are as follows: 
MALIGNANT. 
Rapidity of growth. 
Invasion by infiltration, with ten- 
dency to break down surrounding tis- 
sues. 
Recurrence after removal. 
Formation of metastases. 
Tendency to produce cachexia. 
BENIGN. 
Grows slowly. 
Does not extend by infiltration or 
invasion of surrounding structures. 
(Most benign tumors are circumscribed 
but a few, such as lipomata, may be 
diffuse.) 
Does not usually recur when com- 
pletely removed. 
Practically no tendency to metastasis. 
Does not cause cachectic conditions. 
General Form for Diagnostic Description of Tumors- Situation, 
formation, size, number, consistence, color, mobility, sensibility, 
influence, if any, upon surrounding structures; history of growth; 
history of patient (age, sex, social condition, occupation, habits, 
heredity, general nutrition), and previous history of the organ or 
tissue involved. 
CYSTOMAS. 
A cyst consists of a connective-tissue membrane or supporting 
wall lined by epithelium or endothelium and forming a cavity, the 
contents of which may be fluid or semifluid, uniform in composi- 
tion or made up of a mixture of similar or dissimilar substances. 
Cysts are described as simple or unilocular when single, and multiple 
cysts when there are several cysts together, which are identical in 
cause and structure. 
Proliferous cysts are those in which the cyst walls continue to 
spring from each other or proliferate. 
Multilocular is the term applied to those in which a number of 
cysts together remain distinct, cavernous, to those that communicate. 
Papilliferous cysts are lined with papillomatous masses. 
Classification.-(1) Retention cysts, due to the occlusion of excre- 
tory ducts of glands. (2) Exudation cysts, caused by accumulations 
in cavities not supplied by excretory ducts, as bursse, tendon 
sheaths, etc. (3) Cystoma, a cyst that is the result of a new forma- 
tion. (4) Extravasation cysts, those formed around distended or 
ruptured vessels. (5) Dermoid cysts, congenital cystic results of 
cutaneous inclusion, or inclusion of a blighted ovum. (6) Parasitic 
cysts, caused by animal organisms, as trichinse and other parasites. 
(7) Cysts resulting from necrotic and degenerative changes in solid 
tissues, such as those formed in neoplasms from hemorrhage lique- CYSTOMAS 
491 
faction, necrosis, and other forms of softening, as well as other 
degeneration processes. 
Retention Cysts.-Cysts of the Mucous Glands.-Etiology.- 
Occlusion of the ducts of these glands from inflammatory or other 
causes leads to cystic formation. 
Symptoms.-The cysts appear on the inner side of the lips and 
cheeks and on the under surface of the tongue. In the beginning 
they are quite small, but by constant accumulation of fluid may 
extend until they become as large as a walnut. They vary from 
pink to bluish color, and give very little disturbance unless through 
enlargement they occasion inconvenience by interference with 
movements of the tongue or occlusion of the teeth. 
Diagnosis.-These cysts are differentiated from hemangioma 
because they are more localized and the color is not so dark a 
blue; from lymphocysts because the latter are more irregular in 
form and there is a distinct difference in their contents. The 
author's cases have usually given history of these cysts having 
been more or less frequently opened or ruptured with immediate 
disappearance and later recurrence. 
Treatment.-The author's method of treatment of mucous cysts 
is to inject 2 per cent, solution of cocain into the surrounding 
tissue. He then grasps the mucous membrane close to the border 
of the cyst with a forceps, to carefully follow its outline in dissec- 
tion until the cyst is removed in its entirety without rupture of 
its thin membranous wall. Such a cyst, even of large size, when 
removed, should remain intact, and it should be possible to hold 
it in the palm of the hand with its perfect form complete. When 
this is done there is absolute certainty of the removal of the entire 
cyst, and there is no possibility of its recurrence. The mucous 
membrane edges of the wound surfaces are drawn together and 
sutured with gut sutures. The operation thus performed is pain- 
less and gives practically no inconvenience by reason of the few 
sutures that are necessary. With the continued use of mouth 
washes the healing takes place readily without formation of trouble- 
some scars. Other methods, such as cauterization and curettement, 
are usually less effective and sometimes more troublesome. 
Deep-seated Cysts of the Mucous Glands.-Deep-seated cysts of 
the mucous glands of the tongue arising near the foramen cecum 
and the third tonsil sometimes have long excretory ducts, and these 
cause enlargement of the parts that may be less easily distinguished 
because the symptoms are sometimes quite similar to those of 
hypertrophy of the lingual tonsil. Through contact with the 492 
TUMORS 
epiglottis they may cause irritation and give rise to a cough easily 
mistaken for a symptom of some other affection. 
Diagnosis.-The laryngeal mirror is necessary for diagnosis of 
these cysts. 
Treatment.-Their removal is effected by extirpation or cauteri- 
zation, whichever may be indicated by the conditions of the case. 
Cysts of the Glands of Blandin-Nuhn.-These sometimes appear 
on the tip of the tongue. 
Symptoms.-This form of cyst is rare and appears on the tip of 
the tongue, is quite transparent, covered with pale red mucosa, 
and may become so large as to be an inch or more in circumference. 
Treatment.-The same as described for mucous cysts. 
Fig. 256.-Ranula. 
Ranula (Frog Tongue, Sublingual Cyst).-This is a cyst situated 
under the tongue. The term ranula, as commonly used, may be 
defined as a cyst, situated under the tongue between the frenum 
and the point of the jaw which displaces the tongue upward. Pro- 
test has been made by many authors against the use of this term 
to include mucous and other retention cysts in this region, and all 
agree that it should be confined to cysts of the sublingual or 
submaxillary glands. 
Etiology.-A ranula may be congenital and due to some failure 
of development of the duct of the gland, or occlusion of the duct 
may occur at any period in life from inflammatory processes. 
Symptoms.-In the early stages the swelling is confined to one 
side with the tongue correspondingly displaced. As the ranula 
extends in size it sometimes includes the opposite side of the 
mouth, and the swelling also appears beneath the jaw and chin. 
It may be pink or grayish in color, having the appearance of a 
bladder with the vessels in a thin distended wall quite marked. CYSTOMAS 
493 
These cysts are usually filled with a light more or less viscid fluid, 
but this may vary under some conditions to dark brown color or 
may even be tinged with green or red (Fig. 256). They grow slowly 
and give little disturbance, except as size increases. Sometimes a 
ranula may become so large as to interfere with speech and the 
use of the tongue; in rare instances it may cause difficulty in breath- 
ing. Large ranula in young children may alter the form of develop- 
ment of the jaws. 
Diagnosis.-True ranula may be differentiated from mucous 
cysts of the floor of the mouth and tongue by difference in situa- 
tion; from solid tumors, such as lipoma, angioma, and lymph- 
angioma, or the more solid growths, by difference in consistency 
as well as appearance and mobility, for most tumors become more 
or less adherent. With one finger placed within the mouth under 
the tongue over the cyst and another upon the external surface 
under the jaw below it the free movability and fluctuation of the 
mass which can then be felt usually serves to make these distinc- 
tions quite evident. Confusion in diagnosis may occur when a 
dermoid cyst is situated just under the submaxillary gland and 
displaces it with the floor of the mouth and tongue upward in much 
the same way that these parts are displaced by ranula, and the 
swelling, may be so great as to make it difficult to manipulate the 
tumor within the mouth sufficiently to make an exact differentia- 
tion. Such a case is described and illustrated on p. 500 (Fig. 263). 
Prognosis.-These cysts are benign and the question of their 
recurrence is largely dependent on the success of the method of 
treatment. 
Treatment.-Complete extirpation of the ranula when not too 
large may be accomplished from within the mouth, as described 
for large mucous cysts. When the ranula is of large size and the 
surrounding parts correspondingly displaced, it is sometimes much 
better to remove it by an external incision below the jaw. When 
extirpation is not advisable the ranula may be opened and the 
cyst wall destroyed by curettement. Further destruction may be 
accomplished with carbolic or nitric acid, and packing to encour- 
age granulation from the bottom of the wound to prevent reestab- 
lishment of the cyst wall. 
The author's method of treating ranula (a modification of the 
plan suggested by Deguise) is really very simple. 
Touching the mucous membrane on each side of the swelling 
with cocain makes the passing of a needle through from one side 
to the other quite painless. A wire is thus drawn through and a 494 
TUMORS 
loop formed by bringing the ends together and fastening with a 
compressed shot. The loop is bent into such form as to give the 
least possible inconvenience to the tongue. The natural move- 
ment of the tongue is sufficient to keep the wire loop moving 
slightly so that in the course of time the holes made by the wire 
become permanent and thus continue to serve the purpose of ducts 
Fig. 257.-Illustration of a ranula with wire loop in place as described in the 
text, and performed in the case of a young girl, aged ten years and other cases. 
Although this girl had been operated upon several times before, the ranula never 
appeared again after insertion of the wire loop. 
after the wire is removed. Other methods of treatment are some- 
times very troublesome. The almost immediate recurrence of the 
swelling, after it has been incised, the danger of severe hemorrhage, 
or distressing swelling after cauterization, and other irritating pro- 
cedures are serious considerations. For example, a man who 
had been previously treated for several months without relief, was 
brought to the author, after having suffered an almost uncontroll- CYSTOMAS 
495 
able hemorrhage incident to an attempt to destroy the cyst by the 
actual cautery. In two or three minutes the wire loop was placed, 
the swelling immediately disappeared, and never recurred. Some 
months later the wire was removed. Another patient, a girl about 
ten years old was also relieved instantly and painlessly by the 
same treatment. In this case because of frequent recurrence 
malignancy had been suspected. (See Fig. 257). 
Periosteal Cysts of the Jaws.-Etiology.-These cystic cavities 
occur in connection with roots or parts of roots of teeth, or in sites 
that have formerly been affected by dento-alveolar abscess from 
which the offending tooth root may have been extracted, but with 
the cavity in the bone too large to allow sufficient drainage, and 
thus it has become filled with fluid. In recent years there has been 
much investigation of the degenerative processes whereby epithe- 
liated granulomata become cysts through concentric degeneration 
of the inner part of the granuloma, and a development and pro- 
liferation of the epithelium due to chronic inflammatory conditions. 
Undoubtedly this occurs, but all granulomata do not necessarily 
form cysts. Their contents may be pus, serum, or blood if a 
bloodvessel in connection with the cystic formation has lost its 
integrity sufficiently to allow escape of blood that is retained 
within the walls of the cyst, thus practically converting it into a 
hematoma. 
An example of this type of blood-filled cyst of the jaws is given 
in Fig. 258. The history of this cystic tumor of the lower jaw of 
a young man, aged twenty years, is as follows: The exact time 
and character of its origin was not known. It had been gradually 
forming and increasing in size for many years. Several unsuc- 
cessful operations had been performed for its removal. For five 
years past it had been opened at intervals to allow the escape of 
fluid contents. This gave temporary relief, but in a short time there 
was a recurrence. Wassermann was negative, and there was no 
unusual blood picture except slight indication of anemia, doubtless 
due to continued loss of blood. At the operation a complete extirpa- 
tion was performed. The cyst and the cyst walls including the 
external thin bony covering on the buccal side as well as most of the 
bone on the lingual side of the jaw were removed from an area 
extending from the ramus a little above the angle, to the first 
bicuspid region on the opposite side. The hemorrhage was very 
profuse, but was easily checked, and the entire surface was cleared. 
The form of the jaw was retained by a continuous packing with 
gauze until new bone formation gave sufficient rigidity, as shown 496 
TUMORS 
in Fig. 259. Undoubtedly the periosteum, which had been carefully 
preserved, was an important factor in this restoration. 
Fig. 258.-Radiograph of a cyst of the lower jaw, 
Fig. 259.-The young man for whom the cyst illustrated in Fig. 258 and described 
in the text was removed. The marks indicate the extent of the jaw involvement 
with the exception of a little bone surrounding the anterior teeth; nearly all of the 
affected portion of the jaw was removed. There has been almost complete bone 
regeneration. The outline of both sides of the jaws is symmetrical. 
The most common location of cysts of this character is in the 
region of the roots of the upper lateral incisors, but any part of CYSTOMAS 
497 
either jaw may be similarly affected. By far the vast majority of 
the hundreds of cases sent to the author for surgical treatment 
of these cysts have been more or less directly the result of septic 
conditions of the lateral incisors. Pulp devitalization from trau- 
matism, pulpitis due to exposure by caries, or other causes, lead 
to septic conditions that ultimately involve the anterior part of 
the upper jaw, in which immediately posterior to the incisor teeth 
there are the anterior palatine foramina and surrounding cancellous 
bone structure. 
Treatment such as applied by dentists through the flat, curved, 
or tortuous root canals of these teeth is insufficient, or it may be 
that the condition has been neglected, or there may have been 
failure to make diagnosis of a dead pulp caused by a blow 
where there happened to be no carious cavity to lead to its dis- 
covery. 
Symptoms.-Such cysts are painless in the absence of acute 
inflammatory symptoms. They grow slowly with gradually increas- 
ing thinness of the bony walls, which occasionally bulge out into 
the mouth in marked degree. Sometimes such cysts extend into 
the cavity of the maxillary sinus, or may similarly involve the nose 
and other surrounding parts (Fig. 258). 
Diagnosis.-The history of the case usually makes the diagnosis 
simple. There may have been devitalized teeth or roots in the 
vicinity of the cyst, discolored teeth without carious cavities that 
indicate septic pulp chambers, history of traumatic injury of teeth 
that have been previously diseased even though treated, and roots 
filled or extracted. Quite frequently there is history of repeated 
swelling and discharge of contents of the cyst and enlargement by 
outward extension of the bony wall, which is usually thin and 
yields upon pressure. There may or may not be a crackling sound, 
according to the condition of the overlying vascular supply of the 
bone surface. A radiogram makes diagnosis definite. 
Treatment.-The treatment lies in removal of the cause. Destruc- 
tion of the cyst wall, preferably with a dental or surgical engine 
bur, thorough curettement and packing. The advisability of 
extraction or treatment of the diseased root by amputation of its 
apical portion, and filling the root canal after methods well known 
to all dentists, is a question that necessarily depends upon the 
judgment of the operator. The retention of teeth, especially in 
the anterior part of the mouth, is a matter of importance. In 
many cases, however, their ultimate removal is necessary to prevent 
recurrence of the condition. 498 
TUMORS 
Follicular Odontomas.-These are also known as dentigerous 
cysts and are described on page 502, in connection with odontoma. 
Proliferous or Proliferation Cysts.-These terms are used to 
describe formations more closely analogous to true tumors than 
other forms of cysts. These growths may appear in any of the 
glandular organs, but most frequently affect the mammary gland 
and ovary. The cyst cavity contains serous or gelatinous fluid, 
sometimes called colloid material, and occasionally the contents 
are hemorrhagic in character. The inner lining of the cyst may be 
smooth or elevated irregularly with papillary ingrowths. For this 
reason they are sometimes called papillomatous cystomas. These 
cysts may be unilocular, but are usually multilocular and contain 
Fig. 260.-Multilocular cyst. 
(Westmoreland.) 
Fig. 261.-Multilocular cyst. 
(Westmoreland.) 
two or more large cysts and numerous smaller cavities. Reciprocal 
pressure may cause more or less destruction of the septa, and 
numerous loculi may communicate, thus forming a cavernous cyst. 
The cyst cavities are lined with typical or columnar epithelium and 
a stroma or recticulum of connective tissue. 
Multilocular Cysts.-Diseased roots of teeth, or follicular odon- 
tomas, may give rise to a form of cyst made up of many similar 
cysts. These sometimes attain an enormous size (Figs. 260 and 
261), which the author is able to show through the courtesy of 
Dr. Westmoreland, of Atlanta. In this case the multilocular cyst 
originated from a dentigerous cyst. These cysts are the result of 
embryonic inclusion of epithelial cells. CYSTOMAS 
499 
Diagnosis.-Diagnosis of this variety of cysts is simple, but the 
nature of these growths is not so well understood. 
Prognosis.-They are close upon the border of the malignant 
growths. The tendency to continued proliferation and growth after 
incomplete removal renders such cysts a menace. McCurdy wisely 
calls attention to the fact that proliferating cystomas, unless com- 
pletely removed, even when the remaining cysts may be almost 
microscopic, may cause recurrence, and that in such cases a wide 
and complete operation is necessary. 
Treatment.-Removal should be as complete and effective as 
possible, and a large area of bone and surrounding soft tissue 
removed beyond the outline of the cyst when its size and situation 
will permit this to be done. Total resection of the involved division 
of the jaw is recommended by many surgeons. 
Dermoid Cysts.-Dermoid cysts are congenital cysts caused by 
cutaneous inclusion or the inclusion of a blighted ovum. 
Symptoms.-They are found in many parts of the body, such as 
the ovary, base of the brain, neck, etc. Our interest centers in 
those that are found in the neck, tonsils, pharynx, hard and soft 
palates, the floor of the mouth, and dorsum of the tongue. They 
vary considerably in size. On account of the epithelial lining of 
the cyst, hair, teeth, and sweat glands are not unusual contents. 
According to Brummell,1 the hair may be several feet long, and it 
is usually of light brown color. He also claims that it whitens as 
the outer hair becomes white. Occasionally they contain bone and 
cartilage, an indication that connective-tissue products are also 
present, which points to fetal occlusion. These are called com- 
pound dermoids, to distinguish them from simple dermoids, in which 
no connective-tissue elements are present, and Coplin believes this 
form should entitle them to be classed with teratomas. 
Quite frequently the cyst wall is very thin (Fig. 262), and filled 
with more or less oily contents. 
The tumor shown in Fig. 263, before removal by the author, 
is interesting because it illustrates the difficulties of diagnosis that 
sometimes occur in these cases. The situation of the tumor was such 
as to force the floor of the mouth and the inferior maxillary gland up 
until the tongue was almost completely turned over to the other 
side of the mouth. A history of what was claimed to be surgical 
removal (an error, of course, because whatever other structures 
may have been operated upon the growth itself was not disturbed) 
1 Dental Cosmos, 1905. 500 
TUMORS 
and recurrence complicated the diagnosis. Palpation within the 
mouth was difficult on account of displacement. The submaxillary 
gland could be felt close to the surface, and for a time, in view of 
the history given, it was thought to be a tumor of this gland. 
Fig. 262-Portion of a wall of an ovarian dermoid cyst: a, wall of the cyst; b, pro- 
jecting portion made up of fatty and cutaneous tissue; c, hairs; d, teeth. (Ziegler.) 
Fig. 263.-Dermoid cyst of the neck, 
Incision following the lower border of the jaw and another one 
just anterior to the sternocleidomastoid muscle made it possible 
to expose the mass and enucleate the cyst with little difficulty. 
Recovery was complete and uninterrupted. ADULT EPITHELIAL TUMORS 
501 
Prognosis.--These cysts are chiefly of interest because of their 
possible explanation of unusual conditions that from time to time 
arise in and around the buccal cavity. But they are benign, and 
except when of large size and in dangerous situations removal is a 
comparatively simple matter. 
Parasitic Cysts.-Echinoccus Cysts.-In rare instances hydatid 
cysts have been found in the mouth caused by Taenia echinococcus 
or dog tapeworm. These usually gain entrance in the intestinal 
tract, and in rare instances form cysts in the buccal mucous 
membrane. 
Bertele and others report finding these cysts in the temporal 
and masseter muscles.1 
ADULT EPITHELIAL TUMORS. 
Odontoma.-An odontoma is a tumor composed of one or more 
of the dental tissues arising either from tooth changes or teeth in 
process of development. 
Etiology.-The causes are perversion of development leading to 
diversion of the structures or cellular elements from which tooth 
germs are developed resulting in abnormality of form and character 
through which several kinds of tumors occur. 
Classification.-Broca divides odontomas according to the stage 
of development of the dental- follicles at which they occur. In 
the first or embryoplastic stage the tumor developing in the dental 
sac when the latter is composed of mucous tissue results in a pure 
myxoma. When connective tissue is included it results in a fibrous 
odontoma. 
In the second or odontoplastic stage soft tumors may occur, but 
these have a tendency to become hardened. 
The third period results in tumors the composition of which 
represents calcified tooth structures. When occurring in this stage 
the tumor is composed of structure resembling calcified tooth 
structures. These are subdivided into crown and root formations, 
and may be still further distinguished by indicating whether com- 
posed of enamel, dentin, or cementum, or a composite combination 
of these. 
Sutton's classification, which will be used in further description, 
is designed to distinguish the several forms of odontoma. Clini- 
cally the essential difference lies in differentiation between the 
1 Bulletin of von Bergmann, p. 521. 502 
TUMORS 
forms which result in soft tumors and those of hardened tooth 
structure, and in considering diagnosis and treatment this general 
division is the one principally required. 
Odontoma forms a notable example of the exceptions that must 
necessarily occur in all tumor classifications, viewed in the light 
of our present imperfect knowledge of true etiology. It is true 
that teeth are developed from epiblastic and mesoblastic structures, 
and for this reason odontoma cannot be classified with the epithe- 
lial group in a strict sense. On the other hand, it is of the adult 
typical type, and for this reason it does not seem advisable to 
classify it with the teratoma or mixed epithelial and connective- 
tissue tumors, because these are both adult and embryonic, whereas 
the odontoma is adult and therefore benign. Sutton classifies the 
different forms of odontoma as follows: 
Epithelial Odontoma.-These develop from the remains of the 
epithelium of the original enamel organ. 
Symptoms.-They appear in the form of a series of cysts sepa- 
rated by thin septa and contain mucoid fluid. The color during 
growth is slightly red and not unlike sarcoma. 
Follicular Odontoma or Dentigerous Cysts.-Etiology.- 
They usually form in connection with developing permanent teeth. 
Symptoms.-The bony walls become thin from the formation of 
fluid within the cyst and sometimes bulge out in such manner as 
to cause great deformity. The inner wall of the cyst represents 
the remains of the dental follicle within which in every instance 
there is a tooth or part of a tooth. The cyst is filled with fluid, 
usually serous or mucoid, but occasionally of dark brown color. 
Ordinarily these do not become purulent, but occasionally through 
infection this does occur, and may result in severe inflammatory 
conditions (Figs. 264 and 265). 
Fibrous Odontomas.-Fibrous odontomas are developed from 
the connective-tissue elements of the developing tooth by excessive 
growth of the fibrous capsule of the tooth germ which is derived 
from and closely adherent to the connective tissue of the papilla. 
Symptoms.-The tumor has a firm outer wall with less firmly 
connected inner structure, which blends at the root of the tooth 
with the dental papilla and is indistinguishable from it. In this 
way the developing tooth becomes enclosed within the capsule. 
These tumors are quite frequently seen in animals, especially 
ruminants, etc. (Fig. 266). 
Cementome.-This is a tumor in which by calcification of the 
capsule the tooth becomes embedded in a mass of cementum. ADULT EPITHELIAL TUMORS 
503 
Symptoms.-Cementomes sometimes attain great size. Their 
structure resembles cementum, and is arranged in layers somewhat 
Fig. 264.-Cyst of the lower jaw, having its origin about an undeveloped tooth. 
(Garretson.) 
Fig. 265.-Dental cyst, lower jaw. 504 
TUMORS 
similar to fibrous odontomas. They are rare in human teeth and 
usually occur in the mammalia. Marshall reports a tumor in the 
Fig. 266.-Fibrous odontome, 
(Garretson, after Pierce.) 
Fig. 267.-Radicular odontome. 
(Tomes.) 
Fig. 268.-Composite odontome. 
Fig. 269.-Composite odontome. (Gilmer.) 
mouth of a horse five and three-quarters inches by four and one- 
quarter inches in size, which ultimately caused the death of the 
animal. ADULT EPITHELIAL TUMORS 
505 
Radicular Odontomas.-These tumors form after the develop- 
ment of the crown and during the process of root formation. They 
consist of cementum and dentin in varying quantities, are rare in 
men, but frequent in animals (Fig. 267). 
Composite Odontomas.-These are abnormal growths of all the 
elements of tooth structure, resulting in ill-deformed masses of 
cementum, dentin, and enamel. Thus far they have been only 
found in man (Figs. 268 and 269). 
Compound Follicular Odontomas.-The follicle wall becomes 
thickened into a fibrous capsule. In this there may be portions of 
dentin, enamel, or cementum. Imperfectly or more or less imper- 
fectly formed teeth are all together a heterogeneous mass. Fig. 
270 shows photograph of a compound follicular odontoma which 
contained eleven teeth (Dr. Weeks' case). Rudimentary or other 
teeth have sometimes been found in very large numbers; as many 
as several hundred have been taken from the jaws of one person. 
Fig. 270-Compound follicular odontoma. 
Diagnosis.-Myxomatous and fibromatous forms of soft odon- 
toma, both of which are formed during the embryoplastic or 
odontoplastic periods, are frequently difficult to differentiate from 
other tumors of the jaw, notably cysts, fibroids, and sarcoma. 
The diagnostic guides are slow growth, freedom from pain, 
irregular surface; on section, masses of cement or dentin may 
occasionally be found to be encapsulated. 
Of the hard forms, dentigerous cysts are usually discovered by 
the yielding of the thin bulging wall on pressure, with perhaps a 
crepitant sound; puncture to reveal the character of the fluid 
contents, and on opening a tooth is revealed in cystic enclosure. 
Radicular odontoma, cementome, or composite odontoma can 
usually be diagnosticated with sufficient accuracy to determine 
that the growth is not bone by passing a sharp, light steel probe 
through the overlying tissues until it comes in contact with the 
smooth, dense, more or less irregular surface of the tumor, which 
is recognized by sense of touch. 506 
TUMORS 
This much understood and some form of odontoma looked for, 
its exact character may be determined after removal. 
When doubt exists in differentiation between soft odontoma and 
malignant growths, sections prepared for the microscope must be 
depended on for the final distinction. As there is always a possi- 
bility of benign growths assuming malignant form, such examina- 
tion should be made as a precautionary measure, even when there 
may be reasonable certainty that no such complication exists. 
It is the author's custom as a matter of routine practice to have 
even bony enlargements in the vicinity of impacted teeth or odon- 
toma decalcified and submitted to microscopic examinations, as 
well as surrounding portions of soft tissue. It has often happened 
in his experience that the former sites of these apparently benign 
conditions have given rise to both sarcomatous and carcinomatous 
growths. 
Differentiation from odontoma and exostosis is sometimes ren- 
dered difficult because of the extreme density that these bony 
formations acquire. Actinomycosis or chronic bone diseases, such 
as tuberculosis, syphilis, and other affections in which there are 
alterations in the external form of bone surfaces with tendency to 
bone abscess, are best distinguished by bacteriological examination 
of the contents of the cyst and consideration of the symptomatology 
of the suspected disease. 
In the diagnosis of all forms of odontoma, radiographs are advan- 
tageous, as such tumors show plainly in such pictures, and the 
operation is often simplified by exact knowledge of the size and 
form of the odontoma before removal. Great care should be exer- 
cised to determine with certainty that any growth of similar appear- 
ance upon or in the jaws is not an odontoma or other benign 
tumor before radical excision is performed for a supposed malignant 
neoplasm. Such errors have not infrequently occurred. 
Prognosis.-Odontomas are benign, and the prognosis is gener- 
ally favorable, but inflammatory necrotic or malignant processes 
may follow in their wake. If completely removed, with thorough 
extirpation of the epithelial and connective-tissue elements, there 
is no tendency to recur. This is especially necessary with compound 
follicular odontomas. 
Treatment.-The treatment of odontoma of every variety is 
complete removal of the growth, destruction of the cyst walls, and 
postoperative treatment designed to allow the wound cavity to 
fill in by granulation. 
Almost always these operations can be thoroughly and suffi- ADULT EPITHELIAL TUMORS 
507 
ciently performed from within the mouth, and this should be done 
whenever possible. Occasionally the situation of the growth is 
such as to make external incision not only more effective but more 
direct, and therefore much simpler. Dentigerous cysts require the 
removal of the external wall as completely as possible, and the 
cystic cavity should not only be freed from its contents, including 
the encysted tooth elements, but the entire cyst wall should be 
destroyed at every point. It is the author's practice to accomplish 
this thoroughly with a surgical or dental engine bur, with which 
walls, both bony and membrane of the cyst, can be quickly and 
completely removed. The cavity thus converted as nearly as 
possible into a saucer-shaped form is easily packed. It may be 
expected to fill in by granulation from the bottom without danger 
of the external opening, closing first, as sometimes happens when 
too small an opening is made, and thus causing a recurrence of 
cystic conditions. 
Papilloma or Wart Tumor.-This form of growth, formed from 
cutaneous and mucous papillse, consists of a fibrous stroma or stem 
containing bloodvessels and lymphatics covered by an epithelial 
investment. 
Etiology. - Chronic irritation with a low-grade inflammatory 
process as generally accepted is the most common cause. Irritat- 
ing discharges, as from diseased conditions and especially from 
genital and anal borders, are also etiological factors. In the mouth, 
rough or sharply projecting tooth borders, ill-fitting crowns and 
bridges, imperfect interproxiniate spaces due to carious cavities or 
ill-fitted fillings, or artificial dentures and similar conditions leading 
to local irritation, may cause papillomatous growths. In addition 
to all of the recognized forms of irritation which cause papillomas 
there appears to be some other not understood reason for their 
spontaneous appearance without recognizable external causes. 
Varieties.-(1) Skin warts. (2) Villous warts. (3) Intracystic 
warts. 
Skin Warts.-Skin warts are overgrown papillae with the epithe- 
lium passing from one papilla to another in unbroken line without 
invading the fibrous framework. They may be single or multiple, 
vary in color by becoming mottled with black pigment, attain 
great size, and become cystic. 
Symptoms.-Papillomas have a structure of connective tissue 
with an epithelial covering which passes from one papilla to another 
in an unbroken line without invading the fibrous framework, and 
this has led to some confusion in classification. 508 
TUMORS 
They present the appearance of ordinary warts, and may be 
single or multiple. They are usually sessile, but may assume a 
cauliflower appearance. They are of variable size, occasionally 
very large, and of different color through pigmentation, and may 
become cystic. 
Soft Warts.-The papillomas that form upon mucous mem- 
brane usually have a cauliflower appearance. About the genitalia 
they sometimes become exceedingly prolific, and are called mul- 
berry growths. 
Villous Papilloma.-Villous warts are usually found in the 
bladder, pelvis of the kidney, and similar situations. 
Symptoms.-They appear in the form of long feathery tufts, 
have a connective-tissue core, which is filled with bloodvessels, 
and are covered by epithelium. 
They may be single, multiple, sessile, or pedunculated. Serious 
hemorrhage and even death has been known to result from rupture 
or detachment of a villous papilloma. 
Intracystic Villous Papilloma.-Intracystic warts occur 
within cysts lined with epithelium in glands such as the mammary, 
ovary, and thyroid. 
Cutaneous Horns.-These are epithelial growths and, accord- 
ing to Sutton's classification, are met with in four varieties: 
1. Sebaceous horns are formed by the contents of sebaceous cysts 
exposed to the air by rupture or disease and dried with progressive 
extension of the growth as the process is continued. 
2. Warty horns which grow from warts instead of sebaceous 
glands. These growths usually occur about the head or face, and 
are much more common in the lower animals than in man. 
3. Horns growing from cicatrices, extensive growths, from the 
cicatrices of burns have been reported. 
4. Wart horns are overgrown nails upon the fingers and toes of 
individuals who from any cause have become incapacitated and 
unable to use the parts. 
Symptoms-Rare and somewhat famous cases of horns of 
unusual length have been reported and illustrated in many text- 
books, showing growth of twelve or more inches, and nails of 
unusual length. Interesting as these may be, the really important 
aspect of this subject for our present purpose lies in the papillomas 
so frequently found in the buccal cavity which require careful 
differentiation from malignant growths. 
Symptoms of Papillomas of the Mouth.-These growths are fre- 
quently found upon the dorsum of the tongue, the buccal surfaces ADULT EPITHELIAL TUMORS 
509 
of the cheeks, the gums, particularly in the vicinity of ill-closing, 
interproximate spaces, and the soft palate. They may be small or 
Fig. 271.-Papilloma of the gum. 
Fig. 272.-Papilloma of the gum. 510 
TUMORS 
increase until their size becomes a matter of serious inconvenience. 
The cauliflower form may or may not be evident. The color is 
red, pink, or grayish. The growth is usually quite firm, and some- 
times might be termed hard when covered by squamous epithelium 
(Plates XI and XII). 
Prognosis.--Papillomas are benign growths, and once completely 
removed show no tendency to recur. The danger, as has already 
been indicated, lies in their occasional tendency to become trans- 
formed into sarcomas and, particularly when occurring upon the 
tongue, into cancer. When growths occur in the latter and the 
urethral orifice, rupture of the delicate connective-tissue matrix 
causes serious or fatal hemorrhage. 
Treatment.-Complete extirpation is the only trustworthy 
remedy. The growth should be removed down to and including 
the periosteum, and in order to be safe, tissue should be excised a 
little beyond the line of demarcation of the growth at all points. 
The possibility of development of malignant characteristics in 
these growths should be borne in mind, and the microscope depended 
upon to make the final diagnosis of a benign condition, or the 
reverse. 
Figs. 271 and 272 are examples of many cases in the author's 
practice, all of which were difficult to distinguish from sarcoma 
until the verdict of the microscope settled the question. Subse- 
quent history has confirmed the findings. 
Adenoma.-This form of tumor is constructed upon the type 
of a gland without power to produce the secretion peculiar to the 
gland tissue or type from which it springs, and it has no ducts 
that communicate with the normal gland. They are benign, but 
contain both connective tissue and epithelial cells, which renders 
transformation into sarcoma and carcinoma not only possible but 
extremely likely. They may develop in any glandular structure, 
and may contain any glandular tissue. 
Classification.-The two principal varieties are: 
1. Acinous Adenoma.-These are tumors having acini lined with 
small epithelial cells. The acini communicate with each other, are 
grouped together, and separated by a connective-tissue matrix con- 
taining bloodvessels. This form is exceedingly rare, but fibro- 
adenomas are quite common. 
2. Tubular Adenoma.--This form is quite commonly found in 
mucous membranes possessing tubular glands. It is soft, slightly 
translucent, and somewhat vascular, and exceedingly likely to 
become malignant. PLATE XI 
FIG. 1 
Papilloma of the Tongue. 
FIG. 2 
Papilloma of the Gum. PLATE XII 
Photographic Reproduction of Papilloma. Low Power. (Gaylord.) ADULT EPITHELIAL TUMORS 
511 
The chief species are mammary, sebaceous, thyroid, prostatic, 
parotid, hepatic, renal, ovarian, testicular, gastric, Fallopian, and 
uterine. 
Etiology.-Their origin is believed to be due to some quiescent 
congenitally displaced rudiment. Irritation doubtless plays some 
part in the causation of these as with other tumors. 
Fig. 273.-Unusual epithelial tumor of the palate. (After New.) 
Symptoms.-Adenomas of the mucous membrane of the mouth 
usually occur upon the lower lip and cheeks in the form of smooth, 
firm, nodular enlargements beneath the mucous membrane, but 
slightly adherent. They are usually encapsulated, are not painful, 
grow slowly, and except in rare instances give slight inconvenience, 
unless when in the course of years they attain unusual size, or 
ulcerate or assume malignant character. Occurring as they some- 
times do upon the soft palate, the sound of voice or breathing may 
be more or less affected. Such tumors may attain the size of a 512 
TUMORS 
hen's egg. They are occasionally found at the base of the tongue 
or near the foramen cecum. These, as reported by Wolff, Chamisso 
de Boncourt, Benjamin, Watson, Tewels, and others, were all 
discovered in young women. They were invariably situated in 
the median line, with a smooth, slightly notched surface, elastic, 
and with vascularity well marked.1 They have been found to con- 
tain thyroid tissues, and have been termed accessory thyroid tumors. 
Fig. 274 (same as Fig. 273).-Areas showing the cells' nests. In other areas the 
central part of the nests has dropped out, leaving the outer layer of cells. (After 
New.) 
Differential Diagnosis.-Adenomas must be differentiated from 
glandular enlargements, which are simply an increase of natural 
glandular elements, from retention cysts, and inflammatory con- 
ditions. The distinction between adenoma and carcinoma is often 
very slight. 
"As soon as the epithelial cells lose their regularity of disposi- 
tion and collect in groups, or make their way outside of the acini 
1 Von Bergmann: System of Practical Surgery, i, 859. ADULT EPITHELIAL TUMORS 
513 
into the tissues, then the change from the benign to the malignant 
tumor has begun, and the entire clinical aspect of the case is altered. 
This change may be the result of external irritation, of such tissue 
changes as pregnancy and lactation, or of the undivided changes 
which advancing years seem to produce."1 
Prognosis.-With true adenoma the prognosis is favorable and 
there is little if any likelihood of recurrence. 
Treatment.-The extirpation of the growth is usually effected 
through the mouth. At the base of the tongue under unusual 
conditions some of the operations described (pages 606 and 609) for 
removal of growths in that region may be required. 
Fig. 275.-Adenoma of the palate of a young woman. There was no recurrence 
after its complete surgical removal, which was accomplished without entering the 
nasal cavity. 
Neuroma.-A neuroma is a tumor consisting almost entirely 
of nerve tissue. 
Varieties.-The term, used in a strict sense, applies to a very 
rare form of tumor, but as commonly applied includes tumors 
containing nerve elements and fibrous tissue. These are more 
properly termed false neuromas. Plexiform neuromas appear in 
the form of nodules along the course of the nerve or in a nerve 
plexus (Fig. 276). 
Ganglionic neuromas are tumors composed of or containing gan- 
glion cells. Myelinic neuromas contain newly developed medullated 
1 Park: Modern Surgery, p. 284. 514 
TUMORS 
fibers. Amy clinic neuromas are formed of non-medullated nerve 
fibers. These belong to the false neuromata because the new tissue 
Fig. 276.-Plexiform neuroma, dissected free from all adherent tissues. (Lexer.) 
Fig. 277.-Multiple neuroma. Nerves of the arm, the lumbar plexus, and the 
sciatic nerve. Specimen from the Museum of the College of Physicians and Surgeons. 
(Starr.) ADULT CONNECTIVE-TISSUE TUMORS 
515 
Etiology.-The causes of neuromas are injuries to the nerves, 
such as amputation, which leads to amputation neuromas or bulbous 
masses at the cut ends of nerves. Heredity is supposed to be 
accountable for the multiple fibromas of superior superficial 
nerves. 
Symptoms.-Both the cranial and spinal nerves are subject to 
this affection. Park believes the sensory nerves are more likely to 
become attacked than the motor. The nerve least often attacked 
is the optic. The fifth nerve, through operations for neuralgia and 
by reason of exposure to injury at various points, is subject to 
nerve tumor. Pain, loss of sensation, paralysis, or muscular spasm 
may be objective symptoms according to the nerve or nerve branch 
that may be involved (Fig. 277). 
Prognosis.-Neuromas are benign growths, but many of them 
are sarcomatous from the beginning, and in others malignancy is 
developed as the growth proceeds. The result of treatment will, 
of course, be dependent upon the situation of the tumor and the 
nerve affected and the character of both. 
Treatment.-Excision is the only remedy when the exact location 
of the tumor can be determined, providing its situation is such as 
to make operation possible. The paralysis following operation 
upon the nerve trunk may sometimes be overcome by nerve suture, 
grafting, and similar treatment. 
Glioma.-Gliomas are tumors derived from the sustaining 
tissue of the central nervous system (the neuroglia) and composed 
of glia cells, more or less closely maintaining the normal elements. 
The sites of these tumors are the brain and cord, optic nerve and 
retina, olfactory lobe. They therefore do not require description 
among the tumors of the mouth. 
ADULT CONNECTIVE-TISSUE TUMORS. 
Lipoma or Fatty Tumor.-Etiology.-Heredity seems to have a 
marked influence. Multiple lipomas have been known in families, 
and inherited tendency has been transmitted through several 
generations.- In some cases the tumor is congenital. 
Varieties.-The principal varieties are: Encapsulated, enclosed in 
an exceedingly thin capsule, and diffuse, when the margins are 
not clearly defined. 
Symptoms.-These growths are rarely found in the mouth. 
Knack, upon a study of the literature, collected reports of 29 cases 516 
TUMORS 
of lipoma in the oral cavity, 12 on the tongue, 9 on the floor of 
the mouth, 7 on the lips, and 1 on the gums and soft palate.1 
"In the mouth these growths are usually under the mucous 
membrane of the floor of the mouth and originate deep within the 
muscular layers. The overlying mucous membrane is not adherent, 
and the light yellow color of the lipoma can be indistinctly seen 
through the altered mucous covering. 
''Lipomata of the cheek are situated in the submucous layer and 
easily distinguished from large lipomata of the skin." 
Prognosis.-They are benign and do not recur unless of mixed 
nature. 
Treatment.-This consists in complete extirpation. 
Chondroma (Enchondroma, Enchondrosis, Chondroid, Chon- 
droid Exostosis) .-This tumor is composed largely or entirely of 
cartilage. 
Etiology.-Congenital tendency appears to be hereditary in some 
cases. Irritation as a causal factor is indicated by formation of 
cartilage in the tendons of muscles subject to frequent irritation 
and traumatism by outgrowths of cartilage from bones that have 
been injured or fractured. According to Virchow,2 chondromas 
often spring from remnants or islands of cartilage left in abnormal 
situations. 
Varieties.-(1) Cartilaginous outgrowths, ecchondrosis or ecchon- 
dromas. (2) Cartilaginous tumors or true chondromas which 
originate in non-cartilaginous structures. 
Symptoms.-The tumors occur most frequently on the metacar- 
pal bones and phalanges of the hands, less frequently in other long 
bones, and somewhat rarely upon bones of the face. They are not 
infrequently found in soft parts, as the tendons of muscles, salivary 
glands, tonsils, and other glands of the body. In rare instances 
metastases have been known to occur in the lungs, spleen, brain, 
liver, and heart as reported by Michaeloff3 who collected 14 such 
cases. 
Prognosis.-The prognosis is good. The tumor is benign, grows 
slowly, does not recur after removal, and has almost no tendency 
to metastasis; mixed forms of cartilaginous tumor which are quite 
common may present a more serious aspect. Fig. 278 is an illus- 
tration of gum tissue in the region of the third molar tooth that 
shows the beginning of such a growth. 
1 Von Bergmann: System of Practical Surgery, i, 156. 
2 Stengel: Text-book of Pathology, p. 154. 
3 Coplin: Manual of Pathology, p. 340; Quotation from Patel: Rev. Chir., March 
10, 1904, p. 398. ADULT CONNECTIVE-TISSUE TUMORS 
517 
Treatment.-Surgical removal is indicated whenever the situation 
or threatening aspect of the tumor requires such treatment. 
Osteoma.-Osteoma is a tumor composed of bony tissue. 
Etiology.-Unusual stimulation of the periosteum by irritation, 
traumatic injury, or diseased conditions are among the causes. 
Varieties.-Exostosis, growth from the external surfaces of the 
bone. Enostosis, growth from the internal structure of the bone. 
These may be eburnated, or very hard, compact, or similar to com- 
pact bone structure, and cancellous or spongy. 
Fig. 278.-Gum tissue from the region of an impacted lower third molar, 
showing cartilage formation. 
Sympton s.-They are most commonly found in connection with 
the periosteum of bone, medulla or cartilage, but also occur in 
soft parts of the body, as in the brain structures, diaphragm, 
coat of the eye, air passages, lymph nodes, nerve centers, and 
tendons.1 These may give much or little trouble, according to 
their situation, may grow into the interior of the skull, the frontal 
or other sinus, the cavity of the orbit or the nose. In such situations 
they may give rise to disturbance; otherwise they are painless and 
grow slowly. They sometimes lead to inflammatory conditions 
1 Coplin: Manual of Pathology, p. 341. 518 
TUMORS 
resulting in necrosis and more or less extensive loss of bone 
structure. 
Prognosis.-The prognosis is good, although the question of 
recurrence is necessarily dependent upon correction of the exciting 
cause, as well as removal of the growth. Occasionally such tumors 
become carcinomatous. 
Treatment.-Treatment consists in removal. Complete excision 
of the affected bone. Fig. 279 shows a section of an osteoma of the 
lower jaw in a woman, aged forty-nine years, excited by an impacted 
unerupted tooth. 
Fig. 279.-Osteoma of the lower jaw. 
Fibroma.-Fibromas are tumors composed of wavy bundles of 
fibrous tissue. 
Etiology.-The causes of fibroma, as of other tumors, are more 
or less enshrouded in mystery, but clinically the influence of irri- 
tations is an important factor. This is shown by the frequent 
development of fibromas in old scars or situations that have been 
exposed to injury or chronic irritation. 
Symptoms.-Fibroma may be hard or soft and occurs in many 
different situations and structures of the body, but most commonly 
in the ovary, uterus, the intestines, the gums, nerve sheaths, and 
skin. Hard fibroma is usually oval and globular, smooth, movable, 
and painless, unless attached to a nerve. The soft fibroma is ADULT CONNECTIVE-TISSUE TUMORS 
519 
very similar except that it is more yielding and elastic. Pure 
fibroma is somewhat rare. Most fibromas are in combination with 
other tissues. Simple fibroma of the skin presents a nodule about 
the size of a pea, is of firm consistence and situated loosely in the 
Fig. 280.-Keloid. (Hardaway.) 
tissue immediately under the integument. These are exceedingly 
painful. 
Neurofibromatosis is a rare condition in which there is over- 
growth of fibrous tissue in connection with nerves. True keloid 520 
TUMORS 
is most common in the negro, and is composed of bundles of coarse 
fibers in the chorium, the papillae and epidermis being intact. 
Cicatricial keloid develops in the substance of a scar, and is 
not covered by the papular layer. It is the bete noir of surgeons, 
as it occurs in the scars of sutures and wounds that in the beginning 
may have been very slightly noticeable and shows a tendency to 
recur after it has been removed (Fig. 280). 
Fig. 281.-Negro with keloid on both 
cheeks. (Surgical Clinic of the Southern 
Dental College, Atlanta, Ga.) 
Fig. 282.-Side view of negro, showing 
keloids on cheek and neck. (Surgical Clinic 
of the Southern Dental College, Atlanta, 
Ga.) 
Prognosis.-The prognosis is good. They do not recur after re- 
moval, do not give rise to metastasis, and unless in combination with 
malignant growths are not dangerous except through pressure upon 
the vital parts or interference with the function of important organs. 
Treatment.-Surgical removal is being generally supplanted by 
x-ray or radium treatment, which in cases such as those illustrated 
in Figs. 281 and 282 will insure a better result without fear of 
creating noticeable deformity. 
Myoma.-Myomas are tumors composed of muscle tissue; 
strictly speaking, a leiomyoma or myoma levi cellulare, or when 
composed of non-striated muscle fiber, because many modern 
writers discourage the use of the term "rhabdomyoma," used to 
describe tumors of striped muscle fiber, because this exceedingly ADULT CONNECTIVE-TISSUE TUMORS 
521 
rare form, usually found in the kidney and the uterus, is seldom 
or never a true myoma. 
Etiology.-As with other tumors, there is indication in some of 
misplaced embryonic elements, and in others irritants appear to 
have an undoubted part in causation. 
Symptoms.-They are commonly found in the gastro-intestinal 
tract, uterus, and skin, and according to Coplin are also found more 
or less frequently in the tongue. They may be very small nodules 
or of enormous size, weighing GO to 70 pounds. Williams reports 
one removed by severance weighing 195 pounds. They may be 
single or multiple, and when arising from submucous or subserous 
tissue may be polypoid and hang by a small pedicle. They are 
surrounded by a capsule and quite hard unless altered by secondary 
degenerations, which may be cystic or calcific, with corresponding 
alteration in the character and growth. 
Prognosis.-They are benign and grow slowly. Their only danger- 
ous features occur through interference with other parts by reason 
of their enormous size and the pressure sometimes occasioned, and 
through degenerative changes, to which they are quite subject. 
Treatment.-The treatment consists in surgical extirpation. 
Fig. 283.-Angioma of the lip. (West- 
moreland.) 
Fig. 284.-Same boy shown 
in Fig. 283 after operation. 
(Westmoreland.) 
Angioma.-Angiomas are tumors composed of bloodvessels. 
Coplin uses the term angioma, and includes both blood- and lymph- 
vessel tumors, distinguishing the bloodvessel tumors by the term 
hemangioma. 
Classification.-1. Capillary Angioma (Nevus, Port-wine Marks, 
Telangiectasis).-It is usually congenital. They appear upon the 522 
TUMORS 
skin and subcutaneous tissue in all parts of the body, on the surface 
and the submucous surface of the tongue, inside of the mouth, 
conjunctiva, and in similar situations. Sometimes they spread 
over a relatively large area. 
2. Cavernous angiomas are sometimes called erectile tumors. 
They are occasionally found in the tongue, voluntary muscles, 
larynx, and thyroid, but chiefly upon the skin, and are exaggerated 
forms of capillary angioma (Fig. 285). 
3. Arterial or Plexiform Angiomas.-In these arteries of unusual 
number and character occur in the scalp, occasionally the perineum, 
but rarely in other parts of the body. 
Fig. 285.-Angioma of the gum and palate. (Campbell.) 
Diagnosis.-The diagnosis of angioma is, as a rule, quite simple. 
The discoloration of the skin, recession of blood upon pressure and 
murmur usually make recognition quite plain. In the mouth, 
however, these tumors are not always easily differentiated. The 
author has had many cases like the tumor from an edentulous 
portion of the alveolar ridge of the lower jaw of a woman of middle 
age. Its appearance was not unlike other tumors found in similar 
situations. The history of repeated removal and recurrence con- 
fused the diagnosis until cleared up by the microscope. 
Prognosis.-The prognosis is good. They are benign, but fre- 
quently become the seat of malignancy. 
Treatment.-Surgical removal when the vessels are much dilated 
must not only include a careful dissection of the tumor, but ligation 
of the deeper vessels of supply to prevent recurrence and to check 
immediate hemorrhage. 
The smaller forms may be successfully treated with the electric 
needle, depending upon coagulation of the blood, organization of ADULT EPITHELIAL TUMORS 
523 
a thrombus, and formation of cicatricial tissue as a result of the 
effect of the electric current. Within the mouth, it is the author's 
belief that the most effective way in many cases is by the use of 
the actual cautery. The ligation of vessels supplying the part for 
the purpose of cutting off the blood supply and causing gradual 
reduction of the tumor is not so often employed at the present time 
as formerly. The disfiguring effect of nevi upon the face is some- 
times overcome by removal by careful dissection of the affected 
skin surface and the grafting of new skin upon the denuded area. 
More recently the x-rays have been used with reported good 
results in some cases, also the actinic rays of the Finsen lamp. 
The latest encouragement, however, comes from the use of liquid 
air and carbon dioxide snow. 
Lymphangioma.-Lymphangioma is a tumor composed of dilated 
lymph vessels or lymph spaces. 
Classification.-There seems to be some confusion among authors 
with regard to the distinction in classification of the varieties of 
lymph tumor. It is sufficient for 
our present purpose, however, to 
recognize the following principal 
forms: 
Elephantiasis congenita mollis, in 
which the subcutaneous tissues are 
edematous and may contain dis- 
tinct cystic formations, as in con- 
genital enlargement of the tongue. 
Congenital cystic hygroma is a cys- 
tic formation of the lymph spaces. 
Macroglossia or lymphangioma 
of the tongue. Sometimes the 
tongue is so large as to protrude 
from the mouth, as shown in 
Figs. 286 and 335, p. 611. 
Macrocheilia is the same affec- 
tion of the lip as shown in Figs. 
368 and 369, pp. 646 and 647. 
Nevus lymphaticus, small, closely aggregated, deep-seated, trans- 
parent vesicles varying from a pinpoint to that of a hemp seed. 
When picked, lymph or blood-stained lymph flows from them. 
Symptoms.-The symptoms consist in congenital enlargement 
of certain parts which appears to be entirely due to abnormal 
development of lymph spaces. 
Fig. 286.-Macroglossia. 
(Westmoreland.) 524 
TUMORS 
Treatment.-Surgical removal when necessary is indicated. In 
case of the tongue it is advisable to remove a portion, and if possible 
to preserve the organ in such form as to enable it to fit properly 
within the mouth. 
Fig. 287.-Lymphangioma of tongue. Girl, aged twelve years, treated at the 
Mayo Clinic and reported by Dr. Gordon B. New. She was treated with radium for 
two hours daily with the 22 mg. tube, with no screening, for a period of twelve days. 
Previous r-ray treatments had made no improvement. 
Fig. 288.-Tongue of same girl 
shown in Fig. 287 after treat- 
ment. 
Fig. 289.--Lymphangioma of the tongue 
of a boy, aged two and a half years, treated 
at the Mayo Clinic and reported by Dr. 
Gordon B. New. He was treated two 
hours daily with a 28 mg. tube of radium, 
unscreened, for a period of ten days. 
Gordon B. New, of the Mayo Clinic, reports the successful treat- 
ment of lymphangioma of the tongue with radium. He prefers 
raidum treatment to surgical measures, because excision of the 
tongue tissue is so likely to leave that organ stiff and board-like 
from scar formation. (See Figs. 287-290.) 
Macrocheilia requires exceedingly careful operative treatment 
to remove the unusual thickness of the lip and yet preserve the ADULT EPITHELIAL TUMORS 
525 
cosmetic effect of the border of the prolabium without stiffening 
the lip or altering its appearance during speech and laughter. 
Lymphoma.-Lymphoma is a tumor of the lymph node. This 
term is applied to the glandular enlargements of tuberculosis, 
syphilis, and other infectious diseases. They are usually apparent 
in the lymph nodes of the neck, groin, and maxilla. The character 
of the disease is, as a rule, indicated by such terms as syphilitic 
lymphoma, tuberculous lymphoma, etc. 
Treatment.-Treatment is that of the local treatment of an 
inflammatory process and that of the disease by which it is caused. 
Fig. 290.-Same boy shown in Fig. 289 after treatment. 
Lymphadenoma (Hodgkin's Disease, Pseudoleukemia).-Lym- 
phadenoma is a malignant newgrowth. 
Etiology.-It was generally accepted as being sarcomatous, 
although there were many reasons for assuming that it is sometimes 
of tubercular origin until Bunting and Yates discovered the B. 
hodgkini as described on p. 482. 
Symptoms.-In the beginning, painless enlargement of the lymph 
nodes of the neck occurs. These at first are freely movable and 
without tendency to suppuration or degeneration. Later it extends 
to glands in other regions. The nodes become fused into irregular 
masses sometimes of large size and cause disfigurement. There is 
enlargement of the spleen, anemia, progressive anemia, and death. 
Diagnosis.-Its diagnostic importance lies in the necessity for 
differentiation from other affections of the glands in the region of and 
surrounding the buccal cavity (see p. 482, and Figs. 254 and 255). 
Prognosis.-Death usually results. 526 
TUMORS 
Treatment.-Treatment is unsatisfactory. Arsenic in early 
stages, removal of the individual glands, and the use of the .r-rays. 
They are all recommended. 
Fig. 291.-Face of young woman in whose case nearly all of the lower jaw was 
removed from the ramus on the left side to the molar region on the right for the 
removal of the myxoma shown in Fig. 292. Preservation of the periosteum which 
was permitted on account of the character of the growth and retention of the form 
of the jaw during healing process resulting in new bone formation so that the girl 
is now able to wear a lower set of teeth on the newly formed jaw and is only slightly 
shorter on the left side instead of having the great deformity that would otherwise 
have resulted. 
Myxoma.-Myxoma is mucous tissue tumor. 
Etiology.-The causes of myxoma are identical with those of 
fibroma, and combinations of the two render radical distinctions 
impossible. 
Fig. 292.-Same girl shown in Fig. 291 before the removal of the myxoma, showing 
the extent of the jaw involved. 
Symptoms.-It appears as a homogeneous structural gelatinous 
mass, grayish or reddish white in color, and composed of a gelat- MALIGNANT GROWTHS 
527 
inoid or whitish mucilaginous material. When arising in sub- 
mucous or cutaneous or subcutaneous tissues they may be pedun- 
culated and in the form of a distinct polyp. A pure form of nasal 
myxoma occurs in polyps of the mucous membrane of the nasal 
passages and, accessory sinuses. These polypi may be single or 
in clusters, and their effect is to cause nasal obstruction which 
sometimes leads to diseased conditions of the associated sinuses 
or the pharynx. 
Prognosis.-Under proper treatment this is favorable. 
Treatment.-The treatment consists in removal and, if possible, 
correction of the predisposing condition, otherwise there is likeli- 
hood of recurrence. 
In the case shown in Figs. 291 and 292 the myxoma was peeled 
out with the fingers from the angle of the jaw on the left side of 
the mouth to the middle of the body of the jaw on the opposite 
side. It was removed in large masses, almost intact. 
MALIGNANT GROWTHS. 
Sarcoma.-Sarcoma is an embryonic connective-tissue tumor 
in which the cellular constituents usually predominate over the 
intercellular substance. 
Varieties.-Varieties of sarcoma placed for clinical purposes in 
the order of their malignancy are: (1) Giant cell. (2) Spindel cell. 
(a) Large spindle cell. (6) Small spindle cell. (3) Round cell. 
(4) Mixed cell. (5) Alveolar. (6) Melanotic. 
Most sarcomas are mixed growths. The determination of malig- 
nancy depends upon the character of the cells that predominate in 
the growth, and it is usually described as of a type in accordance 
with the predominating cells. 
Alveolar sarcoma is a rare form in which the cells assume an 
alveolar enlargement quite like carcinoma. 
Giant-cell or myeloid sarcoma is a form resembling the red marrow 
of young growing bone. 
Sarcomatous growths show marked tendency to secondary 
changes which sometimes result in the more or less complete 
development of connective-tissue structures. Thus we have osteo- 
sarcoma when true bone formation occurs, chondroid or chondro- 
sarcoma when cartilage results, myxosarcoma with mucoid tissue, 
endothelioma (plexiform angiosarcoma), a highly vascular tumor 
due to preexisting or newly formed vessels with cell-nest formed 
by proliferation of endothelial cells (Fig. 293). Mixed tumors of 528 
TUMORS 
the parotid gland are quite commonly endotheliomas (Fig. 294). 
Melanosarcoma is distinguished by black pigment in cells and inter- 
cellular substance, and is generally recognized as the most malignant 
of all sarcomas (Fig. 295). 
Fig. 293.--Endothelioma of submaxillary gland. (Brewer.) 
Sarcoma of the Jaw.-Epulis.-This term is applied to tumors 
which spring from the fibrous tissue of the gum and the periosteum, 
and which might be papilloma, fibroma, carcinoma, or sarcoma. 
It is, however, most commonly used to describe giant-cell sarcoma. 
Etiology.-There is usually some local irritation which appears 
to excite the growth. 
Symptoms.-The growth appears upon the gum (Plate XIII, 
Fig. 1), gives little disturbance outside of mechanical interference, PLATE XIII 
FIG. 1 
Epulis. (Grunwald.) 
FIG. 2 
Woman, Aged Seventy Years, with the Sarcoma from which 
the Sections Shown in Figs. 295, 296, and 297 were Cut. MALIGNANT GROWTHS 
529 
spreads gradually, thus forcing the teeth apart, and ultimately 
involving their surrounding structures. 
Fig. 294.-Mixed tumor of the parotid. (Sultan-Kuss.) 
Fig. 295.-Section of melanosarcoma, showing pigmentation. 
Diagnosis.-Giant-cell sarcoma may be differentiated from 
fibroma because it is softer, bleeds more easily, and has a tendency 530 
TUMORS 
to more rapid growth, and in a general way from other varieties 
of sarcoma and carcinoma by benign or malignant symptoms, as 
described (p. 490). This is recognized as the most benign form 
of malignant tumor. The main reliance for final decision must, of 
course, be placed upon microscopic findings. 
Prognosis.-Prognosis in these cases is good. They are the least 
malignant of all sarcomatous growths, and if removed before 
increased malignancy has been acquired, do not recur after com- 
plete removal. That the most malignant sarcoma may sometimes 
develop from conditions that are almost or completely benign is 
Fig. 296.-Spindle-cell sarcoma. A section from the growth shown in Fig. 294, 
quite clearly demonstrated by Plate XIII, Fig. 2, and Figs. 296, 
297 and 298. The history of this case showed that the trouble 
began in the maxillary sinus years before. After the first removal 
there was a period of two years without recurrence. The sections 
indicate very plainly the predominance of spindle cells in the older 
parts of the growth, mixed spindle and round cells in a later section, 
round cell, and finally melanotic sarcoma. Figs. 299 and 300 are 
sections of a growth illustrating one danger. It had been examined 
at a well-known laboratory and reported as inflammatory tissue. 
When the patient came under the author's care a section was made 
which seemed to confirm the previous report, yet deeper sections MALIGNANT GROWTHS 
531 
Fig. 297.-Round-cell sarcoma. A section of the growth shown in Fig. 294 cut from 
a portion of later development than Fig. 296. 
Fig. 298.-The pigmentation of melanosarcoma in a section from the same growth 
shown in Figs. 294, 296 and 297. 532 
TUMORS 
made after removal of the deeper-seated portions of the growth 
show plainly the sarcomatous condition. 
Fig. 299.--Section of a sarcoma of the lower jaw. 
Fig. 300.-Section of a sarcoma of the lower jaw. Same case as Fig. 299. MALIGNANT GROWTHS 
533 
In another of the author's cases microscopic sections failed to 
disclose the malignant character of a tumor. Under these circum- 
stances it was deemed unwise to make a wide resection of the jaw, 
and yet it was subsequently learned that this patient died within 
six months from sarcoma recurring in the same region. In dealing 
with malignant tumors of the jaw, both sarcomatous and carci- 
nomatous, the decision as to the character of the operation is a 
grave one. Undoubtedly many jaws have been resected and the 
future comfort of the lives of these individuals blasted when the 
growths were benign and there was no need of radical operation. 
On the other hand, to do an insufficient operation in the face of 
active malignancy is merely to add fuel to the flame and hasten 
the progress of malignant development (Fig. 301). Immediate 
diagnosis by the microscopic examination of a frozen section at 
the time of the operation, when this can be done, is by all means 
the best method of dealing with such growths. 
Fig. 301.-Sarcoma. (Westmoreland.) 
Operation for Giant-cell Sarcoma.-The growth must be com- 
pletely removed down to and including the periosteum, as well 
as the teeth that may be immediately adjacent to the growth. 
It is the author's practice to remove one tooth upon each side 
beyond the growth and with a surgical or dental engine bur to 
remove the alveolar process down to and including the full extent 
of the tooth socket, so that by no possibility might there be a por- 
tion of the pericementum allowed to remain. 
The treatment of other more malignant forms of sarcoma is 
described with carcinoma under Treatment of Malignant Growths. 534 
TUMORS 
CARCINOMA-CANCER. 
Carcinoma is an embryonic or atypical neoplasm that always 
develops from epithelial cells. 
Varieties.-(1) Epithelial carcinoma or epithelioma. (2) Glan- 
dular carcinoma. 
1. Epithelioma.-There are three principal types of epithelioma 
-squamous, cylindric-cell, and tabulated. 
Squamous Epithelioma.-This form grows upon cutaneous or 
mucous surfaces, and its epithelial elements are much like the 
squamous epithelium of skin and mucous membrane. Transverse 
sections show typical nesting of cells, called epithelial nests. When 
these harden, as by age and keratinization, they are termed pearls, 
and it is called a pearly epithelioma (Figs. 302 and 303). 
Symptoms.-Squamous epitheliomas are usually found where 
skin and mucous membrane join or at the meeting point of two 
kinds of epithelium. The situations which are of special interest 
to our subject are the lower lip, nose, tongue, gums, palate, tonsils, 
and pharynx. The digestive, generative, and similar parts are also 
affected. The hands and feet rarely. 
The first sign of its appearance is usually a small indurated 
nodule just under the epithelium. Later, an irregular ulcerated 
warty surface develops, from which occasionally there is a slight 
exudation denoting ulceration within a surrounding indurated 
border. This leads to incrustation. Beneath the scab, if removed 
or if it drops off without removal, the developing cancer is plainly 
seen. 
Cylindric-cell Epithelioma (Adenoid Cancer, Columnar- 
cell Epithelioma, Malignant Adenoma).-In this variety 
there are tubular cavities in which layers of cylindric cells are 
separated by a stroma. The more nearly the appearance resembles 
true gland formation the slower the growth. When it is unlike 
gland tissue and the cells are small and in irregular arrangement, 
rapid growth and recurrence may be looked for. 
Symptoms.-They are more likely to be found in young patients 
than other forms of epithelioma, are soft and gelatinous and com- 
monly appear upon the mucous membranes of the gastro-intestinal 
tract or the uterus. They also appear in the liver, kidney, and 
other organs, and may grow very slowly or with great rapidity. 
Tubulated Epithelioma (Rodent Ulcer, Lupus Exedens, 
etc.).-This form of epithelioma has irregular pavement epithelium 
arranged in plugs or cylinders, embedded in a stroma of connective CARCINOMA-CANCER 
535 
tissue. The epithelial nests and pearls are not found in these 
growths. Rodent ulcer affects old people, appears most frequently 
Fig. 302.-Squamous epithelioma of the check. (Section from case shown in 
Fig. 303.) 
Fig. 303.-Man with carcinoma of the cheek and lower jaw. Fig. 302 shows a section 
of the growth. The scar of a previous ineffective operation may be noted. 536 
TUMORS 
on the face, tongue, corner of the nose, and in similar situations 
upon skin surfaces. It usually grows very slowly, sometimes for 
years without attracting much notice, or it may progress rapidly 
from the beginning. The ulceration upon the surface is in most 
cases surrounded by an elevated, irregular, indurated border. 
2. Glandular Carcinoma.-This form of carcinoma is a tumor 
springing from preexisting gland tissue. The tendency of modern 
writers is to discourage the use of the term scirrhous or hard cancer 
and encephaloid or soft cancer, and other terms used to describe 
different degrees of consistency of the growth as distinct forms. 
The degenerative processes which lead to these structural altera- 
tions are themselves so variable and so intermingled that clinically 
at least they are not entitled to such positive and absolute dis- 
tinction. 
The use of the terms colloid or gelatiniform carcinoma, mucoid, 
and melanotic, or pigmented sarcoma, are also more properly recog- 
nized as different forms of degeneration and not wholly different 
types of growth. 
Symptoms of Glandular Carcinoma.-Glandular carcinoma is 
found on mucous membrane surfaces, in the digestive tract, the 
mammary gland, pancreas, kidneys, ovaries, and similar situations. 
The tumors appear as nodular infiltrating growths of exceedingly 
variable consistency. Upon section the growth shows a glistening 
white color, has more or less translucency, and there is a lymph- 
like exudation, composed of albuminous fluid containing degen- 
erative epithelium and oil-droplets, that appears on the surface. 
General Considerations and Etiology.-With research labora- 
tories throughout the civilized world actively engaged in the inves- 
tigation of the cause and nature of cancer, and in the absence of 
positive and generally accepted findings, it is impossible to tell 
what complete changes in the present theoretical structures in 
this relation the near future may bring. In the meantime clinical 
features, more or less uniformly recognized by all surgeons, must 
receive due consideration in addition to the theories of cancer 
causation previously described with reference to tumors (pages 
486 to 488.) 
Crile, in his oration on the cancer problem,1 calls attention to the 
fact "that although the cause of cancer still remains unknown, 
many of its phenomena have been carefully studied. It occurs 
1 Med. Record, June 6, 1908/ PLATE XIV 
FIG. 1 
FIG. 2 
Epithelioma of the Lower Lip. 
FIG. 3 
FIG. 4 
Epithelioma of the Lower Lip, with Lips Closed and 
Lower Lip Everted. PLATE XV 
Carcinoma of the Tongue. CARCINOMA-CANCER 
537 
in every climate and among all mankind, savage and civilized, 
in wild and in domestic animals, carnivorous and herbivorous, in 
birds, fishes, reptiles, even in the lowly oyster. Throughout nature 
the histological picture of any definite cancer is the same. 
"Although the primary cause is not known, many of the pre- 
disposing causes and precancer states are known and can be recog- 
nized. The growth of carcinoma rarely follows a single trauma, but 
in the visible fields it is frequently preceded by chronic irritations, 
by scars-and ulcers, by hyperplasia, by chronic inflammation, and 
by preexisting benign growths. Among the benign growths pre- 
disposing to cancer let us note fibromas, papillomas, adenomas, 
and cysts. 
"Most innocent tumors of the parotid ultimately become sar- 
comatous. Many irritated moles freely metastasize as deadly 
melanomas." 
Location.-Extract from summary of Crile's1 operative cases. 
The total number was 132, of which the following were: 
Location. 
Operations. 
Recoveries. 
Deaths. 
Carcinoma of face (including maxillee) 
. . 15 
14 
1 
Carcinoma of lips 
. . 31 
31 
0 
Carcinoma of floor of mouth .... 
. . 4 
1 
3 
Carcinoma of soft palate 
. . 1 
1 
0 
Carcinoma of alveolar process .... 
. . 2 
. 2 
0 
Carcinoma of tongue 
. . 12 
10 
2 
Carcinoma of parotid 
. . 5 
5 
0 
With regard to the "cancer areas" and "cancer houses" theories 
sometimes advanced by those who believe in the infectious character 
of cancer, Simon2 reports five deaths in an old double farmhouse in 
Wales. The farmer's wife died of cancer in 1882; the daughter- 
in-law had cancer from 1886 to 1890, when death resulted; the 
daughter died of cancer in 1896; the woman who lived on the other 
side of the house, who nursed one of the women affected by cancer, 
herself died of the disease in 1900; and this woman's husband died 
of cancer in 1903. Five deaths in different families in the same 
house between 1882 and 1903. 
The fact that epithelioma of both lip and tongue is much more 
frequent among men who are confirmed smokers and who have 
bad teeth is also significant, as is the fact that these growths grow 
in other situations of the mouth where diseased conditions of teeth 
1 Jour. Am. Med. Assn., December 1, 1906, p. 1785. 
2 Practical Medicine Series, 1910, ii, 116. 538 
TV MORS 
and gums are prevalent. Park states that one-fifth of the cases 
of epithelioma of the tongue are preceded by leukoplakia. In other 
regions the well-known chimney-sweep's cancer of the scrotum and 
similar cancers that are known to occur frequently among those 
whose vocations expose certain surfaces to continued or unusual 
irritation all mark very plainly the significance of irritation in this 
regard. E. H. Bashford, in his report of the experimental study of 
the Imperial Cancer Research at the Medical Congress in Budapest, 
calls attention to the fact that by suitable technic it is now possible 
to reproduce all the lesions of cancer experimentally-" local inflam- 
mation, systemic dissemination, and the terminal cachexia"-and 
concludes that " it is now agreed that infection plays no part in the 
experimental transference of cancer, which is a true transplantation 
of living cells."1 
Age.-There is undoubtedly a predisposition, or at least a weak- 
ened resistance, to cancer in persons of advanced age, as evidenced 
by its frequent occurrence between the ages of forty-five and sixty- 
five years and its infrequency in early life. 
Murphy's Laws.-Murphy has laid down the following laws:2 
"Law 1. Repeated mild traumas and irritations, particularly 
at the border-line of different epithelial fields and cicatricial tissue, 
are potent etiological factors in carcinoma. 
"Law 2. Moderately severe traumas once applied never produce 
carcinoma. 
"Law 3. Moderately severe traumas-not to a degree of lacera- 
tion or fracture-are frequently the cause of sarcoma and the 
precipitation of tuberculosis. 
"Law 4. Severe traumas to the degree of laceration or fracture 
never cause carcinoma, sarcoma, or focalized tuberculosis. 
"Law 5. Sudden changes in conformation and vascularity, as 
embryonal defects, pigmented moles, warts, papillomas or cuta- 
neous fibromas usually indicate beginning malignancy and always 
demand immediate removal." 
Symptoms.-The appearance of the different forms of cancer 
has already been briefly described, and is shown in Plates XIV, 
XV, and Figs. 304 and 305. A general description of the clinical 
picture of the patients suffering from this affection, however, 
seems to be required. 
Whether progressing by destructive ulcerative process or as a 
1 Lancet, September 4, 1909. 
2 Practical Medicine Series, 1909, ii, 96. CARCINOMA-CANCER 
539 
tumor mass involving the surrounding structures, there is always 
marked tendency to lymphatic infection, and the lymph nodes 
thus affected really are in the nature of metastatic extensions which 
partake of a full measure of malignancy. 
Epithelioma or carcinoma springing from any of the structures 
of the mouth, such as the lip, jaw, gland, or tongue, may by exten- 
sion involve or include any or all of the other tissues. There 
is usually little if any pain until certain nerve fibers or branches 
of nerves become affected or secondary inflammatory processes 
Fig. 304.-Section of epithelioma of the lower lip from case illustrated in Fig. 301. 
create more active disturbance. Both pain and tendency to severe 
hemorrhage must be expected as the disease extends to the large 
vessels as well as nerves. In some cases the general health and 
appearance seems to be unimpaired for some time, but as the growth 
progresses the characteristic cachexia appears. This is the result 
either of a poisonous toxin incident to the growth itself, or of septi- 
cemic conditions derived from degenerative processes within or 
associated with the tumor. The growth causes a foul odor, and an 
unpleasant flow of saliva dribbles from the mouth as the usefulness 540 
TUMORS 
of the parts is lost, which, with the discouragement of such indi- 
viduals, makes the general picture exceedingly distressing. Death 
usually results from the invasion of some vital part, from mal- 
nutrition, or from infection. 
Diagnosis.-There are no symptoms of cancer which distinguish 
them completely and absolutely from the pathognomonic indica- 
Fig. 305.-Section of epithelioma of the lower lip from case illustrated in 
Figs. 301 and 304. 
tions of other affections. Except in cases in which the growths are 
superficial and of such form as to be recognized by their clinical 
indications, microscopic sections give the only definite means of 
diagnosis. The first and most important question is whether the 
growth is benign or malignant (page 490). 
The differentiation between sarcoma and carcinoma must then 
be made. These Coplin has exhaustively outlined as follows: CARCINOMA-CANCER 
541 
DIAGNOSTIC FEATURES OF SARCOMA AND CARCINOMA.1 
Sarcoma. 
Carcinoma. 
1. Origin. 
Entirely mesoblastic (con- 
nective-tissue type). 
Epiblastic and hypoblastic 
(epithelial tissue type). 
2. Stroma. 
Intercellular. Rarely forms 
alveoli. 
Vascular connective tissue 
which surrounds and forms 
the walls of the alveoli; these 
communicate with one another 
and contain masses of epithe- 
lial cells. 
3. Cell. 
Granulation tissue or em- 
bryonic connective-tissue cells; 
shape and size vary. 
Epithelial cells contained 
within alveoli; shape and size 
vary. Absent, or merely 
fluid. 
4. Intercellular 
substance. 
May he present. 
Absent, or merely fluid. 
5. Vessels. 
Embryonic in character. 
They are in direct contact 
with, or may be formed by, 
the special cells, slightly mod- 
ified, of which the tumor is 
composed. 
Well developed; entirely 
contained within the connec- 
tive-tissue stroma, and sup- 
ported by the walls of alveoli. 
Seldom in contact with the 
cells. 
6. Spreads. 
Primarily and secondarily 
by bloodvessels, rarely by the 
lymphatics. 
Primarily by lymphatics, 
except in later stages, when 
it may also spread by blood- 
vessels, in which case it 
spreads with very great rapid- 
ity. Secondarily by blood- 
vessels. 
7. Secondary 
changes. 
Chondroid, osseous, calci- 
fic, and pigmentary changes 
frequent. 
Very rare. 
8. Growth. 
Not invariably continuous. 
Likely to be interrupted. 
Rapid, continuous. 
9. Site. 
Primarily in deep struc- 
tures; always from connec- 
tive tissue. 
Never encapsulated. 
10. Heredity. 
Seldom hereditary. 
May be hereditary. 
11. Capsule. 
Primarily, pseudo-encapsu- 
lated ; later infiltrates the sur- 
rounding tissue. 
Never encapsulated. 
12. Fat. 
Rarely, if ever, contains fat. 
Nearly always contains fat. 
13. Age. 
Occurs most frequently be- 
fore middle life. 
Most frequent after middle 
life. 
14. Injury. 
Not uncommonly follows 
injury such as trauma. 
Rarely, a history of trauma, 
but may follow prolonged 
irritation. Especially is this 
true of the superficial forms. 
In many cases malignancy can be diagnosticated almost at 
a glance, but in doubtful cases in which prompt and effective 
treatment might produce good results the difficulties are sometimes 
trying- 
When the operation is performed in a properly equipped and 
ordered hospital and section of the tissue can be made immediately, 
1 Coplin: Manual of Pathology, p. 363 (after Woodhead, modified and extended). 542 
TUMORS 
frozen, studied under the microscope, and reported before the 
patient has come out of anesthesia, these difficulties are, of course, 
avoided. 
In other cases the alternative lies between operation without 
full knowledge, with the attendant risk of doing too much or too 
little, and the danger of aggravation by a previous even though 
small cutting from the growth for the purpose of microscopic study, 
with an interval of perhaps a number of days before performance 
of the complete operation. How much or how little actual risk of 
converting operable into inoperable cases occurs in this practice 
is impossible to determine exactly. 
Ryall1 sums up this danger in the following positive manner: 
"In the parent growth the cells are more or less encapsulated in 
fibrous tissue, but some cells escape during operation and find a 
resting place in the wound, which is comparatively unprepared to 
meet and resist the invasion. 
"Cancer cells may escape during operation as the result of 
incising or lacerating the primary growth, cutting across or tearing 
an infected lymph vessel, or even from rupture of a cancerous gland, 
and such cells are quite capable of causing and do frequently cause 
cancer recurrence. 
"In cases of doubtful malignancy, where nature's barriers are 
intact, do not remove a section for examination-remove the tumor 
and make the microscopic study afterward." 
Differentiation between some of the infectious diseases, notably 
tuberculosis, may be confusing, as the two are sometimes associated. 
The special characteristics of infectious diseases usually make 
diagnosis clear, especially in the field of the mouth and jaws, where 
direct examination is possible. Hemolysis has been extensively 
tested to determine the possibility of a positive or negative reaction 
with regard to blood serum and cancer cells. The reports of Blum- 
berg,2 Johnson, Canning,3 Smithy,4 Arnold,5 the experiments of 
others the results of which have come to the author personally, and 
in a limited way tests upon his own cases show that this method can- 
not be depended upon for diagnosis in the present state of our knowl- 
edge. The antitryptic index or the power of inhibiting tryptic 
digestion possessed by a serum as compared with that of a normal 
standard serum has been investigated by Bayly. He reports 30 
cases, 26 of which showed markedly raised index, 3 normal index, 
1 Practical Medicine Series, volume of General Surgery, ii, 121. 
2 Med. Record, January 9, 1909. 
3 Jour. Am. Med. Assn., October 30, 1909. 4 Ibid. 
6 Yale Med. Jour., November, 1909, p. 143. CARCINOMA-CANCER 
543 
and 1 subnormal index, a result evidently too uncertain for practical 
use.1 
Prognosis.-Prognosis in cancer of the lips, floor of the mouth, 
tongue, and jaws is grave to the point of hopelessness. Its future 
aspect is more hopeful than records of the past would indicate, 
and earlier diagnosis and prompt extensive operation with radical 
block dissection of the neck promises much. Crile2 calls attention 
to the fact "that among 48 traced cases operated upon more than 
three years ago, in which radical block section was not made, 9 
are living; and in 12 cases in which block section was performed 
more than three years ago, 9 are living." His conclusions in this 
respect are important. "The head and neck present an exposed 
field. Cancer here, unlike that of the stomach, intestines, or even 
the breast, may be recognized at its very beginning; in every case 
it is sometimes curable by complete excision. That the field of 
regional metastasis is exceptionally accessible, but cancer rarely 
penetrates the extraordinary lymphatic collar of the neck. As the 
growth tends to remain here localized, application of the same 
comprehensive block dissection, as in the radical cure of breast 
cancer and free utilization of .the modern researches of surgery, 
renders the final outcome in cases of cancer of the neck and head 
more promising than that of almost any other part of the body." 
Warren3 reports 122 operations for cancer of the tongue and 
floor of the mouth; 16 (14.2 per cent.) remained free from recur- 
rence over three years. Butlin reports 197 cases of cancer of the 
tongue; 20 died following the operation; 22 were operated upon 
recently; in 55 there was no recurrence for periods averaging from 
thirty to thirty-three years. 
Dollinger reports 6 cures in 58 cases. 
According to Warren the mortality varies with the extent of the 
operation; its lowest (5 per cent.) with the intrabuccal operation, 
and its highest (30 to 35 per cent.) in the operations involving 
division of the lower jaw. 
"A careful study of 4500 cases, exclusive of the thyroid gland, 
traced to their original report in literature, made for me by Dr. 
Kitchings, showed that in less than 1 per cent, have secondary 
cancer foci been found in distant organs and tissues."4 
Treatment of Malignant Growths.-Whenever possible the treat- 
ment of cancer should be begun in the precancerous stage, that is, 
1 British Med. Jour., October 23, 1909. 
2 Jour. Am. Med. Assn., December 1, 1906, p. 1780. 
3 Ann. Surg., 1908, xlviii. 
4 George W. Crile: Jour. Am. Med. Assn., December 1, 1906, p. 1780. 544 
TUMORS 
whenever there are indications which by any possibility might 
lead to malignancy. These should be completely and thoroughly 
corrected. 
Among the many methods of treatment that have from time to 
time been tried, the following have received more or less serious 
attention. 
Injections of mixed toxin of erysipelas and Bacillus prodigiosus in 
the treatment of sarcoma are reported by Dr. William B. Coley1 
to have checked the growth in a considerable number of cases and 
to have effected more or less permanent cures in at least a few 
instances. The number of these, however, is hardly sufficient to 
warrant dependence except when operation is contra-indicated. 
Enzyme treatment as recommended by Beard, injectio trypsini 
and injectio amylopsini respectively, designed to kill and digest 
the cancer cells, and pancreas gland extract containing trypsin, 
amylopsin, and lipase with the milk-curdling ferment, after careful 
tests by Bainbridge,2 have failed to check cancerous progress. 
Frederick Gwyer3 uses the dried thymus gland of the calf, and 
reports improvement as a result of continued administration, 
sometimes in doses as large as an ounce of the powder. 
Park recommends the use of thyroid extract, 5-grain doses three 
or four times a day, simultaneously with the use of the a-rays, 
claiming that the latter enhance the efficiency of the thyroid 
treatment. 
Radium.-The complexity of governing conditions in determining 
the action of radium such as variation in the dosage and methods of 
application by different operators, differences in filters, and in the 
effects of alpha, beta, gamma and secondary rays, have led to much 
confusion in the reports of the results of radium therapy. There have 
been remarkable cures by its use, and also many disastrous failures. 
The following recommendations by Doppert, reported by Ewing4 
seem to be along conservative lines (1) for early localized cases- 
radium; (2) established, or border-line cases-operation; (3) in- 
operable cases-radium; (4) advanced cases-neither radium nor 
operation. 
Cancers of the mouth, tongue, tonsil and pharynx, present 
uncertainties for radium treatment both because of anatomical 
difficulties and great differences in the character of carcinomatous 
growths in these regions. Much progress is being made in the 
1 Ann. Surg., December, 1908, xl, 465. 
2 Scientific Report New York Skin and Cancer Hospital, 1909. 
3 Ann. Surg., xlvii, 506. 
4 Jour. Am. Med. Assn., April 28, 1917, CARCINOMA-CANCER 
545 
direction of overcoming these disadvantages by skilful and intelli- 
gently applied treatment. Radium intoxication is a term applied 
to the phenomena sometimes following long exposure to large 
amounts of radium. The patients suffer from nausea and vomiting, 
extreme muscular weakness, feeble pulse, and diminished urine. 
Ewing in calling attention to this states that "radium in any but 
experienced hands, is a dangerous agent," but "precautions should 
not be permitted to stand in the way of the normal legitimate 
extension of the radium treatment of cancer." 
"In the 'field' of precancerous lesions, hypertrophies, atypical 
inflammatory overgrowths, warts, and polyps of mucocutaneous 
junctions, numerous leukoplakias, cervical erosions, nevi, and many 
accessible benign tumors, radium is both efficient and comparatively 
free from danger." 
Injections into the growth of soap, potassium, and sodium and 
the internal administration of many drugs have all in course of 
time been tried and found wanting. The use of plasters and pastes 
of arsenic destroy the surface in superficial growths upon which 
such paste can be safely applied, and have sometimes proved bene- 
ficial. The serious tissue destruction from the use of the arsenic, 
which after all does no more than other less advantageous agents, 
is, however, objectionable. 
Liquid air has been used to freeze and destroy such tumors. 
In favorable cases it has caused the scab to slough away with 
sufficient tissue to cause cicatrization of the underlying tissues 
without recurrence. 
The actinic rays of the sun were utilized in one case of which the 
author has personal knowledge. It was a rodent ulcer at the angle 
of the nose which had been removed by slight operations four or 
five times with repeated recurrence. The patient, a man, aged 
about seventy years, spent many hours each day with the sun's 
rays focussed upon the ulcer with a magnifying glass, allowing it 
to burn as long as he could support it; after waiting a few moments 
for relief, it would burn again. In the course of a few months the 
scab came away, leaving the skin surface smooth and clean beneath, 
better than it ever appeared after removal by operation, and for 
a longer time without recurrence, although it did recur. 
Ultraviolet or " Finsen light" has proved beneficial in some cases, 
but the number is too limited for it to be considered a valuable 
method of treatment. 
U-ray treatment is by far the best agent exclusive of the knife. 
Unscientific use of the Roentgen rays through undertaking to do 546 
TUMORS 
the impossible, and ignorance of its character, the dosage, and 
other matters which are now thoroughly understood by those 
competent to undertake this kind of treatment, at first caused 
much disappointment. It seems clearly established that upon 
skin surfaces where the growth can be directly reached by the 
rays, their curative powers are remarkable. Rodent ulcers, epithe- 
lioma of the lip at a sufficiently early stage, and cancerous growths 
Fig 306.-Water-cooled retractor in place; wooden spatula protecting tongue 
preparatory to cauterization of epithelium, alveolar margin and cheek, as used by 
Dr. Gordon B. New. 
in other similar situations can be effectively controlled. As both 
the skin and mucous membrane act to some extent in the nature of 
insulators, the x-rays do not always effectively penetrate the deep- 
seated growths or deeper portions of the growth. Used in after- 
treatment directly upon the tissues after operation, as described in 
connection with the author's cases (page 554), x-rays are highly bene- 
ficial and should be a routine measure in almost every case. CARCINOMA-CANCER 
547 
The Percy method of the long-continued application of a degree of 
heat, low enough not to destroy, to any considerable extent, normal 
tissue cells, but of sufficiently high temperature to cause, as has 
been shown that it will, the destruction of cancer cells, has opened 
a wide field of useful treatment, especially in inaccessible situations. 
This is particularly true of the treatment of neoplasms in the region 
of the mouth and jaws. Percy's equipment for this purpose is very 
complete, and is now quite generally used. 
Burning, to destroy the cancer and surrounding tissue, is a 
valuable method when it can be thoroughly applied. 
Fig. 307.-Method of closure of wound after extensive removal of tissue from the 
anterior part of lower jaw and lower lip. The parts are dissected free down to the 
dotted line. 
Extirpation.-The one hopeful remedy at the present time lies 
in complete and thorough excision of the growth; and "block" 
operation upon the lymphatic channels by which the part is drained. 
Operative Treatment.-The varieties of operation for removal of 
malignant growth of the lips, tongue, floor of the mouth, cheek, 
and jaws may, in a general way, be divided as follows: (1) Intra- 
buccal. (2) Inframaxillary. (3) Division of the mandible. (4) 
Resection of the jaws. 
Cancer of the Lip.-In removal of all forms of cancer, care should 
be taken not to allow the knife to touch the cancerous tissue. A wide 548 
TUMORS 
excision should be made, if possible. There should be at least one 
inch of tissue beyond the line of demarcation of the growth. The 
Fig. 308.-The parts closed and the labial border restored by suturing skin and 
mucous membrane. 
author's method of closure after extensive excision of cancer of the 
lower lip is shown in Figs. 307, 308 and 309. By carrying the skin 
Fig. 309.-Result of operation on lower jaw and lip performed as shown in Figs. 
307 and 308. 
and fascia from beneath the jaw, where there is always an abundance 
gives the least possible deformity. After removal of a considerable CARCINOMA-CANCER 
549 
portion of the prolabium very satisfactory plastic repair can be ob- 
tained by suturing the mucous membrane to the skin border along 
the outline of the mouth as reproduced by the newly placed tissue. 
When this is not done, an unsightly and unyielding cicatricial border 
results, but with the mucous membrane carefully carried over and 
neatly sutured, a very fair reproduction of the original vermilion 
border can be secured. In all these cases, even though the cancer 
upon the lip be small, the lymphatics in the submental region 
upon the affected side must be removed. In advanced cases there 
Fig. 310.-Block section for the removal of glands in both upper and lower triangles 
of the neck. (After Crile.) 
should be Crile's block section, including the removal of the glands 
in both upper and lower triangles of the neck; when the growth is 
close to the median line this should be done upon both sides (Figs. 
310 and 311). 
This dissection of the avenues of lymphatic drainage is required 
in all forms of cancer of the lips, tongue, floor of the mouth, cheeks, 
and maxillae. It is best performed in two stages with the mouth 
operation first and removal of the glands as soon after as the 
patient has sufficiently recovered to bear the operation. (Some 550 
TUMORS 
operators reverse this order of procedure, claiming that the removal 
of the glands first reduces the danger of metastatic extension.) The 
dangers of shock and infection are both reduced in this way, and 
the records show a correspondingly marked decrease of mortality. 
Butlin's mortality in 13 cases was 23 per cent., as opposed to 7 per 
cent, mortality when the operation was performed in two stages. 
Crile reports only one fatailty in his last 72 major operations 
in this field as a result of better protection of patients from chilling, 
the employment of skilled anesthetists, and other means to prevent 
Fig. 311.-Block section for removal of glands in both upper and lower triangles of 
the neck. (After Crile.) 
and overcome shock and decrease the number of infections and 
pneumonia. 
Cancer of the Tongue.--Whitehead's Operation for Removal of the 
Tongue.-For unilateral resections, the frenum and mucous mem- 
brane on one side of the tongue are divided. The dorsum of the 
tongue is incised through the median line and split along the raphe. 
Tension is then made by drawing the divided portion upward and 
forward until the geniohyoglossus muscle is stretched to its fullest 
extent. This is divided close to its point of origin; the tongue PLATE XVI 
Diagram of the Nodes and Vessels of the Head and Neck, 
showing the Regions that are Drained into Each Group of 
Nodes. (Gerrish.) 
Deep structures in red, superficial in black PLATE XVII 
Anterior View of Lymphatics of the Tongue, (von Bergmann.) 
The anterior portions of the digastric and the geniohyoid muscles have been 
removed. A large window has been cut in the mylohyoid and the genioglossi muscles 
pulled apart. On the right side the lymphatic vessels which empty into the deep 
cervical glands and pass between the genioglossi are shown (G, F, H, E). On the left 
side the lymphatics of the tongue which empty into the submaxillary glands (A, B, C) 
are shown above. Below at I, K are seen the terminal lymph vessels of the deep 
cervical glands emptying into the large venous trunks. CARCINOMA-CANCER 
551 
may then be drawn so far out of the mouth as to make it easily 
accessible for operation. When the entire tongue is to be removed, 
or on both sides of the anterior portion, the tissues are freed by 
making the same incisions upon both sides. 
The lymphatic systems of the mouth and neck are shown in 
Plates XVI and XVII. It is important to note that the base of 
the tongue is practically separate from the body of the organ, and 
that its lymphatic vessels empty through the system in connection 
with the submaxillary glands, whereas the lymphatics of the 
anterior part of the tongue find their avenues of connection through 
the cervical glands. This makes it possible to spare the posterior 
portion of the tongue in operation for the cancer, and as lymphatic 
anastomosis across the median raphe occurs imperfectly if at all 
Fig. 312.-Inframaxillary removal of the tongue. (Kocher.) 
in the early stages, at least cancer is usually limited to one side or 
the other of the median raphe. The lymphatics of the floor of the 
mouth and of the submaxillary lymphatic glands are in intimate 
relation and following in order. The superficial and deep cervical 
glands complete the chain. 
Inf ram axillary Operations.-Kocher's Operation.-A curved inci- 
sion is made from the chin to the ear, with its lowest point close 
to the hyoid bone. The mouth is entered below the jaw by divi- 
sion of the mylohyoid muscle after dissecting free the submaxillary 
gland. The tongue and floor of the mouth are removed below the 
jaw, together with the lymphatics in the submental region (Fig. 312). 
Temporary resection of the jaws for this purpose is described 
on page 433. 552 
TUMORS 
Warren reports 45 cases of cancer of the tongue with seven 
cures at the end of five years or longer (15.5 per cent.). 
Cancer of the Lower Jaw.-Operation for cancer of the mucous 
membrane and alveolar process of the lower jaw, involving the 
bone, show a high mortality. 
Warren1 reports 40 operations upon these cases at the Massa- 
chusetts General Hospital, 10 deaths as a result of the operation 
(35.7 per cent.), and of these, within a five-year limit, there were 
but three cures. (See Resection of Lower Jaw, page 433.) 
The operations performed upon these 40 cases were as follows: 
Operative 
Cured. 
deaths. 
Resection alone, 12 
. . . . 1 
5 
Resection, neck dissection, 4 
. . . . 1 
2 
Resection, neck, other parts, 3 . 
. . . . 1 
1 
Minor operations, 7 
. . . . 2 
2 
Cancer of Upper Jaw.-See Resection, page 443. 
Cancer of the Cheek.-The incisions for cancer of the cheek can- 
not follow any definite rules, but must be governed by the form 
and extent of the growth. After the growth is completely removed, 
the open surface of the wound may be'closed by plastic operation 
at a later operation if necessary. In these cases the ar-rays can be 
advantageously applied directly to the unclosed wound surface. 
Cancer of the Palate.-Resection of the jaw as described (page 
433) may be required to expose the palatal region completely. 
Cancer in the Region of the Maxillary Sinus.-In the author's 
opinion this can best be treated by A. J. Ochsner's method, which 
he has been kind enough to describe in a special letter as follows: 
"We simply cut away with a chisel all of the diseased tissue 
that we can find and then cauterize the surface furiously with an 
ordinary soldering iron, which is heated to red heat, until every 
particle of diseased tissue as far as one dares to burn has been 
destroyed. Then we pack the cavity with the following solution: 
20 grains of bicarbonate of soda, | ounce of salicylic acid, 3| ounces 
of chloride of zinc, and enough commercial alcohol to make half 
a pint. A little of this is placed in a small glass and a piece of 
gauze saturated in the solution, but not sufficiently to cause it to 
drip. This is packed into the cavity and over it a dry piece of gauze 
is packed to take up all of the moisture which may escape. This 
packing is removed on the second or third day, and from that 
time on the cavity is packed with formalin gauze and is kept clean 
by irrigation." 
1 Ann. Surg., 1908, xlviii, 503. CARCINOMA-CANCER 
553 
The case, a man, aged fifty-four years, was referred to the author 
with an opening through the buccal wall of the maxillary sinus, 
with slight evidence of ulceration of soft tissues at the borders. 
The usual treatment by previous ineffective irrigation through the 
mouth and ilose • had been tried for some time previously. As 
there was no clinical evidence of malignancy at this time, a radical 
operation for empyema of the maxillary sinus was performed. 
The tissue healed quickly and the patient made an uninterrupted 
recovery. As a matter of precaution an elliptical section was taken, 
including the tissue all around the opening into the sinus before 
enlargement was performed in course of the operation. Sections 
from this under the microscope looked suspicious. Some six 
months later the growth reappeared in this region and this time 
was plainly shown to be carcinoma. There appeared to be two 
alternatives in treatment: one, a complete resection of the superior 
maxilla, with its almost certain deformity, the other, Ochsner's 
burning method, which would leave practically no deformity. 
The patient was referred to Dr. Ochsner, who operated by using 
a series (approximately 20) of red-hot soldering irons, with which 
he burnt the tissue in all directions. This was done from within 
the mouth without an external incision. Dr. Ochsner's claim that 
as much tissue could be removed without deformity by actual 
burning as would be taken out by resection, with its greater 
deformity and more risk, and that, in addition to this, sloughing of 
the burn would continue as the area of tissue destroyed would be 
increased by sloughing and bone exfoliation far beyond the actual 
outline of the first wound, thus antagonizing the formation of new 
cancer cells, was fully borne out by the result. A packing of mulip- 
tol was inserted and changed daily, bringing away from time to 
time masses of exfoliated bone and sloughing soft tissue. A second 
burning was necessary after several months because of recurrence, 
but since that time, a' matter of four years, the patient has been 
quite free from growth of this region, and he has suffered neither 
deformity of the external face nor serious inconvenience through 
the loss of teeth and alveolar process which has been supplied by 
a dental plate. In the author's opinion this growth could not 
have been checked as well by any other method. 
This method of deep burning has undoubtedly a wide field of 
application in dealing with malignant growths of the jaws in other 
situations as well as the maxillary sinus, but this particular case 
has been chosen for illustration because of the well-known difficul- 
ties encountered in complete extirpation of rapidly growing cancer 554 
TUMORS 
in this region. A later report of this case approximately nine years 
after treatment shows that there has been no recurrence of the 
growth. Without treatment he could hardly have lived six months. 
Practical Results of the Use of the X-rays after Operation.-Cancer 
of the lip, as has already been stated, requires, in addition to the 
side removal of the affected lip tissue, removal of the lymphatic 
glands under the jaw. In most cases it is safer to remove the glands 
of the neck upon the affected side also. When genuine evidence 
of malignancy is present in any of these glands, it is safer not to 
close the skin surface immediately, but by opening the flap to 
enable the x-rays to be used directly upon the recently exposed 
surface. 
It is well known that both skin and mucous membrane resists 
the penetration of the rays. Upon actual skin surfaces or upon 
directly exposed tissue, however, x-rays destroy malignant tendency. 
One of the author's patients, a man, aged fifty-two years, gave 
a history of the formation of an ulcer at the border of his lower 
lip. It had continued despite the application of salves for a period 
of about ten years, when an operation was performed by the usual 
elliptical excision of lip tissue. As might have been expected, this 
was practically a failure and caused greater deformity than would 
have resulted from a more extensive properly performed operation. 
One cervical gland on the affected side had also been operated 
upon for an abscess, but no record of its nature was available. 
Upon examination the author found cancer affecting the lower 
lip and the gum tissue adjoining the lower incisor teeth. There 
were no enlarged glands apparent, either in the submaxillary or 
cervical region. The tongue was not affected. Operation was 
performed by wide removal of tissue, including the lower lip to 
and beyond the median line down to the chin, as shown in Fig. 
307. The teeth, alveolar structures, and the anterior plate of the 
lower jaw, including the overlying tissues, were removed with a 
surgical engine bur, including also the cancellous structure of the 
bone. The compact bony structure of the inner surface of the 
jaw was left with a clean, smooth, hard surface. Over this the 
external wound was closed according to the author's method, as 
shown in Fig. 308. Prompt healing followed. The parts seemed 
to be entirely free from the old affection, and bridge-work was 
inserted by Dr. Percy B. Wright, of Milwaukee, which was attached 
to the remaining bicuspid teeth. It was composed of vulcanized 
rubber, which would permit of adjustment from time to time as 
the form of underlying tissues changed. For the sake of cleanli- CARCINOMA-CANCER 
555 
ness and convenience this was made removable, and the gold crowns 
which held it in place were made to slip over other crowns which 
had previously been cemented to the bicuspids. The result is shown 
in Fig. 309. Instruction was given to have the cervical glands 
removed at an early day. At a subsequent operation some time 
later (six months) the submaxillary and cervical glands were 
removed by Dr. John L. Yates, of Milwaukee, and it was found then 
that cancer was evident as far as the clavicle, because the patient 
did not have an early operation as directed. Treatment with the 
x-rays by Dr. Otto K. Foerster and Dr. Baer, of Milwaukee, dur- 
ing a period of several weeks, with the skin edges ununited and 
turned back, resulted in shrinkage of tissue until not the faintest 
semblance of malignancy remained anywhere. About this time 
recurrence of the growth upon the site of the author's first opera- 
tion upon the. lower lip became evident. This was opened, a wide 
excision performed, and allowed to remain exposed to the x-rays, 
which were used triweekly with varied dosage. For a consider- 
able time the use of the x-rays in this manner seemed to be 
completely effective, but recurrence and death ultimately occured. 
The dire results of neglecting ulcers- on skin surfaces that 
show tendency to become chronic, whether there be evidence 
of unmistakable malignancy or not, and the futility of ineffective 
operations according to old methods of excising a small portion of 
the lip and allowing the lymphatic glands to remain untouched, 
is very strikingly brought to notice. It is almost invariably advis- 
able to operate upon the lip and mouth, and to perform a "block" 
dissection of the lymphatics, as recommended by Crile, as soon as 
the patient has sufficiently recovered to make operation upon the 
neck safe. Operation for resection of the jaws is described on 
pages 433, 435 and 441 in connection with operations upon the 
maxillae. 
Fig. 313 is a section of a growth which is an example that should 
be particularly borne in mind by dentists. The patient, a man, 
aged sixty-one years, was treated by a dentist for so-called pyor- 
rhea alveolaris affecting the lower incisor teeth. These were later 
removed and a piece of bridge-work inserted. A tendency to per- 
sistent disease of the mucous membrane under the bridge was 
treated for some months. Quite by chance he came under the 
care of another dentist, who immediately removed the bridgework 
and advised proper examination. When referred to the author 
there was evidence of a slight progressive ulceration involving the 
gum and mucous membrane in the anterior part of the jaw. Sec- 556 
TUMORS 
tions of tissue from the gum, sublingual glands, under surface of 
the tongue, other portions of the floor of the mouth, and adjoin- 
ing border of the lip showed carcinoma. Thus under the very 
eyes of the dentist the case had progressed from a simple condition 
to the point of utter hopelessness, because proper treatment would 
have meant complete resection of the lower jaw, removal of the 
tongue and floor of the mouth and glandular structures throughout 
the neck, with little hope of survival and none for future comfort. 
Fig. 313.-Section of cancer in case of a man, aged sixty-one years, that involved 
the lip, jaw, sublingual glands, and alveolar structures, which was treated as pyorrhea 
alveolaris for a long period of time until properly diagnosticated. 
Both surgeons and dentists should be on the lookout for mal- 
posed, impacted, or unerupted teeth, especially late in life, and use 
the z-rays whenever necessary to determine their presence. ' 
The following cases of the author were allowed to reach a hope- 
less condition before the cause was discovered: 
A woman, aged sixty years, gave a history of necrotic condition 
of the lower jaw, which was due to an unerupted tooth. Its removal, 
however, was not accomplished until carcinoma was well under 
way and had involved other structures extensively. 
A woman, aged seventy-one years, had worn artificial dentures CARCINOMA-CANCER 
557 
for many years. A cuspid tooth was found lying close under the 
floor of the nose, and resulted finally in sarcoma and death. 
A man, aged about thirty-seven years, had an impacted lower 
third molar. Before coming under the author's care the disease 
had progressed beyond operative limitations. 
If the first sources of irritation had been discovered in these 
cases before malignancy developed, the author believes there 
would, in all probability, have been no malignancy in that region. 
Even if discovery had not occurred before this prompt diagnosis 
would have made it possible to operate successfully. CHAPTER IX. 
DISEASES OF THE MAXILLARY SINUS. 
In the light of present knowledge of the nasal accessory sinuses 
in man it is evident that pathological conditions of the maxillary 
sinus are so often intimately related to diseases of the other acces- 
sory sinuses that both the etiology and treatment of any one of 
them must be more or less governed by the influence of others 
that may be involved. 
A chapter devoted to consideration of the maxillary sinus would 
therefore be out of place in this work, without description in detail 
of the surgical and therapeutic measures required for the treat- 
ment of each one of the accessory nasal sinuses, were it not for the 
fact that the maxillary antrum has also an important relation to 
diseases of the buccal cavity. These can best be understood and 
diagnosticated by those whose training has made them conver- 
sant with affections of the jaws and teeth, and it is of the utmost 
importance that the subject be given the fullest possible prominence 
from this point of view. 
The author is deeply impressed with the urgent need of develop- 
ment of maxillary sinus treatment along these lines; he is also no 
less convinced that operations upon the frontal, ethmoidal, and 
sphenoidal sinuses and cells can, for the greater part, be more 
successfully performed by operators whose field of practice is con- 
fined to the nose and its diseases; therefore the reader is referred 
to works of this character for more complete description of opera- 
tions upon these sinuses. 
For many reasons this line of demarcation is not clearly defined. 
Many cases could be cited in which some undiscovered septic 
condition of the mouth has caused recurrence and continuance 
of maxillary sinus disease in spite of repeated and otherwise per- 
fectly performed operations by those who were unfamiliar with 
pathological affections of the oral cavity and its associated parts. 
On the other hand, an equal or perhaps greater number might be 
described in which long suffering and ultimate disaster were brought 
about through failure to diagnosticate and establish a cure of dis- 
ease of the nose or nasal accessory sinuses. The operator, though ANATOMICAL CONSIDERATIONS 
559 
skilled in mouth treatment, could not without aid, which was not 
sought at a sufficiently early date, detect the existence of the 
counteracting conditions. 
The author's purpose is so to cover the subject of the maxillary 
sinus and its diseases in all respects as to make possible a more 
general common understanding of the important features of these 
Hiatus 
semiluminari. 
Middle ethmoidal 
cells. 
-Crystalline lenses. 
.Uncinate process. 
.Middle turbinated 
bone. 
'Middle meatus. 
"Maxillary sinus. 
Inferior meatus. 
Inferior turbinated bone 
-Vestibule of mouth. 
-First molar. 
Distal root first molar 
■Inferior dental nerve^ 
Fig. 314.-Anterior view of a vertical transverse bilateral section of the head, 
showing the relations of the jaws and indicating the positions of the turbinates, 
antra, etc. 
affections. This he hopes will lead to a more satisfactory coopera- 
tion than there has been in the past between dentists, rhinologists, 
specialists in sinus operations, and oral surgeons, to the end that 
better results from treatment may be assured. 
Anatomical Considerations.-The maxillary sinus (antrum of 
Highmore) is the largest air cavity associated with the nasal cham- 560 
DISEASES OF THE MAXILLARY SINUS 
ber (Fig. 314). It is situated in the body of the maxilla on each 
side. The shape, size, and thickness of its walls vary greatly in 
different individuals and frequently upon the two sides of the same 
individual. The controlling influence in this respect may be said 
to be age, race, the presence or absence of teeth and tooth germs 
within the jaw, and developmental conditions influencing surround- 
ing bones. It is lined with mucoperiosteum surmounted by ciliated 
epithelium. The typical sinus is pyramidal in shape, the apex 
being toward the malar bone. 
Schaeffer1 gives the following averages based on the measure- 
ments of 90 adult specimens: 
Millimeters. 
Dorsosuperior diagonal 38.0 
Ventrosuperior diagonal . . .38.5 
Supero-inferior 33.0 
Ventrodorsal 34.0 
Mediolateral . . .23.0 
The five walls are the inferior (floor), anterior (facial), posterior 
(zygomatic), superior (roof or orbital), and proximal (nasal). 
The ostium maxillare, an oval-shaped foramen usually situated 
on the upper anterior portion of the proximal wall, gives communi- 
cation between the sinus and the nasal fossa through the hiatus 
semilunaris. 
Partial bony or membranous septa extend across the sinus in 
some cases, and are a frequent source of trouble in treatment. 
Whether these ever are complete, as claimed by some authors, 
is still a matter of more or less uncertainty. 
Eminences upon the floor mark the outline of the roots of teeth, 
which are sometimes in direct communication with the sinus. 
Classification of the Diseases of the Maxillary Sinus.-(1) 
Acute catarrhal maxillary sinuitis; (2) chronic catarrhal maxillary 
sinuitis; (3) acute suppurative maxillary sinuitis; (4) chronic sup- 
purative maxillary sinuitis or chronic empyema of the maxillary 
sinus; (5) diseases of the bony walls of the maxillary sinus; (6) 
foreign bodies in the maxillary sinus; (7) infectious diseases; 
(8) polypi; (9) cysts of the maxillary sinus; (10) tumors. 
Etiology.-Predisposing Causes.-Since drainage and ventilation 
are essential to the health of a mucus-lined cavity, anomalies of 
development in the form of the structures of the nose, the nasal 
accessory sinuses and their ostia, may predispose to maxillary 
sinus disease. Irregular, supernumerary, diseased, neglected, and 
1 Ann. Otol., Rhinol., and Laryngol., December, 1910. NASAL ETIOLOGICAL FACTORS 
561 
uncleanly teeth and mouths may also favor these affections. Con- 
ditions of general health, age, sex, climate, exposure, habits of 
life, and similar factors, insofar as they may tend to reduce resist- 
ance to pathogenic microorganisms, likewise act as predisposing 
influences. 
Exciting Causes.-In a general way and approximately in the 
order of their frequency these may be said to be extension of disease 
from the nose, mouth, other nasal accessory sinuses, or from the 
orbit; occlusion of the ostium maxillare; infection, either through 
the nose, mouth, or other accessory sinuses, or through the circu- 
latory channels; traumatic injury; cystic formations in the mucous 
glands, or those connected with the surrounding walls; and neo- 
plasms primarily situated in the antrum or involving it by invasion. 
Nasal Etiological Factors.-It is known that with acute coryza 
(acute rhinitis) there may be extension of disease to the maxillary 
sinus by continuity of mucous membrane surface, and infection. 
As a result, hypersecretion involves and engorges the maxillary 
sinus. Therefore the causes of acute rhinitis, which are infinite 
in number, may also be accounted exciting factors in the causation 
of maxillary sinus disease. Among these more particularly might 
be noted infection by the Micrococcus catarrhalis, Bacillus seg- 
mentosus,1 pneumococcus, and the infections of influenza, typhoid, 
smallpox, measles, diphtheria, and other exanthematous fevers. 
Chronic rhinitis with turgescence, hypertrophic rhinitis, hyper- 
plastic rhinitis, and atrophic rhinitis may result from factors 
already described as leading to acute rhinitis. This is especially 
true when there are deviations of the septum or other nasal obstruc- 
tions which in the course of chronic disease may cause turgescence 
of the "swell bodies" of the inferior turbinates and hyperplasia of 
the mucous membrane of the middle turbinal, the ethmoidal cells, 
and other structures. Under these conditions there is usually 
retention of secretion by the close approximation of the septum to 
the middle turbinate, and the resulting unhealthy conditions cause 
this to act as an irritant in passing over the mucous membrane 
of the middle and inferior turbinate, thus giving rise to morbid 
changes in these structures. Whether purulent, serous, or mucous 
in character, the secretion frequently fills the maxillary sinus 
through the ostium, which at times becomes obstructed and results 
in its engorgement. This mucous engorgement of the maxillary 
sinus has by some authors been described as a distinct disease, 
1 Walter: Jour. Am. Med. Assn., p. 276. 562 
DISEASES OF THE MAXILLARY SINUS 
whereas it is properly only a symptom occurring in the course of 
other pathological conditions. Affections of the vasomotor ner- 
vous system and general diseases, such as diabetes, scorbutus, 
rheumatism, and similar disorders, are quite commonly associated 
with both acute and chronic disease. Nasal polypi in the region 
of the ostium maxillare not infrequently cause obstruction and 
lead to maxillary sinus disease. 
The obstructive lesion, according to Ballenger,1 may be a deflec- 
tion of the nasal septum, an enlarged or cystic turbinate, an enlarged 
Fig. 315.-The "vicious circle" of the nose; b, the spheno-ethmoidal fossa; c, the 
superior turbinated body; d, posterior ethmoidal cells; e, bulla ethmoidalis;/, anterior 
ethmoidal cells draining into the frontonasal canal; g, frontal sinus; h, the ostium 
of the bulla ethmoidalis; i, hiatus semilunaris; fc, the uncinate process or outer wall 
of the infundibulum or gutter on the outer wall of the nose into which the frontal, 
anterior ethmoidal, and maxillary sinuses usually drain. The high light below and 
anterior to / and k indicates the inferior boundary of the infundibulum or gutter into 
which the sinuses drain. The middle turbinated body is removed to exhibit the 
anatomical details beneath it. (Ballenger.) 
bulla ethmoidalis, or cells in the uncinate process, the median wall 
of the infundibulum. The area to be examined is shown in Fig. 
315 within the circle. These structures he has designated as the 
"key" to inflammation of the sinuses, or the "vicious circle" of 
the nose. 
Nasal operations may lead to infection of the sinuses. Injudi- 
cious dressings, foreign bodies in the nose, either in the form of 
1 Diseases of the Throat, Nose, and Ear, 1914, 4th Ed. ORAL ETIOLOGICAL FACTORS 
563 
splints or dressings or those of accidental lodgment, may excite 
irritation by blocking the ostium or damming back the secretions 
until they are forced into the sinuses and cause sinuitis. 
Nasal polypi may cause obstruction leading to unhealthy con- 
ditions or be so situated as to obstruct the ostium directly and 
thus cause sinus disease. 
Oral Etiological Factors.-There has been and is at the present 
time much diversity of opinion with regard to the frequency with 
which diseases of the teeth and structures of the mouth cause 
antral disease. The older writers, if dentists, were for the greater 
part inclined to the belief that empyema of the maxillary sinus 
was almost invariably caused by diseased teeth, while authors with 
practices limited to the nose and its affections quite universally 
inclined to an almost opposite view. Today, with a better general 
understanding of diseases of the nose and mouth, the differences 
of opinion are less apparent, but there should be even greater 
unanimity in this respect. 
Tiffany1 says: "Diseases of the antrum occur as a result of 
injury, and as an extension from a diseased tooth." 
Baer2 quotes Brophy as claiming that at least 85 per cent, of 
the cases of antral disease are caused by the teeth. While very 
wisely calling attention to the fact that it would require the com- 
pilation of a great many cases to prove the matter one way or 
the other, he states that out of 28 cases that he himself has treated, 
25 started primarily in the teeth, while 3 developed secondarily 
to primary involvement of the frontal sinus. 
Ballenger states that the maxillary sinus may be infected from 
the nose or the teeth, the cases probably being about equally 
divided between these two sources of infection. McCurdy3 quotes 
Dmochowski, who, after making 150 autopsies, holds that but few 
cases have a dental origin, and Fletcher, who examined 500 
skulls, in 252 of which were abscesses of the upper molars, found 
only 12 molars perforating the floor of the antrum, and stated that 
he had never seen a case of antral disease caused by carious teeth. 
Marshall has expressed the belief that alveolar abscess is the 
most common factor in producing suppurative conditions of the 
antrum of Highmore. 
These differences of opinion can doubtless be explained as being 
chiefly due to the following reasons: 
1 American System of Dentistry, iii, 562. 
2 Dental Cosmos, July, 1911, p. 761. 
3 Oral Surgery, p. 115. 564 
DISEASES OF THE MAXILLARY SINUS 
1. Diseases of the maxillary sinus, as of the other sinuses, has 
only recently been diagnosticated in approximate proportion to its 
frequency of occurrence. Therefore many cases not having an 
external dental lesion to call attention to their existence, and with- 
out objective nasal symptoms sufficiently marked to lead to dis- 
covery, have passed unnoticed. Under past methods cf diagnosis 
the cases caused by diseased teeth were more likely to be recog- 
nized, and thus the larger percentage of undiscovered cases would 
be of nasal origin. 
2. In the examination of dried specimens, direct openings from 
the roots of teeth into the maxillary sinus were found to be com- 
mon. It was therefore argued that when the roots of such teeth 
bore evidence of abscess, these necessarily caused maxillary sinus 
disease. But it should be remembered that in the living subject 
the lining membranes of the sinus provide serviceable protection 
against the invasion of pyogenic microorganisms, especially when 
still further protected by the lymph wall of the abscess sac. It is 
now known that such an abscess may form at the root of the tooth, 
even within the bony enclosure of the antrum, without actual 
infection passing through the lining mucous membrane of the 
sinus. 
In many cases of necrosis involving the bony walls, even when 
fractured, the same membranous protection is afforded. Unless 
the soft tissues within the sinus are ulcerated or punctured, as 
sometimes occurs unnecessarily through injudicious attempts at 
diagnosis or treatment, there often need be no antral disease other 
than the external lesion. 
The author is convinced that no satisfactory estimate can be 
made as to the relative frequency of oral and nasal causes of antral 
disease. He believes that in the future the latter will probably 
be found to outnumber the former very greatly, owing to better 
diagnostic methods and improved treatment of the diseased roots 
of teeth, and above all, perhaps, because of the prevention of these 
by oral prophylaxis. He has seen large numbers of patients who 
suffered for many years from the local and general disturbances 
that were incidental to maxillary sinus disease and from many 
unnecessarily ineffective operations that might have been avoided 
had there been early recognition of quite simple and to the trained 
observer perfectly obvious diseases of the teeth and mouth, and for 
this reason he has no desire to underestimate the actual impor- 
tance of careful study of and constant watchfulness for factors of 
this nature in diagnosis. OTHER NASAL ACCESSORY SINUSES 
565 
Other Nasal Accessory Sinuses.-Diseases of the antrum of High- 
more may result from primary pathological conditions of the 
frontal, ethmoidal, or sphenoidal sinuses and cells, and these in 
turn are likewise affected secondarily from the maxillary sinus. 
Figs. 316, 317 and 318 are illustrations of conditions favorable to 
such extension of disease. The decision as to which one of the 
accessory sinuses most often communicates infection to the others 
necessarily depends upon the identification of the one most fre- 
quently diseased. 
Ballenger states that the maxillary sinus is perhaps more often 
affected singly than any of the other sinuses, because in about 
Fig. 316.-Anterior view of vertical transverse section in the region of the first 
molar teeth, showing anterior ethmoidal cells and a cell in the crista galli. The frontal 
sinus extends downward, becoming common with the ethmoidal cells and antrum. 
(After Cryer.) 
one-half of the cases it is infected from the teeth rather than from 
the nose, whereas the other sinuses are nearly always infected 
from the nose. Having a common source of infection, they are 
therefore more often simultaneously diseased. 
He also claims that knowledge of the diseases of the sinuses in 
general has so greatly increased during the last few years that 
ethmoidal, sphenoidal, and frontal sinus affections are diagnosti- 
cated twenty times as often as they used to be. The author is 
convinced that in the near future the importance of these diseases 
from a pathological point of view will be greatly increased, and 
they will be recognized much more frequently than at present. 566 
DISEASES OF THE MAXILLARY SINUS 
J. P. Tunis,1 in his report on inflammations of the maxillary 
sinus with special reference to empyema, based upon the study of 
Infra-orbital sinus 
Infra-orbital canal 
Hiatus 
semilunaris 
Fig. 317.-View of a vertical transverse section through the first molar teeth. 
The right hiatus semilunaris in this subject communicates with the maxillary sinus 
without a true ostium maxillare. (After Cryer.) 
Fig. 318.-Anterior and posterior views of a vertical transverse section in the 
region between the second premolar and first molar teeth, showing a wire passing 
from the frontal sinus into the maxillary sinus. The frontal sinus extended downward 
to nearly the level of the upper portion of the antrum. (After Cryer.) 
1 Laryngoscope, October, 1910. OTHER NASAL ACCESSORY SINUSES 
567 
100 unselected heads examined a few hours after death in the 
autopsy room of the Vienna General Hospital, gives the following 
conclusions: 
"1. In the examination of 100 heads in the autopsy room, 37 
per cent, showed some evidence of pathological changes in the 
maxillary antra. 
"2. Of these 37 cases, 11 were examples of edema, 12 were 
examples of chronic inflammation of empyema, 1 was an example 
of an alveolar or dental cyst, and 13 were examples of retention 
cyst. 
"3. With one or two exceptions all of these cases were undiag- 
nosticated during life. 
"4. The presence of a large amount of pus in 10 out of 12 of 
these cases of empyema may have played an active part in causing 
the death of the patients." 
Schaeffer1 says: "Of the specimens" (ninety) "studied to ascer- 
tain the frontomaxillary relations, 56 per cent, showed that the 
infundibulum ethmoidale was intimately related with the naso- 
frontal duct, or with the sinus frontalis directly in case the naso- 
frontal duct was wanting; 40 per cent, showed that the nasofrontal 
duct directly communicates with the meatus nasi medius, the 
infundibulum ethmoidale ending blindly or in air cells; 2.5 per 
cent, showed two nasofrontal ducts, one continuous with the infun- 
dibulum ethmoidale, and the other communicating with the meatus 
nasi medius; 1.25 per cent, showed a direct communication between 
the sinus frontalis and maxillaris. 
"Since the infundibulum ethmoidale receives the ostium max- 
illare at its dorsal and inferior end in all cases, and the nasofrontal 
duct, or the sinus frontalis directly, at its ventral and superior 
end in over one-half the cases, it frequently serves as a gutter-like 
channel, of varying depth and efficiency, communicating between 
the frontal region and the sinus maxillaris. 
"The sinus maxillaris therefore acts as a reservoir for fluids 
coming to the dorsal end of the infundibulum ethmoidale (the 
ostium maxillare being patent). 
"Frequently the processus uncinatus by a superior curving at 
its dorsal end causes the infundibulum ethmoidale to end in a 
pocket. This pocket is so situated that it directs fluids coming 
to the dorsal end of the infundibulum ethmoidale into the sinus 
maxillaris via the ostium maxillare, which is in the immediate 
vicinity. 
1 Ann. Otol., RhinoL, and Laryngol., December, 1910. 568 
DISEASES OF THE MAXILLARY SINUS 
''Occasionally branches of the superior alveolar nerves in passing 
to the superior dental plexus pass entirely through the walls of 
the sinus, thence under cover of the mucous membrane of the 
cavity to their destination. Rarely the anterosuperior alveolar 
ramus, instead of taking its usual course, passes diagonally from 
the roof of the sinus to its ventral wall-the nerve thus suspended 
freely in the cavity is merely covered with the mucous membrane." 
Dr. Walter V. Brem, of Los Angeles, formerly of the Colon 
Hospital, Cristobal, Canal Zone, has given the author a most 
interesting record of his postmortem examinations of the accessory 
sinuses while acting pathologist at the Ancon Hospital. The 
sphenoidal, frontal, and maxillary sinuses were examined in about 
300 bodies of patients who died of various diseases. Of these, 
about 140 deaths were due to pneumococcus infections. All cases 
of Pneumococcus meningitis showed purulent inflammation of one 
or more of the nasal accessory sinuses. About 70 per cent, of 
the pneumonia cases showed the same thing. Purulent involve- 
ment was found not infrequently in other cases, and chronic and 
subacute inflammations in about 40 per cent. In approximately 
14 per cent, of the non-pneumococcic deaths pneumococci were 
present in one or more of the sinuses. Cocci and unidentified bacilli 
were frequently present. In many of these sinuses the lining 
membranes were thickened, and moist and stained smears showed 
pus cells and bacteria. 
Circulatory Channels.-Diseases of the blood and infections car- 
ried through the circulation may affect the maxillary sinus in the 
same manner as the other anatomical parts. The character of the 
lesion would necessarily depend upon the nature of the infection. 
Traumatism.-Traumatism through injury to external structures 
may excite inflammatory conditions, which in the course of their 
progress sometimes involve the antrum, or fracture of the bony 
walls may open the way for infection. It has been usual in the 
author's experience to find that fractures of the superior maxilla, 
including the walls of the maxillary sinus, even though there may 
be considerable discharge of pus, rarely cause continued empyema. 
In most cases the lining membranes of the sinus protect it against 
direct infection if these are not lacerated, and even when infection 
has occurred and an acute empyema has resulted, the symptoms 
quickly subsided after the fracture was united. 
Symptoms.-Acute Catarrhal Sinuitis.-Pain.-In this form of 
sinus disease there is a sense of fulness on the affected side, or 
pain which is sometimes manifested in the form of a dull headache, CHRONIC SUPPURATIVE SINUITIS 
569 
although occasionally it is more severe and quite generally dis- 
tributed over the frontal, occipital, and facial regions. It may be 
acute, distinctly infra-orbital or supra-orbital, or be chiefly confined 
to the eyeball through pressure from beneath the floor of the 
orbit. 
Discharge.-The nasal discharge in acute rhinitis, which usually 
accompanies this class of cases, is often so active as to prevent 
the sinus discharge from being recognized as a distinct diagnostic 
feature. 
Chronic Catarrhal Maxillary Sinuitis.- Discharge.-These cases 
usually give history of previous acute catarrhal attacks. The 
buccal and palatal walls of the sinus are almost invariably thin, 
and yield to pressure on account of enlargement of the sinus through 
being filled with fluid and long continuation of disease affecting 
the bony walls. Unilateral discharge is usually a more or less 
constant symptom, and when not sufficiently marked, intranasal 
examination will almost invariably disclose that the naris on the 
affected side gives evidence of some form of chronic rhinitis. Usually 
tissues surrounding the ostium appear diseased, and occasionally 
polypi within the maxillary sinus may be diagnosticated through 
the ostium by intranasal examination. More often polypi limited 
to the nasal meatus are present, although this is not pathognomonic 
of antrum suppuration, as was formerly supposed. 
Pain.-Pain in these cases is usually not severe, may be entirely 
absent, or may appear and disappear from time to time as repeated 
engorgements of the sinus occur, or there may be distinct involve- 
ment of the fifth nerve, especially the infra-orbital division which 
passes across the walls of the sinus and in many cases lies com- 
pletely within the bony encasement, protected only by the lining 
membranes, and therefore easily subject to pressure from fluid or 
the direct influence of continued inflammatory conditions. Chronic 
neuralgia, sometimes in the form of tic douloureux, is frequently 
associated with these cases. 
Acute Suppurative Sinuitis.-The symptoms of acute empyema 
are much like those of acute catarrhal conditions, except that 
owing to the presence of pus and formation of gases, the symptoms 
are likely to be in all respects more severe, both pain and pressure 
being, as a rule, quite marked. The unilateral discharge is more 
often a prominent feature, and the dripping of the foul secretions 
into the pharynx is a noticeable and disagreeable symptom. 
Chronic Suppurative Sinuitis.- Discharge.-Unilateral discharge 
is a characteristic symptom of these cases, but is not always a 570 
DISEASES OF THE MAXILLARY SINUS 
dependable indication, because infection may extend to the oppo- 
site sinus, and with the maxillary antra on both sides diseased, 
the discharge would probably be bilateral. 
Pain.-Pain may be entirely absent except during occasional 
acute attacks, or may be of general character; it may be distributed 
through the various divisions of the fifth nerve on the affected 
side or confined to one of them; and it may appear to be directly 
connected with the affected sinus, or reflected to some more remote 
division. There may be tenderness to pressure in the region of 
the infra-orbital or the supra-orbital foramina, or both. Slight or 
severe pain may be felt in the eye or may be entirely absent, or only 
sufficient to produce a stiffness in movement, or the floor of the 
orbit may be forced upward by pressure sufficiently to excite pain 
in the eyeball and cause it to be so compressed as to have the 
appearance of glaucoma. 
Other Symptoms.-The bony walls of the antrum may be bulged 
outward and cause noticeable swelling on the affected side, or 
there may be no outward sign of the disease other than the thin- 
ness of the external wall, which causes it to yield to pressure with 
a more or less crepitant sound. Examination of the ostium usually 
discloses discharge of pus, which, if wiped away, appears again. 
By packing the ostia of the other sinuses and applying suction, 
the pus from within the maxillary sinus can be brought into view. 
In many of these cases there is a history of awakening in the morn- 
ing with a foul mass of secretion in the pharynx, an unpleasant 
odor which disappears during the day, and a sense of fulness or 
even pain which is relieved by lying with the face turned upon the 
opposite side. 
Differential Diagnosis.-The clinical aspect of maxillary sinus 
disease so seldom presents a typical series of symptoms that it is 
frequently necessary to make diagnosis from some one or more of 
the indications which lead to suspicion of the existence of the 
affection. Under these circumstances it is important that a num- 
ber of diagnostic aids should be employed in order that correct 
diagnosis may result. 
Nasal Discharge.-In acute maxillary sinuitis the unusual secre- 
tion and other symptoms which accompany ozena are unmistak- 
able. Quite frequently upon stooping or turning the head upon 
one side there is a momentary gush of fluid from the nose. In 
chronic cases the only indication of unilateral discharge may be 
an unhealthy appearance at the external opening of the naris on 
the affected side, or the patient may admit being barely conscious PAIN IN DISEASES OF THE MAXILLARY SINUS 
571 
of freer discharge from one naris than the other. There may or 
may not be a foul odor from the nasal secretion or from the patient's 
breath; on the other hand, constant dropping of foul secretion from 
the nasopharynx is sometimes a distinguishing feature, or this may 
only be noticed upon waking in the morning. In marked cases 
the unilateral nasal discharge is quite evident. A sense of fulness 
and discomfort when the patient lies with the head turned upon 
the affected side, which is correspondingly relieved by lying upon 
the opposite side, or cessation of the discharge when lying upon 
the back, are symptoms of importance. The presence of diseased 
secretion in the maxillary antrum, when not otherwise demon- 
strable, may be tested by suction applied at the ostium maxillare 
to draw out the fluid and allow its nature to be determined. In 
differential diagnosis to decide whether the case is one of simple 
empyema (confined to one sinus) or whether the discharge comes 
from the maxillary or some other sinus, pack the region of the ostia 
of all the sinuses except the maxillary and then apply suction. 
In open empyema (with the ostium open) these tests will be effi- 
cient, and in closed empyema (with the ostium closed) the result 
will be negative. 
In latent empyema, a case in which the ostium is not fully closed 
and not completely open, secretion may be drawn from the sinus, 
but not as freely as in open empyema cases. 
Intranasal Examination.-Internal examination of the nose will 
sometimes show an appearance of ulceration or other disease of 
the mucous membrane in the region of the ostium. This indicates 
that it is more or less constantly bathed with vicious fluids, even 
though this may not be apparent through an external discharge 
and may not at the moment be otherwise demonstrable. It must 
be remembered that in chronic antral disease there is great differ- 
ence in the quantity and nature of the secretions at different times. 
An ordinarily open ostium may for the time being be closed by 
inflammatory processes affecting the surrounding mucous mem- 
brane, or be occluded by a polypus or some other obstruction, and 
thus in effect be the same as closed empyema.. The inner wall of 
the antrum is sometimes forced toward the septum. 
Pain.-In acute cases, whether the fluid be pus or other secre- 
tion, the pain sometimes is intense owing to pressure upon the 
nerve as previously described. In chronic empyema the same 
condition may occur during acute attacks, or for the same reasons 
there may be periods during which pain may be distributed over 
the entire side of the face and extend to the frontal, temporal, and 572 
DISEASES OF THE MAXILLARY SINUS 
occipital regions. As the engorgement of the antrum becomes 
relieved, this pain gradually subsides. These cases are frequently 
mistaken for periodic migrainoid headaches until the antrum dis- 
ease is discovered by other diagnostic indications. Pressure over 
the malar bone or the infra-orbital or the supra-orbital foramina 
may elicit tenderness. A more or less considerable skin surface 
may be so hyperesthetic as to be sensitive to the slightest touch. 
Supra-orbital or infra-orbital neuralgia or pain reflected to other 
divisions of the fifth nerve or tic douloureux may be manifest with 
maxillary sinus diseases. None of these may be considered pathog- 
nomonic, because many other sources of irritation give rise to 
similar symptoms, but taken with other corroborative diagnostic 
signs their significance is valuable. 
In rare cases the sinus may be so greatly enlarged as to cause a 
bulging outward of the cheek upon the affected side until it appears 
to be swollen, but unless the infection finds its way through the 
walls of the sinus into the overlying soft tissues there is no actual 
swelling of these structures. Much more frequently the buccal 
wall is sufficiently enlarged and forced outward to be easily recog- 
nized in oral examination. Pressure with the finger along this 
wall usually discloses one or more points at which the bone is 
exceedingly thin and yielding, often with a crepitant sound upon 
pressure, especially when there has been a long-continued necrotic 
condition of the sinus. 
The palatal wall in chronic cases is generally thin and yielding, 
and not infrequently bulged out of form through enlargement of 
the sinus. 
Teeth.-The teeth upon the suspected side should receive an 
exceedingly careful examination. If diseased roots of teeth are 
present they must be tested to determine whether they may not 
have been the first cause of the antral disease. The socket of any 
diseased root that it may be necessary to extract should be disin- 
fected and a probe forced gently upward to the end of the alveolus, 
to determine whether it actually enters the sinus cavity. Great 
care should be exercised to avoid forcing the probe upward in such 
a manner as to carry infection that might not otherwise reach it 
directly into the sinus. 
When there is no evidence of dental caries or dento-alveolar abscess, 
teeth with fillings should be tested with hot gutta-percha, hot 
instruments, or ice. The light reflected from an electric mouth 
lamp should be employed to ascertain the condition of the tooth 
pulps. If the tooth crowns are dark and it is evident that the PLATE XVIII 
Right 
Left 
Transillumination of the Antra. (Coakley.) 
Right, healthy; left, diseased. RADIOGRAPHS IN DISEASES OF MAXILLARY SINUS 
573 
pulps have been -devitalized in the course of treatment or through 
some pathological process, the question as to the proper filling of 
the roots must be determined. 
The absence of a normal tooth from the jaw upon the affected or 
suspected side must be accounted for either by history of previous 
extraction or its position if unerupted must be definitely deter- 
mined. The presence or absence of supernumerary teeth must also 
be considered and tested. Interstitial gingivitis, ulcerative or other 
forms of stomatitis, will be readily recognized, and with a probe 
the passageway for infection located. 
Transillumination.-The patient is placed in a dark room and the 
lips are tightly closed around an electric light held in the mouth. 
When the appearance is as shown in Plate XVIII, and there is 
opacity over the lower eyelid, a non-luminous pupil, absence of sense 
of light when the eye is closed, and a darkened area outlining the 
antrum on the affected side, the indications would point to empyema 
of the maxillary sinus. The difficulty, however, with this method 
of diagnosis lies in the fact that maxillary antra sometimes vary 
so greatly in size and the thickness of their walls in the same indi- 
vidual. The author has repeatedly noted marked opacity upon 
one side in the region of the maxillary sinus in comparison with 
the opposite one, even when both antra were normal. 
Ballenger, who recognizes the uncertainty due to anatomical 
differences, says the three points to be noted in transillumination 
are: (1) The red pupillary reflex; (2) the crescent of light correspond- 
ing to the position of the lower eyelid; and (3) the sense of light in 
the eye when closed. If the red pupillary reflex and the crescent 
of light are absent the antrum is probably affected. By noting 
both sides at once it may be determined which side, if either, of 
the maxillary sinuses is affected. 
Radiographs.-The use of the z-rays is undeniably valuable in 
these cases. It is the most reliable method of determining the 
etiological relation of teeth and roots in many respects that other- 
wise might be exceedingly difficult or impossible to distinguish. 
Root fillings that have been imperfectly inserted, crowns attached 
with pins that project through the sides of the roots, extensive 
dento-alveolar abscesses, and the acute penetration of roots into 
the antrum, as well as the presence and situation of impacted 
teeth, may be causes of maxillary sinus disease or the presence of 
such teeth within the maxillary sinus itself. 
Fractures and diseased conditions of the antral walls that might 
otherwise escape notice are also shown by this aid. How far the 574 
DISEASES OF THE MAXILLARY SINUS 
average radiograph may be trusted in portrayal of the disease 
itself is a matter of grave question. Sometimes, undoubtedly, 
empyema is plainly discernible in this way; but it is not safe to 
be too positive in regard to this evidence without confirmation 
from some other indication. 
Fig. 319.-Radiograph showing left maxillary sinus cloudy when compared with 
the opposite antrum, an indication that it is full of pus. 
Puncture.-Puncture of the maxillary sinus through the inferior 
meatus to permit the withdrawal of its contents by suction, aspi- 
ration, or washing out through the ostium is one of the final methods 
of determining the actual state of the sinus. Puncture with a 
trocar and cannula through the anterior wall gives the same result, 
and if carefully done is not likely to cause infection, but carelessly 
done, a previously healthy sinus might be infected. 
Prophylaxis of the Maxillary Sinus.-Study of sections of the 
heads of embryos shows that from the fourth month of embryonic 
life, when development of the maxillary sinus takes place by invagi- 
nation of the lining membrane of the nose from the hiatus semi- 
lunaris, until birth, certain marked changes take place. All of ALVEOLAR OPERATION 
575 
these are subject to developing dental organs, and after birth this 
same developmental dependency continues throughout the period 
of growth. 
With these principles rightly comprehended, it must be apparent 
that in the course of the development which precedes the eruption 
of the permanent teeth, and afterward during their existence, oral 
hygiene, oral and dental prophylaxis, the care of children's teeth, 
and above all prompt attention to the early expansion of dental 
arches (described on pp. 621 and 622), are measures of vital impor- 
tance in endeavoring to avoid pathological states of the maxillary 
and accessory sinuses. 
Laying aside for the moment all corroborative knowledge gained 
through unlimited and undisputed clinical evidence of the fre- 
quency of pathological conditions of the nasal accessory sinuses 
in individuals who have any of the associated nasal, palatal, or 
maxillary malformations, the result of restricted maxillary growth 
upon the nose, as shown in the groups of sections of dogs' heads 
(p. 639), is alone sufficient to banish every doubt of the great 
advantage as a preventive measure of giving free and unrestricted 
growth to all this region, by prompt and efficient separation of the 
maxillae. 
Similarly, any abnormal tendency evidenced in the nose and 
throat should receive treatment. The removal of adenoids, of 
enlarged tonsils, and the correction of hypertrophic or other intra- 
nasal conditions that predispose to disease are demanded quite as 
much for the prevention of future sinus disease as for the immediate 
remedial effect upon the nasal condition. 
Surgical Treatment of the Maxillary Sinus.-The following 
operations are the ones usually employed: (1) Alveolar, (2) palatal, 
(3) intranasal, (4) Kuster, (5) Caldwell-Luc, (6) Denker, and (7) 
Canfield-Ballenger. 
Alveolar Operation.-The alveolar operation, sometimes called 
the Cooper operation, has been extensively practised in this and 
other countries. In this method a tooth or root was extracted and 
its socket enlarged and elongated until an opening into the antrum 
was effected. In edentulous jaws an opening was made through 
the alveolar ridge of the mouth into the sinus. Irrigation and 
drainage through this opening were supplemented by the use of 
drainage tubes of rubber or metal, which were kept in place by 
attachment to teeth or to plates resting on the surface of the jaws. 
It seemed a most radical and effective surgical procedure after 
the earlier and still less effective plan of treatment by irrigation 576 
DISEASES OF THE MAXILLARY SINUS 
through the root canal of a tooth, which most dentists formerly 
employed. 
Large numbers of cases of antral empyema have been success- 
fully treated by the alveolar method, but other operations are to 
be preferred, principally for the following reasons: (1) It is not 
always necessary to sacrifice a tooth because the maxillary sinus 
is diseased. No tooth should be lost that a skilful dentist can 
make useful and cure with sufficient certainty to remove danger 
of future infection from this source. (2) The thickness of bone 
structure between the apical end of the alveolus of the extracted 
tooth root and the sinus, is usually greater than one unaccustomed 
to the operation would expect. Raw surface is thus exposed to 
infection, and more pain caused in packing or irrigation than is 
necessary for even more radical operations. (3) In many cases it 
is impossible to gain complete access to all parts of the sinus through 
openings of this kind and of the size usually recommended. (4) 
No drainage tube can be inserted with certainty of giving 
complete drainage for a sufficient length of time to be effective. 
Those worn, as many were, for periods of ten, fifteen, or twenty 
years, simply served to prevent acute attacks and also as effec- 
tively prevented the possibility of cure. 
It is frequently advisable to extract one or more diseased teeth 
when these are etiological factors or a menace to the future health 
of the sinus. In such cases the socket should be reamed out and 
the opening enlarged, but the regular operation for radical treat- 
ment must be performed without reference to the alveolar opening, 
except that by extending it to the tooth socket the fullest possibility 
of access and drainage is secured. 
Palatal Entrance.-Treatment through an opening in the palatal 
wall may sometimes be necessary when pus has already found an 
exit in that direction and a large portion of this bone surface has 
been destroyed. Those who are familiar with the difficulty of keep- 
ing the antrum clean during the very slow progress of closure of 
an opening in this situation are not likely to adopt it as a regular 
procedure when once cognizant of the advantages of other methods. 
When this is done, however, it is possible to curette and pack 
the sinus quite satisfactorily. 
Intranasal Operation.-Puncture of the naso-antral wall and 
irrigation through a cannula are sometimes all that is necessary 
for the cure of acute inflammatory conditions of a maxillary sinus, 
especially when there is no history of similar attacks. The trocar 
and cannula may be passed through the naso-antral wall at the REMOVAL OF THE NASO-ANTRAL WALL 
577 
inferior meatus or the anterior wall at the canine fossa. The naso- 
antral entrance is preferable because it offers less opportunity for 
infection. A cannula can be passed into the antrum almost as 
easily at this point as through the oro-antral wall at the canine 
fossa. If carefully done, however, puncture through the thinnest 
portion of the anterior wall offers an exceedingly direct and simple 
method of entrance; with proper antiseptic precaution the danger 
of infection need not be seriously considered. 
When the trocar is withdrawn, a rubber tube is attached to the 
cannula, and through this irrigation with normal salt solution is 
continued until the fluid as it passes from the nose becomes clear 
and inoffensive. When the ostium is closed, whether it be due to 
abnormal development, temporary obstruction by inflammatory 
processes, polypi, or crusts, this method will not be successful, 
because the fluid will simply serve to increase the engorgement of 
the antrum and be likely to cause more or less pain through increased 
pressure. In such cases, unless the opening through the ostium 
can be reestablished, it will be necessary to make a second opening 
or to enlarge the one already made sufficiently to afford all fluids 
free exit. 
Removal of the Naso-antral Wall.-In the performance of this 
operation a large opening is made through the naso-antral wall. 
Experience has proved that small openings from the nose into the 
maxillary sinus will close, but that a large opening will remain 
permanently open. 
Local anesthesia and freedom from hemorrhage are secured by 
applications of cocain and adrenalin solution to the inferior tur- 
binal and the inferior and middle meatus. The anterior half of the 
inferior turbinate body is removed with a knife, scissors, saw, or 
other suitable instrument. Baer dislocates the inferior turbinate 
upward, and after the operation is performed replaces it. He 
claims this is a material advantage because function is not so much 
impaired in this way as when a portion of the inferior turbinate 
is removed. With the inferior turbinate out of the way the naso- 
antral wall is punctured and a large portion of its surface removed. 
There are many ingeniously devised instruments for this purpose, 
as, for example, Vail's antrum saws, Corwin's antrum chisels, 
different forms of trephines and forceps, such as the Nobel-Cordes 
forceps (Fig. 320). 
Stein1 uses his own notched gouge chisels (Fig. 321) for this 
1 Laryngoscope, St. Louis, February, 1910. 578 
DISEASES OF THE AI AXILLARY SINUS 
purpose. He describes his method of performing the operation as 
follows: 
"If a large opening into the antrum is desired one of two proce- 
dures may be followed: (1) For an opening with the removal of 
part or all of the lower turbinate. Enter one point of the V with 
Fig. 320.-Removing the naso-antral wall with the Nobel-Cordes forceps 
(Ballenger.) 
the concavity of the instrument directed toward the floor of the 
nose, just within the pyriform process of the antral wall, driving 
backward and outward until the sharp point perforates into the 
antrum cavity, then, with the instrument still in situ, depress the 
handle and push backward; this gives a gentle upward curve through 
the thin bone of the middle meatus region, one blade of the V 
being in the antrum and the other in the middle meatus. As you 
Fig. 321.-Stein's antrum chisel or gouge. 
progress backward gradually elevate the handle so as to direct the 
cutting V downward in the direction of the lower turbinate again, 
passing through it at any part the operator may select. Remove 
the instrument and reenter at the point of first incision, but with 
the handle elevated and the concavity directed upward, thus forc- THE KUSTER OPERATION 
579 
ing the instrument below the turbinate, one blade of the V being 
in the antrum and the other one in the lower meatus. Gradually 
depress the handle so as to force the cutting V to follow as close 
to the floor of the nose as the thickness of the bone at this part 
will permit, causing it finally to meet .the incision from above at 
the selected spot. The oval piece of bone made up of turbinate 
and naso-antral wall is removed with forceps en masse. (2) For 
an opening without removal of turbinal tissue. Enter one point 
of the V through the naso-antral wall of the lower meatus, namely, 
below the inferior turbinate, at a point as high up under its anterior 
attachment as possible. Push backward, keeping the cutting V 
as high as can be. When the desired length of incision is reached 
remove the instrument and reintroduce at the beginning, only 
direct the cutting V as close to the floor of the meatus as possible, 
driving backward to meet the first incision above. By using two 
instruments, with one blade of the V longer than the other, this 
latter operation is made easier, the longer blade being the one to 
perforate into the antrum." 
The Kuster Operation.-In performing this operation the anterior 
wall of the antrum is opened through the canine fossa. This open- 
ing should be large enough to permit the introduction of the index 
finger. In this way septa, sequestra of dead bone, and any abnor- 
mality in form of the sinus that may exist can be recognized, proper 
treatment applied, the sinus curetted and packed. 
The author's method of performing this operation is illustrated 
in Fig. 322. 
As a preliminary step the naris upon the affected side should 
be packed with gauze far enough back to cover the ostium and 
with a portion of the packing projecting out from the nose in order 
that it may be quickly removed and changed if necessary and 
that there may be no danger of its working back into the pharynx 
during anesthesia. Unless this is done much blood may be lost 
through the ostium without its quantity being noted, and hemor- 
rhage of this character adds considerably and unnecessarily to the 
danger of blood inspiration. Having packed the nose, a pad con- 
sisting of two or three gauze sponges clamped together at one cor- 
ner with the forceps is placed between the teeth. With a retractor 
a corner of the mouth is drawn back out of the way. If necessary, 
another sponge may be packed into the corner of the mouth with 
a forceps attached for safety. In this way the patient is effectively 
protected against the danger of unusual hemorrhage, and the field 
of operation is quite clear. 580 
DISEASES OF THE MAXILLARY SINUS 
The upper lip is elevated and an incision made at the labio- 
g'ngival junction, carried to the periosteum, and made sufficiently 
long to give free scope in the removal of the bony wall. Some 
little annoyance may be saved by picking up with a hemostat any 
small vessels which may threaten hemorrhage. The periosteum 
is raised sufficiently to expose the canine fossa. 
By finger pressure the most yielding place in the anterior wall 
is readily discovered. The bone at such points is usually suffi- 
ciently thin to admit the passage of a reasonably stiff probe directly 
into the sinus in an upward, backward, and inward direction. A 
Fig. 322.-Anterior wall of the maxillary sinus opened at the canine fossa. 
bur in a surgical engine is then passed through the bone following 
the direction of the probe. The purpose of this is to prevent the 
possibility of such errors as have frequently occurred when through 
some anomaly of development the sinus is unusually small and 
the naris upon the affected side much enlarged; or when some 
other unusual anatomical condition has made the exact situation 
of the sinus misleading, as a result of which the sinus has not been 
properly entered. The author has known of a number of cases in 
which irrigation had been continued for a long period without 
relief, until it was finally discovered that the opening made led 
into the nose and not into the sinus. THE KU ST ER OPERATION 
581 
The bur is then carried forward until the anterior extremity of 
the sinus is reached, and backward as nearly as possible to its full 
extent in a posterior direction. The floor is sloped downward as 
much as may be permitted without injury to the apical ends of the 
roots of the teeth, and the opening enlarged until a finger can be 
inserted. When hemorrhage becomes excessive, packing tightly 
with gauze for a few minutes will usually serve to check it suffi- 
ciently to permit careful progress after its removal. 
When the interior of the sinus is thus exposed by the aid of prop- 
erly adjusted or reflected artificial light, satisfactory examination 
of the actual conditions may be made. One's finger quickly becomes 
accustomed to areas of bone that are rough and feel dead to the 
sense of the touch. Bony septa may be mere ridges extending 
across the floor of the sinus; or a septum may extend up so high 
as to appear to form the actual sinus wall, and thus lead the operator 
to believe that the sinus has been opened completely, when) as a 
matter of fact, the most diseased portion may lie behind this 
barrier. 
Quite recently the author found what appeared to be a septum 
extending almost through the central portion of an unusually large 
sinus, and later discovered that it was the nasal wall which had 
been forced over into this position. 
A dental or surgical engine bur should not be trusted as a substi- 
tute for a curette, because even with the greatest care much damage 
may be done to surrounding parts. A bone curette will readily 
remove all bone that should come away except such as hereafter 
described. The extent of curettement depends entirely upon the 
nature of the disease. In long-standing cases of chronic empyema, 
when there has been extensive destruction of the lining membrane, 
and large areas of diseased bone are in evidence, the curettage 
must be complete; but when polypi are found and the lining mem- 
brane is merely in a hyperplastic condition, it is better not to make 
such extensive curettement as to expose the bone surface entirely. 
Removal of the polypi and diseased mucous surface is all that 
is required, and the undisturbed periosteum favors more prompt 
recovery than when the bone is denuded. 
The author's experience has taught him that when antra are 
unusually large, with an extension curving backward and inward, 
and the extreme point of the inner portion of this wall feels rough 
and yielding, it is advisable to puncture in order to ascertain 
whether or not there is close contact ■with a diseased sphenoidal 
sinus (Fig. 323). 582 
DISEASES OF THE MAXILLARY SINUS 
In a number of instances when patients gave a history of at 
least several previous radical operations for empyema of the max- 
illary sinus, and when upon opening into the sinus little or no pus 
was found, puncture at this point allowed pus to flow in consider- 
able quantities from the sphenoidal sinus, or some cell connected 
therewith, which made direct communication with the maxillary 
sinus possible. After careful curettement, drainage, and irrigation, 
these cases were cured, as they otherwise could not have been, 
even though the sphenoidal sinus might have been opened by 
enlargement of its ostium and treatment in the usual manner. 
These cases, of course, are rare, but they are likely to be those 
concerning which the prognosis is most grave; and it is incumbent 
upon the operator to bear in mind the possibility of their existence. 
Fig. 323.-Anteroposterior division through the center of the orbit, maxillary sinus, 
and molar teeth, showing a large maxillary sinus and a large sphenoidal sinus. 
In chronic cases, when the sinus has been sufficiently curetted, 
the pressure against the nasal wall with the finger inserted through 
the opening in the anterior wall usually reveals that the bony 
separation between the nose and maxillary sinus is thin and more 
or less diseased. This thin nasal wall can usually be broken quite 
readily by finger pressure and the thin bony flakes drawn away 
through the opening in the sinus, leaving only a membranous 
division between these two cavities. 
This not only removes an element of danger of recurrence of 
disease from bone affected by nasal or sinus conditions, but it 
leaves the case in condition to be readily controlled if at any time 
it should prove to be absolutely necessary to have a large opening 
from the sinus into the nose, because it is only necessary in that 
event to cut through the soft membrane. THE KU ST ER OPERATION 
583 
Last of all, the floor of the orbit should be carefully examined. 
This wall is undoubtedly more often imperfect than the average 
operator realizes. The bone in places is exceedingly thin and non- 
resistant; many times its surface is incomplete as a result of destruc- 
tion by disease or anomalous development, and there will be found 
to be one or more points at which there is only a membranous 
division between the orbit and the sinus. 
Carelessness in curettement under these circumstances might 
easily cause serious damage to the organs through traumatic injury 
or infection. 
Care should be taken to have the borders of the opening through 
the canine fossa smooth and symmetrical in order that packing 
may be easily performed with as little pain as possible. It should 
be packed with gauze, wrung out in compound tincture of benzoin, 
or 2.5 per cent, carbolic acid, or in syphilitic cases 1 to 10,000 solu- 
tion of bichloride of mercury. No attempt should be made to use a 
solution that might be expected to act as a powerful germicide. 
The danger of irritation and of poisoning is too great. The purpose 
should be to prevent the gauze itself becoming a source of infec- 
tion through absorption of bacteria-laden secretions. There is no 
need of powerful germicides when the work has been thoroughly 
performed with proper surgical cleanliness. Gauze used for pack- 
ing should be folded into a long, narrow strip with the edges so 
turned in that threads of the gauze may not become detached 
and cling to the walls of a sinus at the time of removal, and thus 
become a source of future infection. The strip should be suffi- 
ciently long to fill the sinus completely and thus avoid error at 
the time of removal, because there will then be no chance of any 
portion being left behind. Moreover, its removal is facilitated, 
because it can be drawn out continuously from one end; and when 
packed into place,a sufficient pressure will be made to check ten- 
dency to hemorrhage and to force the tissues away from the open- 
ing and give as unobstructed a view of the interior of the sinus as 
possible when the packing is removed. The buccal surface should 
be coated freely with collodion to keep out secretions and hold 
the gauze perfectly in place. 
The first packing under ordinary conditions may be safely left 
forty-eight hours. This gives the patient time to recover from the 
effects of the operation. Afterward it should be changed daily, 
using a little less pressure from day to day. The number of times 
that the sinus should be packed will depend upon the character 
of the disease. On general principles the less packing an antrum 584 
DISEASES OF THE MAXILLARY SINUS 
receives beyond actual requirements the more will its return to 
healthy conditions be encouraged. In ordinary cases from one 
to three packings is sufficient. Old chronic cases may require the 
dressing to be changed daily for ten days. 
The purpose of the packing is to allow the wound to become 
protected to some extent against infection by the formation of 
new granulations. As soon as this is accomplished the packing is 
left out and the patient instructed to irrigate through the sinus 
with saline or boric solution twice daily. At intervals of two or 
three days a swab dipped in tincture of iodin may be used to wipe 
out the inner surface and the borders of the buccal opening. 
The capillary drainage supplied by the gauze packing is undoubt- 
edly an important factor, and much more effective than drainage 
tubes of any kind could be. 
Most operators who have had occasion to treat chronic cases of 
empyema of the maxillary sinus, which had previously been treated 
according to the methods of a decade ago, will remember how often 
it occurred that foreign bodies found their way into the antrum 
through small openings, especially when treatment was made 
through the socket of the root of a tooth. When these sinuses 
were properly opened up all kinds of foreign substances were from 
time to time found lodged therein, such as old, foul-smelling pieces 
of cotton, pieces of gauze, hard- and soft-rubber tubes, metal tubes, 
portions of roots of teeth, pieces of instruments, fragments of wooden 
toothpicks, insoluble particles of food, etc. 
Fig. 324 shows the picture of a patient, a woman, aged forty- 
eight years, who had been operated on through a small opening in 
the canine fossa, and had a Kilian operation performed upon 
her frontal sinus. At the time she came under the author's care, 
pus was discharging so freely from the frontal sinus, and through 
the side of the nose and maxillary sinus, that there was almost a 
continuous flow which dripped out upon the face. Upon examina- 
tion it was found that her nose contained approximately two inches 
of badly rotted rubber tubing that had been passed from the 
mouth into the sinus and had worked out through the ostium into 
the nose. This tubing had been lodged in that position for about 
two years. This was removed, and when the maxillary sinus was 
properly opened it was found to be partially filled with black- 
looking particles, which proved to be bismuth paste, that had been 
forced into the sinus evidently in the fond hope that it might effect 
a cure, notwithstanding surrounding conditions. One complete 
operation, which included the maxillary sinus, the side of the nose, THE CALDWELL-LUC OPERATION 
585 
and the frontal sinus, was all that was necessary to check the 
offensive pus formation and set in motion progress toward complete 
recovery, which followed shortly afterward. 
This is simply a marked illustration, but in its main aspect it is 
not unusual. The author has never had much sympathy with the 
use of bismuth paste (Beck's paste) in the treatment of maxillary 
sinus disease. For it has always seemed that there was no advan- 
tage in attempting to avoid the thorough and complete radical 
operation which such cases require; and that even though the 
bismuth paste might be effective in some cases, its use is unnecessary. 
Fig. 324.-Woman with chronic disease of both frontal and maxillary sinuses 
External fistulee are shown at nose, eye, and brow. 
Removal of Foreign Bodies from the Maxillary Sinus.-When 
the roots of teeth from extraction have been forced into the max- 
illary sinus, or any other foreign substances that cannot be expected 
to pass safely out through the ostium, even though apparently 
harmless, they should be removed by opening up the sinus, as for 
the performance of a radical operation. 
The author, after a number of years of rather wide experience 
in the treatment of maxillary sinus disease, has opened the sinus 
many times without an anesthetic; has used local anesthesia, 
nitrous oxide, oxygen, and ether, but has found ether the most 
reliable when radical operation is performed. 
Caldwell-Luc Operation.-In this operation (see Fig. 325) the 
anterior wall of the antrum is exposed by an incision at the labio- 586 
DISEASES OF THE MAXILLARY SINUS 
gingival junction, and the bone surface uncovered by separation 
of the per'osteum and overlying tissues, in the same manner as 
for the Kuster operation, except that it is more carefully done 
in order to favor closure of the wound by sutures. 
The bony wall is removed in precisely the same way. A large 
opening is then made through the naso-antral wall. To accomplish 
this the anterior half of the inferior turbinated body is sometimes 
Fig. 325.-Anterior wall of the maxillary sinus opened for the Caldwell-Luc 
operation. 
removed with a swivel knife or with scissors or with a saw, and 
the opening from the nose into the sinus effected by the use of 
specially formed chisels and saws, or with a Nobel-Cordes forceps 
(as shown in Fig. 320), or some similar instrument; or the naso- 
antral opening may be made from the antral side, entrance being 
gained through the oro-antral opening, as prescribed for the Kuster 
operation, except that it is carried completely through the mucous 
membrane and a large naso-antral opening established. The end THE DENKER OPERATION 
587 
of a strip of gauze packing of sufficient length is carried into the 
sinus through the oral opening and out through the nasal opening 
into the nose, and its end left slightly projecting from the external 
opening. With the remaining portion of the gauze strip the sinus 
is packed in such a manner as to permit of the immediate closure 
of the oral wound with catgut sutures, as illustrated in Fig. 326. 
At the end of the second day the gauze packing is finally With- 
drawn through the nose, future treatment being in the nature of 
irrigation with mild antiseptic solutions. 
Fig. 326.-Caldwell-Luc operation completed by closure of the oro-antral opening. 
The Denker Operation (Fig. 327).-In the Denker operation the 
anterior wall of the maxillary sinus is removed in the same manner 
as in the Kuster and Caldwell-Luc operations; and in addition to 
this the remaining section of bone between the canine fossa and 
the lower portion of the pyriform opening of the nose is cut away. 
The sinus is curetted and diseased membrane, granulation tissue, 
polypi, or dead bone removed. The mucoperiosteum of the anterior 
meatus of the nose and of the inferior turbinated body is detached 
with a small, flat periosteal elevator of such form as to make it 588 
DISEASES OF THE MAXILLARY SINUS 
adaptable to the parts. From this a mucoperiosteal rectangular 
flap is cut and turned outward onto the floor of the sinus. The 
bony naso-antral wall and the anterior portion of the inferior tur- 
binated body are cut away sufficiently to make as large an open- 
ing as for the Caldwell-Luc operation. The mucoperiosteal flap 
which has been turned onto the floor of the sinus is held into posi- 
tion for from twenty-four to forty-eight hours with a bismuth 
gauze dressing. 
In after-treatment the parts are kept cleansed and the tissue, as 
granulation takes place, is touched from time to time with tincture 
of iodin or caustics if required to check excessive granulation. 
Fig. 327.-The Denker antrum operation: a, the area of bone removed in the 
Kuster and the Caldwell-Luc operations. In the Denker operation additional bone 
is removed from b to the pyriform aperture. (Ballenger.) 
Canfield-Ballenger Antrum Operation.-This operation is illus- 
trated by Figs. 328, 329, 330, 331 and 332, and is described by 
Ballenger as follows: 
" Technic.-Anesthesia: (a) Induce anesthesia of the nasal 
mucous membrane by the local application of cocain or any other 
drug preferred; (6) induce anesthesia of the vestibular skin of the 
naris by the injection of Schleich's solution. This solution should 
also be injected beneath the periosteum of the canine fossa via 
the vestibule of the nose. CANFIELD-BALLENGER ANTRUM OPERATION 
589 
"Incision.-Distend the wing of the nose with a nasal speculum, 
as shown in Fig. 328, to bring the anterior angle of the naso-antral 
Fig. 328.-Canfield-Ballenger opera- 
tion: a, the margin of the pyriform 
aperture, the point of incision for the 
Canfield-Ballenger antrum operation. 
(Ballenger.) 
Fig. 329.-Canfield-Ballenger opera- 
tion: b, the incision. (Ballenger.) 
Fig. 330.-Canfield-Ballenger opera- 
tion: c, the naso-antral angle removed, 
thereby exposing the cavity of the an- 
trum. (Ballenger.) 
Fig. 331.-Canfield-Ballenger opera- 
tion: d, the naso-antral wall being 
severed with the Wagener forceps. 
(Ballenger.) 
wall into prominence. Then with a small scalpel make an incision 
the whole length of the exposed portion of the naso-antral angle 590 
DISEASES OF THE MAXILLARY SINUS 
(margin of the pyriform aperture, Fig. 329). Then elevate the 
membrane, including the periosteum over the canine fossa 
(Fig. 330). 
"Opening the Naso-antral Angle.-The antrum should be opened 
via the naso-antral angle (margopyriformis) with rongeur bone 
forceps, as shown in Fig. 330, or with a gouge and mallet. In some 
subjects the bone at this angle is dense, requiring considerable 
force to bite through it, while in others it is extremely thin and 
easily removed. While the incision extends higher than the 
Fig. 332.-Interior view of the Canfield-Ballenger antrum operation: a, middle 
turbinal; b, line of attachment of the inferior turbinal, which is left intact; c, the naso- 
antral wall removed, extending from the floor of the nose to the attachment of the 
inferior turbinal and from the anterior to the posterior limits of the antrum. 
attachment of the inferior turbinal (to allow retraction), the bone 
at the angles should only be removed below the line of attachment 
of the inferior turbinated body. In removing the bone constituting 
the canine fossa, it is usually only necessary to remove enough to 
admit of the introduction of the Wagener antrum forceps, as 
shown in Fig. 331. If, however, after making the opening through 
the naso-antral angle it is determined that the whole of the mucous 
membrane is not accessible to the curette, as much of the canine 
wall may be removed as will fully expose it. CANFIELD-BALLENGER ANTRUM OPERATION 
591 
" Removal of the Naso-antral Wall.-The biting jaws of the 
Wagener forceps (Fig. 331) are placed astride the naso-antral wall and 
the wall bitten away from the attachment of the inferior turbinate 
body down to the floor (Fig. 332). This makes an opening about 
one and one-half by five-eighths inches in size. An opening of this 
size will never close by granulation. It was formerly thought neces- 
sary to also remove the anterior half of the inferior turbinate body, to 
expose the naso-antral wall to surgical interference. By this method 
it is rendered unnecessary, hence the inferior turbinal is unmolested 
and is preserved and continues to perform its respiratory functions. 
"Intermediate and After-treatment.-If the mucous membrane of 
the antrum is edematous and has not undergone polypoid or granu- 
lation degeneration, it is not necessary to curette it away (Myles). 
When such a pathological condition is present, packing the antrum 
with gauze moistened with the compound tincture of benzoin 
daily for three or four days will relieve the edema, and the mucous 
membrane will resume its noririal structure and function. When, 
however, the mucous membrane is converted into large granula- 
tion masses or polypi, it should be thoroughly removed with a 
sharp curette, thereby denuding the bony walls. If this is done a 
new mucous membrane will not form, but the walls will become 
covered with thick fibrous tissue, which partially obliterates the 
antral cavity. Such tissue does not develop columnar epithelium, 
but continues to secrete a semipurulent fluid. For this reason, curet- 
tage should be avoided unless the pathological condition warrants it. 
"After three or four days the gauze dressings should be discon- 
tinued. The cavity may then be swabbed or sprayed daily with 
a 10 per cent, solution of ichthyol to stimulate local hyperemia 
and leukocytosis (raise the resistance; raise the opsonic index), 
thereby hastening the reparative process. 
"In conclusion, I wish to say that this method of operating is 
(a) radical, inasmuch as it fully exposes the cavity of the antrum 
to inspection and treatment; (6) it is conservative, as it is attended 
by the least possible destruction of physiological structures, par- 
ticularly the inferior turbinal, which is neither temporarily nor 
permanently resected; (c) furthermore, the operation may be done 
under local anesthesia, whereas other operations equally radical 
(and more destructive) must be done under general anesthesia; 
(d) the time required for this operation is much less than that for 
other radical operations."1 
1 Ballenger: Diseases of the Nose, Throat, and Ear, 1914, 4th Ed. 592 
DISEASES OF THE MAXILLARY SINUS 
Comparative Review of the Several Maxillary Sinus Operations.- 
It should be remembered that many acute diseases of the maxil- 
lary sinus recover without treatment. As the inflammatory symp- 
toms subside and the ostium becomes patent, natural drainage 
takes place and the excessive and frequently offensive secretion 
disappears, with ultimate complete resumption of normal function. 
Proper treatment of intranasal conditions is required to relieve 
the acute, rhinitis which is a natural associate of acute sinuitis. 
In this connection it must be urged that the prime requisite in 
the treatment of all diseases of the maxillary, as of the other nasal 
accessory sinuses, is the removal of the first cause of the disease. 
Any nasal obstruction or intranasal defect which may act as a 
predisposing factor should receive appropriate treatment. 
Operative treatment of the sinus itself therefore should be 
resorted to only when absolutely required. 
Puncture and irrigation through the naso-antral wall is all that 
is required in many acute cases. * When the nature of the case 
demands other treatment, this, of course, should be given, but 
radical means should not be employed unless it has been demon- 
strated that this treatment is insufficient, or when there are indica- 
tions present which make it apparent at the outset that more 
extensive opening is necessary. 
The alveolar and paZataZ points of entrance are objectionable for 
the reasons stated in the description of these operations. 
The intranasal operation is usually all-sufficient, and in these 
cases is by all means the operation of choice. 
The reasons why it is not adequate to the requirements of cer- 
tain cases are that it is not practicable to curette the antrum 
satisfactorily when it is unusual in size or form and contains granu- 
lation tissue, polypi, or diseased bone, requiring complete and 
thorough removal. 
While in most cases a large opening in the naso-antral wall gives 
sufficiently complete drainage, it is well known that the floor of 
the antrum is frequently lower than instead of on a level with or 
higher than the floor of the nose. 
Thus the question of perfect drainage is somewhat problematical 
from this aspect. 
The Caldwell-Luc operation is quite generally advocated and 
does give opportunity for access to all parts of the sinus. It has 
the added advantage which is gained by a large opening through 
the naso-antral wall, and immediate closure of the opening in the 
oro-antral wall by sutures. While it may not give as complete REVIEW OF THE MAXILLARY SINUS OPERATIONS 
593 
freedom from infection by mouth bacteria as is claimed, it cer- 
tainly reduces the danger in this direction to a minimum. In such 
cases as are adaptable to this operation the results would unques- 
tionably be more satisfactory than with the Kuster operation. 
The author's experience lends support to the opinion that there 
are occasional conditions in which it is most desirable that the 
oro-antral opening be maintained for a longer period than that 
required by the technic of the Caldwell-Luc operation. The intra- 
nasal operation is unsatisfactory when conditions are such as to 
require unobstructed access to all parts of the sinus, however 
irregular its shape may be, and more or less long-continued capillary 
drainage by means of gauze packing. The author believes that in 
certain cases these are important advantages in the Kuster opera- 
tion in comparison with the results of the immediate closure of the 
oro-antral wall as performed in the Caldwell-Luc operation. 
For example, one of the author's patients had a history of antral 
disease extending over a period of approximately fifteen years, 
during which time many operations of various kinds had been 
performed with unsatisfactory results. When operated upon, and 
when the sinus was completely opened, a large black sequestrum 
of bone, which included almost the entire floor of the sinus, was 
found. It had evidently been there during all of the fifteen years 
since an attack of typhoid fever, and by its situation was pre- 
vented from exfoliating. The sequestrum, evidently a result of 
exanthematous necrosis, had remained as a sequel of this disease. 
As a matter of course it was impossible to relieve this condition 
by any sort of intranasal operation. It would have been equally 
inadvisable to close the oro-antral opening in such a case until 
after the local results of the necrosis had been overcome. 
As has already been stated, it has not infrequently happened, 
in the treatment of the author's patients, that a connection has 
been found between the maxillary sinus and some extension or 
cell from the sphenoidal sinus. Under these conditions it seems 
as though there could be no question as to the value of keeping a 
maxillary sinus packed with gauze and freely open for a sufficient 
time to effect a cure of the sphenoidal sinus disease as well as that 
of the maxillary sinus. 
There are some cases also in which it seems to be expedient to 
continue drainage for the benefit of the ethmoidal cells and the 
frontal sinus, when through unusual conditions there is a more than 
ordinarily direct communication for the transmission and contin- 
uance of infection. 594 
DISEASES OF THE MAXILLARY SINUS 
The Denker operation appears to be quite unnecessary, more 
especially because the Canfield-Ballenger operation seems to give 
all the advantages of the Denker operation in the way of opening 
the antrum and securing free access, without the same degree of 
disadvantageous opportunity for mouth infection. 
Whether the loss of bone attachment occasioned by removal of 
the intervening portion of the bone between the opening of the 
canine fossa and the naris, as described in both the Denker and 
Canfield-Ballenger operations, could by any possibility interfere 
with the function or appearance of the lip or face muscles, through 
destruction of their point of attachment, the author is not pre- 
pared to say. While he is convinced that unusual cases of necro- 
sis or pus formation in closely adjacent extensions from the sphe- 
noidal sinus could be reached only with much difficulty, if at all, 
through an opening such as that described for the Canfield- 
Ballenger operation, yet he feels assured that if these objections 
are or can be overcome, such an operation would undoubtedly be 
an improvement over all the others. 
Operations upon the Maxillary Sinus from the Point of View 
of the Oral Surgeon.-Strictly speaking, it may be said that the 
treatment of the maxillary sinuses, in common with the other 
nasal accessory sinuses, belongs largely to the field of rhinology, 
except when etiological factors or pathological conditions related 
to oral diseases exist. 
With the acute and other less grave maxillary sinus affections 
eliminated, the work of the oral surgeon naturally resolves itself 
into the treatment of pathological conditions of the maxillary 
antra, which have not yielded, or may not be expected to yield, 
to intranasal or other methods of treatment, except such as give 
opportunity for complete radical removal of diseased tissues from 
every part of the maxillary sinus 
In the author's experience the danger of infection of maxillary 
antra through an oro-antral opening, by mouth bacteria, is not 
serious if packing has been properly inserted and renewed with 
sufficient frequency to protect the sinus until such time as nature 
has had opportunity to guard the recently curetted surfaces by 
granulation, and if the antrum is frequently irrigated with normal 
salt solution or any mildly antiseptic non-irritating preparation. 
The opportunity for continuous irrigation and drainage in some 
instances is essentially valuable. In short, cases can be cured in 
this way that seem to resist every other method of treatment. 
In making this statement the author is fully aware that in many FOREIGN BODIES IN THE MAXILLARY SINUS 
595 
other cases both the intranasal and the Caldwell-Luc operations 
may give apparently quite as satisfactory results, with less post- 
operative treatment. 
It naturally happens that the classes of cases which come to the 
oral surgeon for treatment are such as have resisted other methods, 
and the great majority of these require more than ordinarily 
thorough treatment, which precludes the expectation of prompt 
recovery. 
Fig. 324, illustrating a case already described, is another example 
of the complications that make it advisable not only to have free 
access to all parts of the maxillary sinus, but to have an equally .good 
opportunity for observation of its inner surface and the surround- 
ing parts, during postoperative treatment. 
In another case, in a man who had had many operations in this 
country and in Europe during a period of more than five years, 
a considerable quantity of diseased bone was found in the region 
of the floor of the sinus. It would undoubtedly have escaped 
notice at the time of the author's operation, as it did at the time 
of previous operations, if the wide opening in the oro-antral wall, 
and the situation disclosed in the course of repeated packing, had 
not afforded opportunity for the observation and study of actual 
bone conditions. In this way the real cause of the continuance 
of the disease was readily discovered, and therefore cure brought 
about. 
A great number of cases in the author's practice could, if neces- 
sary, be cited to emphasize the almost incalculable value of this 
treatment. At the same time he is fully alive to the advantages 
of other methods in suitable cases. 
Foreign Bodies in the Maxillary Sinus.-It is not unusual for 
foreign bodies to find their way into the maxillary antrum. Teeth 
or portions of their roots or crowns, or pieces of bone, have often 
been forced into the sinus in attempted tooth extraction. Drain- 
age tubes, such as the piece of rubber tubing that has already been 
described with reference to one of the author's cases, tubes of 
vulcanite and of different kinds of metal, were commonly found 
in this situation when the use of drainage was generally employed 
in treatment of these cases. Balls of cotton or strips of gauze and 
small instruments frequently escape through openings in the antral 
walls when through misguided surgical treatment they have not 
been sufficiently enlarged. Pieces of metal and other foreign sub- 
stances have often been forced through the walls by gunshot or 
other severe traumatic injuries. Sometimes foreign bodies have 596 
DISEASES OF THE MAXILLARY SINUS 
remained in this situation, and attempts to cure such cases were 
necessarily ineffective, until the real cause of continued irritation 
was discovered and removed. 
Symptoms and Diagnosis.-Foreign substances in the maxillary 
sinus usually cause continued inflammation with excessive or 
offensive purulent discharge, in accordance with the nature of the 
substance. In diagnosis, under some circumstances, alteration of 
the form of the walls might be noticed; as a rule, however, such 
bodies are best diagnosticated with the Roentgen rays. Under 
favorable conditions they have been felt and located by probing 
through the external opening, but this cannot be depended upon 
in all cases. 
Treatment.-The first step toward cure must necessarily be 
removal of the foreign substance, whatever it may be. Usually 
this involves a radical operation, but when once the source of irri- 
tation has been relieved the treatment of such a sinus is identical 
with that which would be indicated for any similar pathological 
affection or lesion. 
Infectious Diseases.-Symptoms.-All of the exanthemata and 
other infectious diseases, such as tuberculosis, syphilis, actino- 
mycosis, etc., are prone to attack the maxillary sinus, because of 
its double susceptibility through the mucous membrane of the nose 
and periosteum of the bone. 
The symptoms under these circumstances are identical with any 
other indication of the disease, whatever it may be, in a similar 
situation. 
Treatment.-The treatment of infectious diseases affecting the 
maxillary sinus resolves itself into an effort to overcome the deplet- 
ing effect of the disease upon the system, and to relieve the local 
lesion. For example, syphilis may attack the lining membrane of 
the sinus by syphilitic ulceration or gummatous formation, or it 
may bring about syphilitic necrosis with extensive bone destruction. 
Under all of these circumstances the first consideration must be 
the constitutional treatment of the disease and the upbuilding of 
the patient to increase resistance, supplemented by local measures 
in the way of direct treatment of the lesion itself. Precisely the 
same principles must govern the treatment of all other antral 
affections occurring secondarily to infectious diseases. 
Polypi.-Hyperplasia of the mucous membrane in the form of 
polypi is a common feature of sinuitis with or without pus, and 
would be treated altogether as a symptom rather than a distinct 
affection, as the term is commonly used, were it not for the fact TUMORS OF THE MAXILLARY SINUS 
597 
that polypi may also be tumors of fibroid, myxomatous or even 
sarcomatous types. Their symptoms and treatment are included 
in the descriptions of the sinus diseases and tumors with which 
they are associated. 
Polypi have been held by some writers to be pathognomonic of 
sinus suppuration; but after careful consideration of the many 
varying reports, the only point that really seems clear is that their 
presence or absence is not a matter of great significance except 
with regard to treatment. 
Cysts.-Cysts of the maxillary antrum are not uncommon, and 
may be formed by the distention of the mucous glands quite sim- 
ilar to mucous cysts in other situations. These may be small or 
so large as almost or entirely to fill the cavity of the sinus. Upon 
puncture they are found to contain mucous, mucopus, or serum. 
Dentigerous cysts may be so situated as to be partly or entirely 
within the maxillary sinus. 
Dental cysts may form from diseases of the teeth and extend 
into this sinus, and in the course of their enlargement may encroach 
upon surrounding parts sufficiently to cause more or less disturb- 
ance or even deformity through alteration of the form of the bony 
walls 
Treatment.-A mucous cyst requires the complete opening of the 
sinus and removal or obliteration of the cyst wall. 
In the treatment of both dentigerous and dental cysts care 
should be taken to prevent infection of the lining membrane of 
the antrum, which, although it may be forced into exceedingly 
small compass, is nevertheless usually found to be intact, and 
under proper treatment of the cyst, through the external opening, 
will again be restored to its normal situation and condition. 
Cystocele.-It has been claimed that the entire sinus may 
become encysted under certain conditions through the collection 
of fluids when the ostium is completely obstructed. Many such 
cases are reported, but the evidence appears to rest upon the point 
that when opened the sinus was found to be filled with serous 
fluid and the ostium closed. But there appears to be an element 
of doubt in all these cases as to whether the condition was really 
one of cystocele or an enlarged mucous cyst. 
Tumors.-Tumors of the maxillary sinus are not uncommon. 
Failure to discover the disease in chronic cases seems to offer a 
favorable opportunity in this situation for the formation of malig- 
nant growths. Many of the author's cases of sarcoma and carci- 
noma began in the maxillary sinus., 598 
DISEASES OF THE MAXILLARY SINUS 
The etiology, symptoms, and treatment of neoplasms affecting 
this region are similar to those described under Tumors. 
The necessity for prompt and careful diagnosis, however, cannot 
be too frequently urged. It is sometimes confusing to differentiate 
between the gumma of syphilis, distortion of the anterior wall of 
the sinus from a cyst, or destruction of the bony walls from long- 
continued suppuration in malignant growths. 
It may be said in general terms that when an enlargement in 
this region is opened with a knife and there is reason to suspect 
the presence of pus, if none be found then the operator should at 
once be on guard against syphilis or a neoplasm. 
The x-rays are sometimes exceedingly helpful in disclosing 
growths that fill the cavity of the sinus, but are not otherwise dis- 
cernible. The history of the case and the Wassermann test facili- 
tate the diagnosis of syphilis; but the microscopic findings must 
be depended upon to determine the benign or malignant character 
of the growth. CHAPTER X. 
DISEASES, TUMORS, AND MALFORMATIONS OF 
THE TONGUE. 
DISEASES OF THE TONGUE. 
Stomatitis.-All forms of stomatitis and nearly all of the diseases 
of the mucous membrane which have been described (pp. 168 to 
214) may appear primarily upon the surface of the tongue, or 
extend to that organ from other parts in the mouth. 
Glossitis.-Inflammation of the tongue may be acute or chronic, 
circumscribed or diffuse. The so-called strawberry tongue of 
scarlet fever shows how the appearance of the tongue may become 
an important diagnostic feature in exanthematous fevers and other 
infections. Superficial glossitis is also due to local irritations, 
the effect of drugs, and similar influences, and is evidenced by 
increased redness and swelling of the papillae, which alter the 
surface appearance of this organ. 
Furring of the Tongue.-In mild catarrhal conditions of the 
mucous membrane of the mouth there is constant desquamation 
of the epithelium. When this takes place actively, the cells are 
retained upon the surface, portions of food and bacteria cling to 
the masses of desquamated cells, and the result is the whitish or 
brownish furring of the tongue that is common to many diseases. 
In more or less chronic cases when this heaping of epithelial cells 
occurs in localized areas, characteristic irregular patches some- 
times result, and to this condition the term geographical tongue 
(see Plate XIX, Fig. 2) has been applied. 
Dr. Kirk has shown that when there is an unusual amount of 
lactic acid in the salivary secretion, whether caused by activity 
of the lactic acid-producing bacteria concerned in the process of 
dental caries or otherwise, the mucin of the saliva is precipitated. 
Undoubtedly the increased agglutinative power thus acquired 
by the oral secretions is in a large measure responsible for the 
accumulations of epithelial cells, bacteria, and food products 
upon the mucous membrane and particularly upon the tongue 
surface. 600 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
Circumscribed Glossitis.-Circumscribed glossitis is usually due 
to irritation from the sharp edges of a tooth or root, ill-fitting or 
otherwise imperfect dental plates or bridge-work, accidental biting 
of the tongue, burns, pipestems, cigars, the continued application 
of hot smoke; the nervous mouth habits, however, are among the 
most important causes, as they are likely to be overlooked. These 
habits have been referred to in connection with the etiology of other 
buccal affections. 
The tongue naturally seeks any unusual or roughened place 
about the teeth, imperfect interproximal spaces in which particles 
of food have lodged between teeth, or the spaces occasioned by 
loss, and this may easily become a habit leading to both acute and 
chronic conditions. 
Circumscribed lingual inflammatory processes may result in 
local degenerative conditions with hypertrophy or induration, 
or if superficial, an ulcer may be formed. When the affection 
penetrates more deeply, a localized abscess sometimes results. 
These do not differ materially from other abscesses, except when 
they cause general glossitis. 
The pathology, symptoms, and treatment of these affections 
closely resemble those in similar conditions in other tissues. 
Chronic Glossitis.-When glossitis, whether superficial or cir- 
cumscribed, becomes chronic, structural changes may take place, 
which are quite similar to those of any chronic inflammatory 
process. When caused by specific forms of infection the charac- 
teristic lesions appear. Malignant tumors are prone to develop 
at the site of such chronic inflammations. These are often difficult 
to differentiate from benign affections. They usually require the 
aid of a microscope for diagnosis, but certain forms are occasionally 
so distinctive that no confirmatory evidence is required (Plate XIX, 
Fig- 3).. . 
Syphilis.-In syphilis (Plate III, Fig. 1) the primary sore is 
found upon the tongue in a large proportion of cases, and secondary 
lesions are also frequent, but leukoplakia (Plate VII, Fig. 2), gumma, 
and the indurated scar tissue following healed lesions (Plate III, 
Fig. 1) are not only of common occurrence among patients affected 
by this disease, but are often particularly difficult to differentiate 
in diagnosis from neoplasms, tubercular lesions (Plate XIX, Fig. 1), 
and the results of inflammatory affections of other origin (see 
Syphilis, p. 117). 
Leukoplakia (Plate VII, Fig. 2).-This, it is admitted, may or may 
not be syphilitic. Tubercular affections are less frequent, but, as PLATE XIX 
FIG. 1 
Tubercular Cicatricial Destruction of the Tongue. 
FIG. 2 
Geographical Tongue. 
FIG. 3 
Glossitis. DISEASES OF THE TONGUE 
601 
may be seen from examination of the illustration shown in Plate 
XIX, Fig. 1, can sometimes only be diagnosticated by discovery 
of the bacillus, or recognition of the disease by methods such as 
have been set forth in the description of this affection (p. 202). 
This is also true of syphilis, and the methods indicated for diag- 
nosis of the disease (p. 117) must be depended upon for its recog- 
nition rather than the appearance of the lesions. 
Diagnosis.-Diagnosis is the all-important feature, because early 
correction may often prevent the development of serious local 
conditions, and by leading to the institution of remedial measures 
when general diseases are involved, much additional benefit may 
ensue for the reason that these might not otherwise be recognized. 
Dentists should make it a rule to inspect carefully the tongue 
and tooth surfaces of all patients. Thickened or irritated areas 
upon the tongue should receive immediate attention. Any rough, 
sharp, or improperly shaped tooth surface, diseased roots or teeth, 
or imperfect dental work should be removed, smoothed, or other- 
wise corrected. 
Every case in which there are lesions that cannot be accounted 
for should without delay receive the benefit of all modern diag- 
nostic aids, to determine, if possible, the real cause. 
Physicians should be on the lookout for causes of local irritation, 
and refer such cases, with clearly defined directions, to a competent 
dentist. 
Treatment.-The treatment of all of the foregoing forms of 
glossitis consists in removal of the cause of irritation, local applica- 
tions to relieve the lesions, and attention to general underlying 
factors if necessary. 
Phlegmonous Glossitis.-When glossitis becomes diffuse and 
affects interstitial structures (interstitial glossitis), it may be asso- 
ciated with the production of an excess of connective tissue, or 
acute parenchymatous inflammation may result (parenchymatous 
glossitis); suppuration may follow and then the condition is known 
as phlegmonous glossitis. 
Etiology.-This affection may result from extension of the cir- 
cumscribed inflammatory conditions of the tongue, caused by local 
irritation, or infection. It may, on the other hand, be secondary 
to phlegmonous processes in the region of the palatal tonsils, or 
to Ludwig's angina or other inflammatory lesions affecting the 
floor of the mouth and surrounding parts. 
ErysipelasThis disease is a somewhat rare but very serious 
cause of phlegmonous glossitis. Although the mucosa and the 602 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
uppermost layer of the submucosa are principally affected, some- 
times excessive swelling of the tongue is caused, and there is danger 
because of the likelihood of edema of the glottis. 
Foreign Bodies.-Fish-bones and substances of this nature are 
not infrequently forced into the tongue, but, contrary to expecta- 
tion, these do not often cause phlegmonous glossitis. 
W. Murray1 reports that f x | x | inch of a vulcanite pipestem 
remained in the mouth of one of his patients eight months before 
being discovered. 
One of the author's patients, who had previously been subjected 
to the ill-advised use of cocain with electrolysis for the extraction 
of a tooth late one afternoon, had swelling of the tongue during 
the same night that almost caused fatal suffocation, which was 
avoided only by the most energetic treatment. 
Symptoms.-In glossitis chiefly confined to the preepiglottic 
region, the situation in which local irritations are usually first 
manifested, the symptoms are those of an acute angina. There 
is difficulty in swallowing, soreness, perhaps pain, and much dis- 
comfort, but no serious danger unless the root of the tongue becomes 
involved. When this occurs, the swelling may be confined to one 
side or Include the entire organ. The tongue is distended to such an 
extent that it becomes too large for the mouth, and is sometimes 
forced between the teeth. The resulting pressure is so great that the 
floor of the mouth is forced downward, the structures of the pharynx 
backward, and the soft palate upward. Respiration is thus 
mechanically interfered with even though there may not be an 
edema of the glottis. 
Under these circumstances patients are obliged to bend their 
heads back as far as possible in order that air may be drawn through 
the nose over the back of the tongue. The characteristic position 
is shown in Fig. 88, p. 188. The face is congested. Movements 
of the tongue are so curtailed that speech is impossible, and masti- 
cation and swallowing almost or entirely prevented. The saliva 
dribbles from the mouth, and the pressure of the tongue against 
the teeth causes soreness of its borders and adds materially to the 
general distress. In the region of the circumvallate papillae the 
tongue becomes hard and board-like, and this condition in most 
cases also extends to the submental and hyoid regions. 
Treatment.-There is danger of asphyxia and inspiration pneu- 
monia from the uncontrolled saliva which cannot be swallowed 
1 British Med. Jour., January 1, 1910. DISEASES OF THE TONGUE 
603 
and has a tendency to overflow into the respiratory channels. 
Being filled with pyogenic microorganisms, bronchial and pneu- 
monic affections are natural consequences. The toxic and septic 
influences common to all virulent infections are also to be feared. 
Treatment must therefore be prompt and energetic in order to 
be effective. A deep incision with the point of a curved, narrow- 
bladed bistoury passed back over the tongue, under guard of a 
finger, introduced just behind the circumvallate papillee, and 
carried forward through the body of the tongue, gives free blood- 
letting and an exit for serum, or pus if present. This usually allows 
the excessive swelling to subside sufficiently, at least, to give a 
measure of immediate relief. 
If the hemorrhage is excessive the wound is packed with gauze, 
otherwise it is allowed to remain open until the swelling has sub- 
sided and then closed with sutures if necessary. Mildly antiseptic 
astringent mouth washes should be used constantly to reduce the 
inflammation and guard against further infection. 
Symptoms of suffocation require an immediate tracheotomy, 
after which other measures Mor controlling the swelling may be 
resorted to. 
In less severe cases, or whenever the exigencies of the case permit, 
irrigation with hot solutions, the face being turned upon one side 
to allow the fluid to run out freely and to flow continuously for a 
sufficient time, is sometimes beneficial at the onset of the affection, 
and may abort the progress of the inflammation sufficiently to 
make more radical measures unnecessary. 
Kummell recommends for cases in which there is a marked 
induration in the submental region, with the skin red and edematous, 
a deep incision extending between the genioglossi muscles and the 
wound, and enlarged in the substance of the tongue by blunt dissec- 
tion. He states that: 
The' evacuation of the foul-smelling pus always produces an 
immediate amelioration of the pain and dyspnea. This incision has 
the advantage, moreover, of a complete evacuation, without the 
danger of pus and blood finding their way into the air passages."1^ 
Gangrene of the Tongue.-Gangrene of the tongue may be due 
to pressure against the teeth when it is swollen, or to vascular 
disturbance incident to a phlegmonous glossitis; to severe injuries, 
burns, noma, Ludwig's angina, and other destructive processes 
which occur in the course of typhoid, puerperal, and other infections. 
1 Von Bergmann: System of Practical Surgery, i, 839, 840. 604 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
Pseudomembranous Glossitis.-This is a rare affection accom- 
panied by marked exfoliation. Sometimes casts of the tongue 
are exfoliated. The diphtheria bacillus, streptococci, and some- 
times pneumococci have been known to give rise to this condition. 
Treatment.-Local measures are of little avail. Antistreptococcic 
serum treatment and helpful measures of a general nature must 
be relied upon. 
Psoriasis.-Psoriasis of the tongue is a term used by some 
authors synonymously with leukoplakia buccalis.1 
Nigrities Linguae.-This disease, also known as black tongue, 
is a form of hypertrophy of the papillae of the tongue with pig- 
mentation. 
Etiology.-The cause is not known. Dr. Kirk, of Philadelphia, 
made careful bacterial examinations in an interesting case that 
came under his care, but without definite identification of a specific 
bacterium. 
Symptoms.-The dorsum becomes covered with a hair-like 
coating, dark brown or quite black in color. 
Treatment.-The only treatment that can be satisfactorily 
employed without exact knowledge of the cause is a thorough 
cleansing of the tongue surface and of the mouth generally, the 
use of dioxogen to aid in freeing the mucous membrane surface 
from its coating, and general care of the health of the individual. 
Nervous Affections of the Tongue.-Atrophy of the muscles of 
the tongue results from bulbar palsy and other forms of muscular 
dystrophy. 
Smooth atrophy of the root of the tongue is characterized by dis- 
appearance of the follicles, thinning of the epithelium, and later 
by muscular atrophy and occlusion of the mucous glands. Some 
writers have claimed that this is a symptom of syphilis, but it 
is now known to occur in other diseases such as tuberculosis, senile 
changes, and other degenerative processes. 
Tremor of the tongue is evidence of nervous disease, as is also the 
deviation of the tongue to one side, when protruded from the mouth. 
Hemiglossitis.-A transitory, unilateral swelling of the tongue 
believed to be of nervous origin. 
Symptoms.-The tongue becomes enlarged upon one side. During 
the early stages there is acute pain and high fever, which usually 
subside by the end of the first day and the swelling after three or 
four days. 
1 Dorland: American Medical Dictionary, p. 627. TUMORS OF THE TONGUE 
605 
Treatment.-Palliative treatment may give a little comfort, but 
the affection usually runs its course. Nerve tonics, hygiene, and 
similar aids to general nerve resistance are indicated. 
Foot-and-mouth Disease.-Vesicles and painful swelling of the 
tongue are prominent symptoms. In such cases diagnosis and 
treatment of this affection as described (p. 179) are required. 
Actinomycosis (p. 142), Glanders (p. 149), and Leprosy (p. 155). 
-These have tongue lesions which are included in the description 
of these diseases. 
Riga's Disease.-This disease is a sublingual growth in infants. 
It is essentially an ulcerative or pseudomembranous lesion on the 
under surface of the tongue which involves the frenum. 
Etiology.-It is undoubtedly caused by infection which is pre- 
sumably influenced by difficulty in eruption of the lower incisor teeth. 
Symptoms.-For the greater part it affects nursing infants and 
begins by an ulcerative or necrotic process, which is followed by 
a granulomatous growth that sometimes closely resembles papil- 
loma or fibroma. 
Treatment.--On account of the susceptibility of infants, the 
local treatment must be such as can safely be applied to inflamma- 
tion in an infant's mouth. 
Careful examination of the erupting teeth should be made and 
inflammatory processes relieved by incisions through the gum over 
their crowns if necessary. If digestive disturbance is evident, 
corrective measures must be employed. 
Myositis.-The various forms of myositis may affect the muscles 
of the tongue the same as other muscles. Acute conditions are 
apparent in myositis. The form of acute poliomyositis, called 
d'ermato-mucoso-myositis, sometimes attacks the tongue, and may 
be associated with stomatitis with or without ulceration or angina. 
Etiology.-This is believed to be caused by infection, but the 
fact that the condition is sometimes accompanied by polyneuritis 
lends color to the belief that nervous conditions may also be impor- 
tant in its causation. 
Symptoms.-The muscles are swollen, red or pale yellow, some- 
times streaked with gray or reddish striae. In consistency they 
may be firm or soft and boggy, and are sometimes accompanied 
by hemorrhages. 
TUMORS OF THE TONGUE. 
Cysts.-Varieties.-Retention Cysts- The retention cysts some- 
times found at the tip of the tongue are caused by occlusion of the 
glands of Blandin-Nuhn. For further description see p. 492. 606 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
Hydatid,, Echinococcus, and Cycticercus Cysts.-Hydatid cysts, 
echinococcus cysts, and all forms of cysticercus cysts, caused by 
the scolex or larvae of tapeworms, have in rare instances been 
found. They resemble mucous cysts in roundness of form, but 
are harder, less transparent, can be moved about with the finger 
and are always multiple. They may be distinguished from mucous 
cysts by these features (see p. 491). 
Dermoid cysts are sometimes situated between the genioglossi 
and extend into the body of the tongue (Fig. 333). The detailed 
consideration of dermbids may be found on p. 499. 
Fig. 333.-Dermoid (ad-hyoid) cyst at base of tongue. (Marchant.) 
Treatment.-The removal of a dermoid cyst at the base of the 
tongue, as shown in Fig. 333, requires an incision in the median 
line from the chin to the hyoid bone. Division of the tissues is 
made down to and between the geniohyoglossi muscle and retraction 
effected to expose the tumor, which is freed by blunt dissection. This 
is comparatively easy to accomplish unless the cyst walls are bound 
by inflammatory adhesions. Great care must be used to avoid, if 
possible, rupture of the cyst wall. After removal of the cyst the 
wound is packed with gauze, if necessary to control hemorrhage. 
Otherwise drainage is inserted and the wounds closed. TV MORS OF THE TONGUE 
607 
Cysts at Base of Tongue.-Cysts at the base of the tongue are 
sometimes found occupying the sinus pyriformis. 
Etiology.-These cysts are apparently caused by remains of 
the fetal thyroglossal duct. 
Symptoms.-They seldom give much disturbance. The symp- 
toms are usually quite similar to hypertrophy of the^lingual tonsils. 
Reflex cough and a sense of discomfort such as might be caused 
by any foreign substance in the throat may occasion annoyance 
(Fig. 334). 
Fig. 334.-Thyroglossal cyst. (Brewer.) 
Diagnosis.-A laryngeal mirror facilitates diagnosis. 
Treatment.-Incision and cauterization will usually accomplish 
their removal. 
A. S. Taylor1 reports the following interesting cases of cyst 
of the thyroglossal duct: 
"A man, aged forty years, for three years had had a cyst just 
above the larynx, which gradually became more annoying, so he 
had to have it removed. A transverse incision was made over 
the cyst, which extended from the upper border of the larynx to 
the under surface of the hyoid. From this point a small fistulous 
opening penetrated the hyoid and extended to the base of the 
tongue. The growth was shaped somewhat like an Indian club 
above the hyoid and ran up to the dorsum of the tongue. The 
cyst below the hyoid had pushed the thyrohyoid membrane 
1 Ann. Surg., February, 1910. 608 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
back until it almost touched the wall of the pharynx. Although 
the patient is a singer, this has not interfered with his voice. The 
cyst was entirely removed; no drainage was used; primary union." 
Lipoma.-Lipoma of the tongue is exceedingly rare, although 
such tumors have been found in this situation more frequently 
than in other parts of the mouth. It is believed that in a consider- 
able portion of these cases the condition is congenital. 
Papilloma and Fibroma (see pp. 507 and 518).-These tumors 
are sometimes found upon the dorsum of the tongue. As they 
are painless and of slow growth, their chief significance lies in the 
likelihood of their becoming malignant, or in the course of slow 
development giving more or less serious inconvenience. Their 
removal when required may usually be easily effected, and the 
same rules apply as for the treatment of similar growths in other 
parts. 
Adenoma.-For general description, see p. 510. 
Lingual Goiter.-So-called accessory thyroids at the base of 
the tongue are tumors consisting of tissue derived from the thyroid 
gland, which until recently have been described as adenomata. 
The suprahyoid glands are remnants of the imperfect middle 
lobe of the thyroid gland. They are found embedded in the sub- 
stance of the tongue where the thyroglossal duct empties at the 
foramen cecum. The accessory thyroids usually found in females 
are situated farther down near the hyoid bone. 
Ectopic or supernumerary thyroids may also be found in the 
base of the tongue. 
These tumors are now recognized as aberrant goiters. 
Etiology.-They originate from the remnants of the median 
thyroid outgrowth or an ectopic thyroid embodied in the base of 
the tongue. Histologically they are similar to other varieties of 
goiter. 
Symptoms.-These strumous growths are situated in the median 
line. They form a round swelling behind the circumvallate papilla?; 
are covered with smooth mucosa or have slightly notched surfaces; 
are elastic and quite vascular; numerous veins may be seen cours- 
ing over the surface of the thin mucosa; they seldom or never 
ulcerate, but do often cause hemorrhages; their growth may be so 
slow that the swelling may pass unnoticed; it may be continuous 
or progress to a certain point and become stationary; or may 
change to an acute condition in which increase in size takes place 
rapidly. These tumors are painless, but may become so large as 
to interfere with speech, deglutition, and respiration. TUMORS OF THE TONGUE 
609 
According to M. Leulier,1 "Myxedema seems to be unusually 
frequent in these goiters, and assumes all forms from idiocy to 
early perceptible symptoms." 
Diagnosis.-Differentiation must be made from malignant 
disease of the glands. Thyroglossal duct cysts from dermoids, 
ranula, lingual tonsils, and angiomas. Slowness of growth usually 
excludes malignancy Angioma is more spongy, more irregular 
in outline, of a purple color, and usually showing venous extension 
to one of the lateral pharyngeal areas. 
Treatment.-The extirpation of these tumors is required if the 
functional disturbance is sufficient to make their removal impera- 
tive. If a thyroid is normal, complete removal is indicated. When 
the thyroid is abnormal and there are signs of myxedema, a portion 
of the thyroid tissue of the tumor should be left, to prevent 
cachexia. 
The removal of these growths may be performed through the 
mouth after preliminary tracheotomy and tapping of the trachea. 
The tongue is drawn forward with ligatures and the growth 
removed. Wolf recommends temporary resection of the maxilla 
for infants. It would seem as though this might be the safer 
procedure in cases with tendency to severe hemorrhage. 
Charles Mayo2 gives the following operative description: 
"In the enucleation of lingual thyroids the tongue and pharyn- 
geal areas are cocainized, the patient anesthetized with ether 
and a rapid operation made while the tongue is held in extreme 
tension. The free hemorrhage is controlled by deep sutures. 
In very extensive superior lingual goiter it may be advisable 
occasionally to ligate the lingual arteries and make a laryngotomy 
as a preliminary procedure. It will rarely be necessary to divide 
and separate the lower jaw. 
"While the operations for the removal of lingual thyroids through 
the mouth have been quite bloody, they have been successful; 
practically no fatalities have been reported. Although there have 
been approximately but 50 cases recorded, undoubtedly there have 
been many others in which patients have been operated on." 
Hemangioma.-These growths are congenital, although they may 
not be noticed until enlargement calls attention to their existence. 
Varieties.-Simple angiomata appear upon the tongue as bluish- 
red, elevated patches of variable size, usually about as large as a 
pea. They may be single or multiple. 
1 These de Paris, quoted in Presse Medicale, May 18, 1918. 
2 Jour. Am. Med. Assn., September 2, 1911, p. 786. 610 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
Cavernous angioma presents dark blue ridges or masses above 
the surface of the mucous membrane, and sinks deeply into the 
submucous tissues. Under pressure the blood in these tumors 
recedes and immediately returns when pressure is removed. They 
show more or less increase in size when the patient stoops and are 
again smaller when the head is erect. 
Cavernous angioma sometimes invades surrounding tissue so 
excessively that almost the entire tongue may become involved. 
Hemorrhages may occur as the vessel walls become thin and lose 
resistance. 
Treatment.--Small circumscribed angiomata require no treat- 
ment other than cauterization, and ordinarily may even be allowed 
to remain without serious disadvantage. 
Cavernous angiomata when very small may be excised under 
cocain anesthesia, but tissue outside of the distended vessels should 
be included to avoid excessive hemorrhage. A somewhat larger 
angioma may be incised, and the spongy mass thoroughly curetted. 
To do this the affected tongue area is cocainized and the tongue 
clamped to prevent excessive bleeding. After pressure is removed, 
bleeding vessels are ligated. In operations upon very large cavern- 
ous angiomata of the tongue every precaution against the ill results 
of hemorrhage must be taken. The pharynx must be packed with 
gauze and other precautions that have been described for the 
management of hemorrhage from mouth operations observed. 
Ligation of the lingual arteries or even the external maxillary 
arteries may be necessary. 
Thiersch's method of ignipuncture has met with considerable 
success. He forces a Paquelin cautery into the tumor at several 
points, thus creating an inflammatory action which tends to cause 
an obliteration of the growth. 
Lymphangioma.-Lymphangiectases are sometimes found on 
the end of the tongue. They contain a viscid fluid, may attain 
considerable size, and usually have a base made up of smaller 
cysts. 
Nodular lymphangiomata are small, isolated, hemispherical 
elevations scattered over the base and back of the tongue, singly 
or in groups. The roughened surface is covered with minute 
vesicles that contain watery, turbid, or bloody fluid. These lesions 
have a firm base which has been shown to be an inflammatory 
product caused by temporary periods, during which the growths 
are slightly inflamed and enlarged. The induration remains as 
a permanent result. TUMORS OF THE TONGUE 
611 
One of the author's cases, that of a little boy, aged about three 
years, showed several small lymphangiomata along the border 
and anterior third of the tongue, and although it did not seem 
likely that the small red elevations upon the tongue surface could 
by any possibility interfere with speech, yet the child could only 
utter a few words, and these very indistinctly. 
Treatment.-Deep cauterization under local anesthesia, repeated 
at intervals, if necessary, will cause a disappearance of these 
growths in the course of time. (See Lymphangioma and Macro- 
glossia, pp. 523 and 613.) 
True Cavernous Lymphangioma.-This may lead to enlarge- 
ment of the tongue, which is one form of macroglossia. The 
condition exists at birth, but is more noticeable when the tongue 
has become so large that it projects beyond the teeth and lips. 
Fig. 335 shows a typical case of lymphangioma of the tongue. 
Fig. 335.-Lymphangioma of the tongue-macroglossia. (Westmoreland.) 
Treatment.-The excision of wedge-shaped pieces to reduce the 
size of the tongue, and this repeated at intervals, with the removal 
of a portion of the tip also, if required, will overcome the trouble 
in the course of time (see p. 611). 
Endothelioma.-This tumor affects the tongue rarely. 
Sarcoma.-Sarcoma is found more frequently in this situation, 
Carcinoma.-Carcinoma is unfortunately very prevalent in 
but is not common. 
persons of advanced years. The diagnosis and operative treatment 
of these growths are described under their several headings, page 
534, etc. 612 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
MALFORMATIONS OF THE TONGUE. 
Aglossia (Congenital Absence of the Tongue).-This deformity 
is never found with malformation of the face alone. It is assumed 
that, in common with congenital tongue defects, this is caused 
by the formation of amniotic bands and adhesions which restrain 
and interfere with the development of the embryonal fissures. 
Bifid Tongue.-Agnathia, the congenital absence of the lower 
jaw, is always accompanied by absence of the tongue or bifid 
tongue. Bifid tongue has been found with a case of divided lower 
jaw. The tongue is sometimes divided as the result of accident 
or disease, noticeably sclerotic syphilitic glossitis. The natural 
appearance of the mucous membrane in the former condition as 
distinguished from the cicatrized surface of the latter, together 
with the history of the case, makes diagnosis comparatively simple. 
Fig. 336.-Lobulated tongue. Child, aged seven years. 
Lobulated Tongue.-Congenital clefts in tongues sometimes 
take the form of lobes projecting out from the body of the tongue. 
An example of this is shown in Fig. 336, taken from the photograph 
of the tongue of a little girl, aged five years, who came under 
the author's care for treatment of congenital cleft palate. It was 
difficult to determine to what extent the tongue defect was respon- 
sible for her inability to speak, because of associated nasal and 
palatal defects. 
Microglossia.-A congenital condition in which the tongue is 
small enough to warrant this descriptive term is rare, but there are 
cases in which the tongue- is so small as to appear to be almost 
entirely absent. 
A newly born infant that was brought to the author for treatment 
had a tongue so small that its tip was barely discernible when the 
mouth was opened. MALFORMATIONS OF THE TONGUE 
613 
The base seemed fairly large, and in the belief that some congenital 
insufficient development of the glossopharyngei muscles or adherent 
bands of tissue might be holding the organ back, an attempt was 
made to cut these muscles and draw the tongue forward to fill its 
natural place. It was found to be impossible to benefit the child 
by surgical assistance. 
Macrogiossia (Megaloglossia) (see Lymphangioma, p. 523).- 
Enlargement of the tongue also takes place in acromegaly, and 
its control is subject to general treatment of this affection as 
described (p. 611) and such operative procedures as may be required 
to give relief. 
Long Tongue.-Abnormally long tongues sometimes become a 
menace through danger of their being swallowed. Cases have been 
reported in which suffocation has occurred from this cause. Girod 
reports a case in which the tongue could be extended 7 cm. beyond 
the line of the incisor teeth. Naturally only the exceedingly long 
tongues have occasioned sufficient notice to be reported; but the 
author believes that in certain individual types a long, narrow 
tongue resembling the tongue of a dog when protruded is not 
unusual; and in these cases there is very likely to be speech difficulty. 
Lingua Plicata or Dissecata.-This is a congenital condition in 
which the tongue is moderately enlarged and has a number of 
longitudinal transverse folds. In these cases there is absence of 
uniform and smooth surface, although the mucous membrane 
appears to be otherwise unchanged, and the parenchyma retains 
its soft character. 
Treatment is not required in these cases unless enlargement 
of the dental arches may be indicated or some correction required 
because of annoyance to the patient. 
Ankyloglossia, Lingua Fraenata, or Tongue-tie.-This is caused 
by a large and anteriorly displaced frenum. 
Symptoms.-Attention is usually called to the trouble in infants, 
because they have difficulty in sucking, and upon examination it 
is found that the tip of the tongue cannot be raised, or is turned 
downward when the tongue is protruded. Mothers and even 
attending doctors often overestimate the importance of this con- 
dition. In most cases if the finger can be introduced beneath the 
tip of the tongue and that organ drawn forward over the alveolar 
border an incision is not required, and should not be made unless 
obviously necessary. 
Ankyloglossia in greater or lesser degree is sometimes found in 
older persons, and in these cases decision as to the best procedure 614 
DISEASES, TUMORS, AND MALFORMATIONS OF TONGUE 
is sometimes difficult, as indicated by descriptions of cases which 
follow. 
In many of the author's cases of children past the age for the 
natural acquirement of speech, and even adults, the difficulty 
was chiefly noticed because of defective speech. Some of these 
had had slight but only temporarily effective operations, while the 
tongues of others were bound with sufficient tightness to interfere 
with taking nourishment. If there were no other bar to speech 
progress than the tongue-tie, the diagnosis would be simple, but 
in many instances there were indications that the individual was 
to some extent otherwise defective. When in such cases there was 
a more or less considerable ability to move the tongue, even though 
contraction at the tip during protrusion showed that it did not 
have complete freedom, it was hard to say whether defective speech 
was due to one or the other of the following causes: (1) Entirely 
to ankyloglossia; (2) primarily to restriction of the tongue and 
secondarily to failure of development of the speech centers; (3) 
to inability or reluctance to make the necessary effort to acquire 
speech, because of the impediment; or (4) to central causes, which 
would by no means be improved through any sort of tongue 
operation. 
Treatment.-Cutting of the frenum with scissors in infants is 
a very slight operation; and usually the constant movement of the 
tongue may be depended upon to prevent the parts from reuniting. 
As already indicated, operative interference need only be resorted 
to when there is absolute indication of its necessity. 
In the treatment of older children and adults the operator is 
confronted with the embarrassing possibility of performing an 
operation which will not be a benefit if the speech affection be due 
to some other cause than the tongue condition. In these cases, 
especially when imperfectly treated in infancy, there is sometimes 
not alone the actual frenum to be dealt with, but an interweaving 
of muscular or cicatricial fibers from the frenum along the under 
surface of the tongue to the tip, which retracts the tip of the tongue 
during protrusion, because development along this surface has not 
kept pace with the growth of other parts of the organ. In such cases 
only a plastic operation which will give actual increase in the length 
of the constricting portion of the tongue might be expected to give 
sufficient freedom to enable the tip of the tongue to be readily 
placed in the positions required for correct phonation. 
The author's custom in these cases is to direct a course of speech 
training or other tongue movement for the purpose of demonstrating MALFORMATIONS OF THE TONGUE 
615 
whether the inability to move the tongue can be improved by 
training. If the general intelligence and the sense of hearing are 
such as to permit improvement in the utterance of the elementary 
sounds least affected by the tongue condition, then operative 
procedures are indicated to give the greatest possible freedom in 
the use of the tongue. Otherwise the surgeon might be subjected 
to the mortification of performing an operation which could not be 
beneficial. 
Adherent Tongue.-This term is applied when the surface of 
the tongue and mouth are adherent or bound by bands of tissue. 
Usually these are attached to the edge of the tongue and inner 
surface of the lower jaw. Cases have been reported of the tongue 
being attached to the cheek. In infancy these bands of tissue can 
easily be broken with the fingers or with a dull, suitably shaped 
instrument. Occasionally a cut with the scissors may be necessary. 
Sometimes the anterior portion of the tongue must be dissected 
free, and the mucous membrane infolded in suturing the wound 
so that there may be no raw surfaces in contact to cause recur- 
rence of adhesions. The author has done this recently for a boy, 
eight years old, with very satisfactory speech improvement. CHAPTER XL 
NASAL DEFORMITIES AND DISEASES IN RELATION TO 
THE MAXILLAE. 
Etiology.-Developmental Factors.-In the short period between 
the fertilization of the human ovum and the fifth to the seventh 
week of embryonic life, examination of the sections through fetal 
heads discloses that important changes have already taken place. 
Even at this early stage they are indicative of the principles that 
must govern the treatment in correction of deformities during the 
entire period of development of the individual. 
"The first pharyngeal arch divides at its anterior extremity into 
two parts-(a) superior and inferior maxillary protuberance. The 
latter unites very early to its fellow of the opposite side to form 
the lower jaw. The superior maxillary protuberances are displaced 
outward and unite to the external nasal process; from this part 
are developed the internal plate of the pterygoid process, the 
palate bone, the superior maxillary, and the malar. The lateral 
masses of the ethmoid, the os unguis, and nasal bones are furnished 
by the internal nasal process. The rest of these processes on either 
side are united by a single protuberance, the incisive tubercle, 
from which the intermaxillary bone and the middle of the upper 
lip are formed, and according to some the vomer."1 
It is important to note in Fig. 337, which shows a section through 
the head of a human embryo at approximately the fifth week, 
that complete coalescence of the divisions of the forming face and 
mouth, resulting from progress in this direction of the palatine 
lamellse which are given off from the maxillary tuberosities and 
unite to form the palate, and become joined to the incisive bone 
to form the anterior part of the mouth and upper lip, has not yet 
been completed. If, therefore, approximately between the fifth 
and ninth week of embryonic life, arrest of development interferes, 
a union in this particular region will not take place. The result 
of this will be harelip, cleft palate, or both in any of the various 
forms in which these maldevelopments appear. Reestablishment 
1 Gray's Anatomy. ETIOLOGY OF NASAL DEFORMITIES 
617 
of growth in its natural course may and usually does result in the 
correct formation of other divisions of the head and face, except 
insofar as they may be influenced by the effect of the disarrange- 
ment of muscular and other physiological action through the 
deformity which has now become established. 
Inspection of a section through the jaws at^this period, under 
higher magnification, shows the epithelial Jcord which marks the 
appearance of the first indication of the tooth germs. ■ 
Fig. 337.-Section through the head of a human embryo at approximately the fifth 
week. (Latham.) 
Passing in succession through a series of similar sections (Figs. 
338 and 339) at important periods until birth, we find that in the 
absence of arrest or other interference with normal growth the divi- 
sions of the palate become completely united, and the spaces for 
the nares so much enlarged that they occupy a very considerable 
portion of the facial division. The palatal surface at this time is 
flat, because development of the alveolar regions has not yet taken 
place to any considerable extent. 618 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
As the tooth follicles increase in size, and their eruption thus 
becomes more completely established, some of them are situated 
high up and just outside the nares. If growth of the alveolar 
Fig. 338.-Section through the head of an embryo at approximately the twelfth week 
Fig. 339.-Section through the head of a human embryo at approximately the 
twelfth week. Developing teeth may be seen high up at each side of the nose and 
beneath the tongue. ETIOLOGY OF NASAL DEFORMITIES 
619 
ridges takes place in natural form, unimpeded by any factor which 
may tend to restrict the natural size of the arch, the developing 
tooth crowns, the germs for both temporary and permanent sets 
of which are in place before birth, can pass on downward and 
outward in the natural course of their eruption. In this way they 
make it possible for the nares and their dividing septum, as well 
as turbinal and other nasal structures, to assume in due course 
normal form and proportions. When surgical, mechanical, devel- 
opmental, or pathological causes interfere with the natural expan- 
sion of the arch, which represents the alveolar ridge and later the 
dental arch, there naturally must be crowding through lack of 
space, and the tooth crowns cannot assume their rightful posi- 
tions in relation to others that are being pushed onward by the 
forces which cause tooth eruption. The first effect of pressure 
from crowding must naturally react upon regions of the maxillae 
in which the tooth crowns at this time are located. Effort at read- 
justment takes place in the direction of least resistance. This 
must be in the direction of the nares, and causes in greater or 
lesser degree abnormality of form, which is chiefly shown by their 
restricted size. 
The second effect is overlapping of the tooth crowns, evidenced 
by their eruption on the outside or the inside of the true line of 
the arch, resulting in labial, buccal, or lingual occlusion. When 
the process of eruption has continued to a point where the cusps 
of the teeth in the occluding jaw can come in contact with each 
other, the muscular forces of jaw movement, acting upon the 
inclined planes of the cusps and the crown surfaces of the teeth, 
bring into play the active factors through which regular or irregular 
forms of dental arches are determined. 
Glancing for a moment upon the reverse side of this develop- 
mental picture, we must recognize that from the moment of the 
very first respiration at birth, one of the most potent influences 
upon which this jaw expansion and development depends is the 
physiological action of correct respiration. Thus we have estab- 
lished backward and forward an interrelation of growth so evenly 
balanced that it would seem to preclude its being unusually impor- 
tant to any one division more than the other. 
Another interesting feature in the embryonic stages is noticed 
in the large size of the tongue in proportion to the jaws. This 
is important in its influence upon the maxillary ridges, and is of 
great significance. Being so out of proportion in size, arrest in the 
growth of the jaws consequently fails to give the tongue that space 620 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
during early childhood which will enable its free use in speech. 
Such children learn to speak with great difficulty, if at all, or, as 
might be expected, are reluctant to make the unusual effort required 
of them in learning to form certain words. Thus the brain cells, 
directing this action, do not develop, and in the course of time 
such children come to be considered defective, and ultimately really 
become so, because natural progress of the speech centers is arrested. 
Undoubtedly many might have been at least approximately nor- 
mal if there had been correction at a sufficiently early date. In 
summary of etiological factors pertaining to these affections it 
may be said that: 
1. Any influence which can affect intra-uterine growth, and this 
includes arrest of development from any cause, be it hereditary, 
metabolic, incidental, or accidental, can directly bring about or 
predispose to the malformation of nose and mouth. 
2. Any interference with continuous and complete embryonic 
growth will manifest itself in imperfect form, directly due to the 
arrested development and in asymmetrical exaggerations thereof, 
including alteration in both form and structure by the imperfect 
physiological action of the immediately affected and surrounding 
parts. 
3. After birth any abnormal muscular activity, whether due to 
the unusual stress of habit, accident, or other cause, will make its 
influence manifest in distortion of the form of the growing 
parts. 
4. With obstruction of the upper air passages complete sym- 
metrical formation of the palate and upper maxillary arch cannot, 
as a rule, be expected. 
Conversely, any factor which tends to contract the form of the 
palate in such a manner as to bring about crowded and high-arched 
conditions of the palatal vault, with the usually attendant saddle- 
shaped narrow dental arch, must in greater or lesser degree tend 
toward contracted nares, deviated nasal septa, and commonly 
associated nasal defects. For these reasons it is manifest that 
adenoids and enlarged tonsils, whether first or second in etiolog- 
ical succession, are always and invariably contributing factors of 
first importance. The propriety of their removal as a corrective 
measure is obvious. A discussion of the question of etiological 
precedence may be omitted, since all treatment must resolve itself 
into procuring increased space for the purpose of more complete 
physiological action in respiration and also room for development 
in the dental region. TREATMENT OF CONTRACTED NARES 
621 
Treatment of Contracted Nares, Deviated Nasal Septa, and 
Other Intranasal Deformities by Direct Separation of the Supe- 
rior Maxillae through the Median Suture.-As the author has shown 
in previous writings upon this subject, the appliance he uses for 
separating the maxillae is merely an adaptation of well-known ortho- 
dontic instruments and principles. The space that appears between 
the central incisors, which is indicative of division through the 
median maxillary suture, has been frequently noticed by many 
dentists and orthodontists, who have had it occur accidentally in 
the course of their treatment. 
His only claim of originality lies, therefore, in the application 
of these principles for the specific purpose of producing maxillary 
separation in order that widening of the nares and correction of 
nasal defects might be the direct result. The surgical operation 
for the immediate accomplishment of maxillary separation as 
described and illustrated in this chapter is believed to be new, and 
original with the author. It is undoubtedly true that, having 
thus obtained the increased size in the dental arch through expan- 
sion, the proper space allowed enables nature to correct many 
dental irregularities in considerable measure without further'inter- 
ference. Unless locked in lingual, labial, or buccal occlusion, or 
for some other reason held in malposition by forces or factors 
which cannot thus be overcome, the natural tendency of all teeth 
is to seek their rightful positions in the dental arch and to assume 
proper occlusal relations. 
The author has previously estimated that about 75 per cent, of 
the orthodontia now considered necessary would not be required 
were this simple procedure performed at a sufficiently early date. 
Others have made somewhat higher estimates. Notwithstanding, 
he wishes it to be clearly understood that this method is in nowise 
brought forward as a complete substitute for well-known ortho- 
dontic systems. It is often necessary to employ the principles 
and methods of orthodontia to complete what has been accom- 
plished by maxillary separation and to secure permanence for the 
improved condition by correct occlusion of the teeth in both 
jaws. 
The kind of pressure exerted in the ordinary course of tooth 
regulation by orthodontists and dentists will not give the increased 
intranasal space or make possible the correction of nasal defects, 
in anything like the same degree, even in young children, and in 
adult cases it is extremely doubtful if any improvement of suffi- 
cient value to improve marked deflection of the septum could be 622 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
secured in any other way than by direct pressure which will cause 
separation of the maxillary bones. 
The reasons for this statement are exceedingly simple. The 
principles of the various orthodontic systems now in vogue require 
pressure which will cause a gradual movement of the teeth. The 
result of pressure so exerted is to cause bone absorption. This 
Talbot has amply proved. 
There are many reasons why slow movement of teeth is advan- 
tageous when applied to the correction of dental irregularities. 
In order to carry the effect to the higher region of the nose, the 
less movement of the teeth through the alveolar structures takes 
place the better the result will be, insofar as widening of the nares 
is concerned. 
For this reason more or less disappointment has sometimes 
occurred when rhinologists have referred these cases to orthodon- 
tists and dentists. Although the teeth may have become beauti- 
fully straightened and symmetrical arches secured, the nasal 
improvement was not such as it might have been had the process 
of direct pressure here recommended been applied and a positive 
result'obtained within a period of approximately two weeks. 
Practical illustrations of the truth of this statement are almost 
unlimited, and could be multiplied by descriptions of almost innum- 
erable cases in practice during the last few years. The pathological 
explanation seems to be established with equal certainty when 
Talbot's experiments on dogs are considered and the author's own 
results of expansion upon green skulls. Both are here given. 
Talbot's experiments with regulating appliances in the mouths 
of dogs were as follows: The screws, which were given one-fourth, 
one-half, and one full turn every evening, were 60 threads to the 
inch. The teeth of the three dogs were moved -2^0-, and -/o' 
of an inch daily, respectively. The process in which the screw 
was turned one-fourth and one-half turn each day was continued 
for seven days; the one in which the screw was turned one full 
turn was continued for two weeks. The object was to set up 
pathological changes in the alveolar process similar to those pro- 
duced in the human mouths. Talbot's findings, proved by micro- 
scopic sections of jaws of the dogs thus treated, show beyond 
question that movement under these conditions is effected by the 
ordinary processes of bone absorption.1 
The surgical division to which the author's practice is limited, 
1 Talbot: Interstitial Gingivitis. TREATMENT OF CONTRACTED NARES 
623 
and the constant observation of the marked nasal and maxillary 
deformities which occur in harelip and cleft palate cases, have 
impressed upon his mind the fact that there are some principles 
having a direct bearing upon this subject. Its rationale in naso- 
maxillary developmental relation can be more accurately observed 
in those cases than in the course of normal growth, because through 
the opening in the palate and in the lip the form of the nasal septa 
affected by normal conditions can be directly studied with the 
entire field in view. The resulting changes in form and structure 
of both osseous and cartilaginous nasal structures by adverse 
muscular action can also be plainly seen. 
Although conditions may in many respects be radically different 
when there are no fissures through the palate or lip, the factors 
which play a part in determining both intra- and extranasal form 
results, though modified in degree, are in effect precisely the same. 
The reader is therefore referred to the illustrations of these cases 
and the descriptions which accompany them for confirmation of 
the principles which underlie this method of correcting lesser nasal 
defects. 
The author believes the defects to be accounted for by the 
double development of the nasal septum which occurs more often 
than is commonly realized. Not only is the effect noticeable in 
bulging or buckling on opposite sides of the same septum, but 
the author has recently had under his care an infant, born with 
double harelip and cleft palate, in which there was a continuous 
line of attachment from the nasal septum to the maxillary division 
of the palate upon each side, the entire central portion being open 
and apparently not connected with the nares. This condition was 
discovered in an effort to pass a catheter through the nose for the 
purpose of continuing anesthesia during the operation for closure 
of the palate. The catheter, when inserted and passed through 
the nose, appeared quite close to the Eustachian opening, and 
could not be passed directly through into the wide open space in 
the center of the palate (Fig. 340). 
The best description of the double development of the anatomical 
parts of the nasal septum, the nasal processes, the vomer, the 
vertical plate of the ethmoid, the upper maxillary, the triangular 
cartilage and its caudal prolongation, and the relation of the pre- 
maxillary wings, as affected by developing tooth germs, reflecting 
upon the form of the septum, has been given with supporting evi- 
dence from the anatomical room in an exceedingly complete series 
of illustrations by Harris Peyton Mosher, of Boston, who states: 624 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
"The septum at birth is almost cartilage. The only bony parts 
are the vomer and the two premaxillse and their processes. The 
vomer consists of two leaves of thin bone, which are united below, 
but are open and flaring above. This formation is a relic of its 
double origin, evidences of which the vomer never entirely loses. 
The premaxillary wings spring from the posterior half of the upper 
face of the premaxillse. In the groove which they form rests the 
tip of the vomer. Two other processes spring from the superior 
surface of the premaxillae, namely, the nasal spines. These again 
make a slight gutter, into which in its turn fits the tip of the pre- 
maxillary wings. The tip of the vomer rests in the gutter of the 
premaxillary wings, and the tip of the premaxillary wing rests in 
the gutter of the nasal spines, like the arrangements of the sections 
Fig. 340.-Double development of the nasal septum, with central groove through 
nose and median fissure of the upper lip and palate. 
of the old-fashioned wooden drain. The upper border of the adult 
vomer is gutter-shaped, like the vomer at birth, the gutter not 
being so deep. 
"A large number of deviations of the septum are caused by 
asymmetry in the development of the bones which make the hard 
palate. This inequality of the development is usually due to 
delayed or irregular eruption of the incisor teeth, especially of 
the middle incisor. When the eruption of one central incisor is 
sufficiently belated it causes a deformity or hypertrophy of the 
maxillary wing above it. This distorts the retaining groove made 
by the premaxillary wings. As a result the septum slips from its 
bed in the vomer, and the grooves made by the two leaves of the 
vomer spread open, one leaf on the side of the vomer disappearing. 
This produces a spur along the upper edge of the vomer. As the 
cartilaginous part of the septum slips from its bed the lower edge TREATMENT OF CONTRACTED NARES 
625 
curls upward and outward, so that its lowest portion becomes 
concave. Higher up on the septum this concavity gives place to 
a compensatory convexity. The convexity generally is toward 
the spur. On the side of the delayed tooth a short basal spur 
indicates the enlarged premaxillary wing. The upper wisdom tooth 
may deform the septum posteriorly. This asymmetry shows in 
the nasal notches anteriorly and in the choanae posteriorly and in 
the mouth. Abundant dissecting-room findings prove that devia- 
tions so started may extend far backward on the septum and 
become obstructive." 
It is interesting that this evidently painstaking and exhaustive 
study of embryonic and later anatomical study, supported by 
evidence from the dissecting room, coincides so perfectly with the 
results of our study of maldevelopment and clinical experience in 
this region. With Mosher's illustrations and descriptions before 
one, there can be no doubt of the practical corrective efficiency of 
a method which would separate the halves of these developing 
parts sufficiently to supply space for their assumption of their 
normal form, which had been denied them through insufficient 
room for proper development. The elaboration of the gutter form 
of the premaxillary wings and vomer, and other evidence submitted 
shows that with deviations of the septum the first tendency is to 
slip out of the trough which forms its natural resting place. This 
makes plain the reason why straightening of the septum, even in 
adult patients, takes place in such marked degree when the max- 
illary bones are separated. This has been proved over and over 
again in our clinical experience, but there has been some hesitancy 
about claiming it to the extent which results seemed to warrant, 
but now the assumption may be that the separation must neces- 
sarily reestablish the gutter form and allow the naturally resilient 
septum to seek its proper resting place. 
Obviously, the simple and most natural method of correction 
must lie, insofar as possible, in the application of force, which 
will directly overcome not only the first causes, but the secondary 
results as well. 
The author's appliance, as shown in Fig. 341, is constructed by 
adjusting metal bands to fit the cuspids and the first or second 
molar teeth upon each side of the mouth. These are connected by 
rigid metal bars which rest against the lingual sides of all inter- 
vening teeth. To the side bar upon one side a metal tube is attached 
into which fits a threaded wire extending from the opposite side 
with a nut adjusted to fit. These are so arranged as to make direct 626 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
pressure across the palate at the point of greatest constriction 
when the nut is turned. Force thus applied is distributed against 
all of the teeth upon each side of the dental arch, and by turning 
the nut twice daily, continuing each time until firm pressure is 
felt but no pain whatever experienced, the maxillse can be separated 
through the median suture of the palate and division between the 
central teeth. When this occurs, the incisor teeth are moved 
apart, and since the appliance does not touch them in any way, 
Fig. 341.-Expansion appliance as used by the author in separating the maxillae to 
widen the nares. 
the only explanation is that the bones in which their roots have 
been embedded have been moved away from each other. Both 
intra- and extranasal measurements prove that in this movement 
the nasal bones and other attached parts have also been included, 
with the result that there is a direct and immediate increase of 
space within the nares. To prove this definitely, similar appli- 
ances were adjusted to green skulls. The result is shown in Figs. 
341 and 342, in which the parted sutures can be plainly noted, 
with increase in actual measurement of one-eighth of an inch across SEPARATION OF SUPERIOR MAXILLARY BONES 
627 
the base of the nose and one-sixteenth of an inch across the upper 
third. 
When the upper dental arch has been expanded it is obviously 
necessary to enlarge the lower jaw to correspond in order to secure 
correct occlusion of the teeth. This can be done without unusual 
difficulty by orthodontic methods. 
Fig. 342.-Front view of skull shown in Fig. 341. Division between the maxillary 
bones up to the nose may be noted. 
The Immediate Surgical Separation of the Superior Maxillary 
Bones to Widen the Nares for the Improvement of Respiratory 
and Other Conditions According to the Author's Operation.-The 
day before the operation is performed an expansion splint is 
cemented to the teeth. This appliance is in all respects the same 
as previously described for the slower method of rapid maxillary 
separation, except that additional bands are cemented on both 
second bicuspid teeth with hooks to slide over the side bars to 
give greater firmness. 
The upper lip is raised and a vertical incision about three-eighths 
inch long in the median line above and between the roots of the 
central incisor teeth is carried down to the bone close to the frenum 
labialis superioris. The periosteum is then slightly raised on each 
side of the incision and the tissues retracted to expose the inter- 
maxillary suture. 628 
NASAL DEFORMITIES AND DISEASES OF MAXILLA 
Fig. 343.-Shows splint in place with expansion screw bar across the palate. 
Vertical incision as made above and between the roots of the central incised teeth 
down to the bone at the intermaxillary suture. 
Fig. 344.-Chisel at the intermaxillary .suture being driven between the bones by 
gentle blows with a mallet. SEPARATION OP SUPERIOR MAXILLARY BONES 
629 
A fine chisel is inserted into the suture at this point, followed 
with a larger, more wedge-shaped chisel. A few blows with a mallet 
forces the chisel between the bones and by tightening the screw 
the separation is made complete (see Fig. 345). 
In this way the maxillae are forced apart, carrying with them 
the attached nasal bones. The result is a direct increase in size 
of the nares. 
Fig. 345.-Turning the nut on the cross bar of the appliance after the maxillary 
bones have been partially set free by separation through their intermaxillary and 
median palatine sutures. The space between the central incisor teeth which are 
not touched by the appliance indicates the complete accomplishment of the separa- 
tion of the maxillae. By turning the nut during the first few days after the opera- 
tion as much enlargement as necessary may be secured. It is therefore both 
undesirable and unnecessary to apply much force with the expansion screw during 
the operation while the patient is unconscious. In this way any possible danger 
of injury to the teeth is avoided. 
The almost instantaneous effect of forcing the maxillae apart 
after surgical separation appears to exert a more pronounced 
influence in the graver types of cases than the slower method of 
depending upon pressure against the teeth alone as in non-surgical 
rapid expansion of the upper dental arch. 
The freer bone movement thus allowed gives less tendency to 
flanging of the teeth, and the relation of intranasal enlargement 
to the increased width across is proportionately improved. 630 
NASAL DEFORMITIES AND DISEASES OF MAXILLA 
Clinical Results.-The following cases are fair examples of the 
usual clinical results. Fig. 346 shows a young man, aged twenty 
nine years, whose nose was injured by a baseball in early youth. 
Fig. 346.-Young man, aged nineteen years, with nose injured in early youth. 
Badly buckled septum and almost complete stenosis of one naris. 
Dr. Nelson M. Black, by whom the patient was referred to the 
author, found the septum buckled in such a way as to give almost 
complete stenosis of one naris, the turbinal bodies much enlarged, 
Fig. 347.-Same young man, about ten days later. Separation between the 
ventral incisors confirmed by intranas^l examination, which disclosed enlargement 
in this region, evidence maxillary separation. 
and hypertrophic conditions generally marked. The patient was 
greatly troubled by attacks of sneezing when he bent his head 
downward. The appliance was adjusted April 6, 1908. Within SEPARATION OF SUPERIOR MAXILLARY BONES 
631 
two weeks the space between the central incisors appeared as 
shown in Fig. 347. Actual enlargement of the nares was confirmed 
on examination by Dr. Black, and by the improved breathing 
experienced on the part of the patient himself, thus proving that 
Fig. 348.-Casts of the mouth of a boy, aged fourteen years, before and after 
expansion. The space between the central incisors closes itself in the course of 
time without operative influences. 
even at this patient's age the desired result had been quickly 
accomplished. Most of the time the patient, who resides in another 
city, was at a distance from the author, and had the appliance 
turned by one of the members of his family. 
Fig. 349.-Skiagrams of the mouth of a girl, aged eight years, a, Showing appli- 
ance in place but before pressure has been applied-taken June 29, 1913. b, the 
same mouth July 29, 1913. This result might have been secured much earlier 
except for delays which occurred by the patient being out of the city. 
Fig. 348 gives the central measurement with a millimeter gauge 
of two casts of the mouth of a lad, aged fourteen years, one taken 
before the arch was separated, the other at the time when the 
division through the central incisors was evident, and his rhinolo- 632 
NASAL DEFORMITIES AND DISEASES OF MAXILLA 
Fig. 350.-This girl had for years been a great sufferer from bronchial asthma. 
Her father at forty years of age is still a great sufferer from the same affection. 
She has been almost entirely free from severe attacks for a long period and although 
having more or less mild asthmatic disturbance, was able to attend school regularly 
all last winter. This was impossible before her upper dental arch was expanded 
and nose enlarged. There is also much improvement in the form of her chest and 
back. It is confidently believed that she will now entirely outgrow all of these 
defects. 
Fig. 351.-Girl formerly affected by asthma who has been entirely free from 
attacks since upper maxillary expansion was performed, which warrants the statement 
that she is entirely cured. Formerly she could not ride behind horses without 
having severe asthmatic trouble. SEPARATION OF SUPERIOR MAXILLARY BONES 
633 
Fig. 352.-Tubercular girl with marked scoliosis who is now in good health. 
Repeated von Pirquet tests negative, although her back will undoubtedly require 
additional corrective treatment. 
Fig. 353.-The same girl shown in Fig. 352. The shape of the face, nose, and chest 
indicate the necessity of this treatment. 634 
NASAL DEFORMITIES AND DISEASES OF MAXILLA 
gist reported sufficient improvement of his nasal condition. This 
is a fair example of the approximate increase in width of the palate 
that is required in such cases. Figs. 356 and 357 show what may 
Fig. 354 
Fig. 355 
Fig. 354.-Skiagram of the mouth of a boy, aged twelve years, who /was a chronic 
sufferer from hay fever, headaches, bronchitis, and general nervous conditions, 
particularly noticeable in winking of the eyelids. Marked improvement in all 
these symptoms followed widening of his upper dental arch in July, 1912. The 
skiagram of his palate was taken January 11, 1913. The thick black line along 
the line of the median palatine suture seems to indicate new bone formation in that 
region. During these six months his growth in height was increased two and three- 
quarter inches. 
Fig. 355.-Skiagram of the palate of a young man, aged twenty-eight years, for 
whom wide separation of the median palatine suture was performed, with great 
benefit to nasal and general pathological conditions; taken two years afterward. 
The thick dark line shown where new bone had formed in the line of the formerly 
separated median palatine suture proves that the osteogenetic layer of the palatal 
periosteum does become active under these conditions and that new bone formation 
results. 
Fig. 356.-The result of traumatic in- 
jury. (Wurdeman and Black.) 
Fig. 357.-Correction made possible 
by widening the nares as a preparatory 
measure. (Wurdeman and Black.) SEPARATION OF SUPERIOR MAXILLARY RONES 
635 
be done by maxillary expansion to prepare for surgical correction 
of nasal deformity in other respects. 
To these, if repetition by citation of other cases were either 
necessary or advisable, a long list of other patients who have 
received the same treatment with precisely the same result in the 
author's practice during the last few years might be added. All 
show deviation of the nose from the central facial line, an imagi- 
nary though clinically a very useful line, taken through center of 
forehead, tip of nose, and center of chin. Deviation from this 
line, one way or another, is a fairly certain indication of perverted 
nasal and maxillary growth, leading almost invariably to pathologi- 
cal conditions. 
Especially among growing children treated by this method has 
there been marked physical improvement, tendency to growth in 
height, as well as general development and increase in weight. 
Many had previously been unable to attend school regularly 
because of the tendency to nose, throat, and bronchial affections. 
Nervousness was almost invariably very greatly relieved, and this, 
it is believed, for two reasons: (1) The well-understood results 
from the improvement in breathing apparatus, with general health- 
fulness to be expected from better aeration and freedom from dis- 
eased nasal secretions; (2) the relief from the crowding together of 
the dental arches, with tendency to nerve irritation. This condi- 
tion quite frequently manifests itself, not only in increased nervous- 
ness of a general character, but also in the development of neurotic 
tendencies leading to chorea, epilepsy, and other similar affections. 
In some instances, at least, these disorders might perhaps have 
been averted if the patients could have been tided over critical 
periods in their development. It is a curious fact that even with 
the disadvantage of having the appliance in their mouths and the 
bar across the palate, children who are subject to such pathologi- 
cal states almost immediately become less nervous, have increased 
appetites, and general development goes forward almost from the 
very first few days after pressure has begun to be exerted. 
This treatment might be made a very great factor in safeguard- 
ing against tuberculosis. It is so easily accomplished and the 
results are so greatly beneficial that it should be applied to hun- 
dreds of thousands of growing children, who are unquestionably 
more susceptible to pneumonia and bronchial affections because 
of imperfect breathing. It offers a possibility of relief which is 
especially important because such defects are well known to be 
on the increase, arrested development in the maxillary region 636 
NASAL DEFORMITIES AND DISEASES OF MAXILLA 
being more marked in each generation under the conditions of 
our so-called civilization. 
In final proof of the foregoing theoretical and clinical conclu- 
sions, the author is privileged, through the courtesy of Dr. Lee 
W. Dean, of the State University of Iowa, to submit the following 
record of a young girl, aged seventeen years, a patient of Dr. 
Dean, for whom maxillary separation was performed to aid the 
correction of serious nasal and other defects. These measurements 
were made with an instrument invented by Dr. Dean for the 
purpose, and taken by his associate, who had no special interest 
in the case, and whose accuracy could in nowise be consciously 
or unconsciously affected by any preconceived idea or expectation. 
They are therefore absolutely correct. 
A 
May 
28, 1909 
B 
August 
11, 1909 
C 
February 
18, 1910 
R. 
L. 
R. 
L. 
R. 
L. 
Anterior end of inferior turbinate to septum 
5 
6 
8 
9 
9 
10 
Middle of inferior turbinate to septum . 
5 
4 
7 
6 
7 
6 
Posterior end of inferior turbinate to septum 
10 
12 
10 
12 
12 
12 
Anterior end of middle turbinate to septum 
2 
2 
2 
2 
4 
4 
Middle of middle turbinate to septum . 
1 
2 
2 
2 
■ 2 
4 
Having thus fully demonstrated the practicability of the improve- 
ment of nasal deformities and attendant disease by separating the 
maxillary bones and directly increasing the size of the nares, it 
only remains to prove that constriction or arrest of growth in 
width across the palate could cause deviated septum, contracted 
nares, or even complete stenosis. 
This the author has been able to do.1 Several pups eight weeks 
old were operated upon by passing a wire through the maxillae 
from a point above the roots of the teeth upon one side above the 
palate and out at a corresponding point upon the opposite side. 
The palate was compressed sufficiently to force the upper teeth 
inside or in lingual occlusion with the lowers, so that the upper 
and lower jaws of these puppies were placed in about the same 
occlusal relation that exists in growing children whose bicuspid 
teeth meet the corresponding lower teeth in lingual (inside) instead 
of buccal (outside) or normal occlusion. Not nearly so much 
force in compression was used as would be necessary to close a 
case of palate fissure according to the method which was formerly 
widely practised upon infants with cleft palate. The purpose was 
1 Through the courtesy of the Parke, Davis & Co. Laboratory, in whose Biological 
and Research Department he was permitted to do original work on puppies, with 
the able assistance of Dr. Ferry and his associates in the laboratory. SEPARATION OF SUPERIOR MAXILLARY BONES 
637 
Fig. 358.-Back and shoulder view of a girl, aged fifteen years, with marked 
spasm of the right side of the face, right arm and right leg. Explosive and slurring 
speech. Almost total relief from these symptoms was secured in less than thirty 
days after pressure was applied to spread the upper maxillae apart to enlarge the 
nose. Three months later she was so improved that she was able to crochet a pair 
of silk slippers with a needle held in her right hand which was formerly quite helpless. 
(Author's article, Ochsner's Surgery, vol. i.) 
Fig. 359.-Same patient shown in Fig. 358. The shape of face and nose gives little 
indication of her great need of nasal widening. 638 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
to reproduce as nearly as possible the maxillary condition of typical 
cases of mouth-breathing children. One pup was kept without 
operation as a control, and all were allowed to develop until they 
reached the age of six months, which, it was estimated, would 
approximately correspond to the age of a child aged eight or nine 
Fig. 360.-Boy, aged eleven years. Diagnosis: Little's disease. At the time 
his jaw was expanded he was unable to walk without assistance and had practically 
no control of his tongue, so that it was almost impossible to understand his attempts 
at speech satisfactorily, a drooling from his mouth constantly, and other typical 
symptoms of this affection. He is now able to walk about without assistance and 
speaks sufficiently well to be understood, can grasp a pencil in one hand and write 
his name (Sam). No other treatment has been given since his maxillary expansion 
was performed. 
Fig. 361.-Back view of same boy shown in Fig. 360. 
Fig. 360 
Fig. 361 
years. The puppies were then killed, the heads frozen, and sec- 
tions cut through the nose and upper jaws at short intervals. The 
result is shown in Figs. 362 and 363. Marked difference between 
the nares will be noted in both series, but the section marked C 
in each is exactly at the point where compression was made. The 
almost complete stenosis in Fig. 363 contrasts strongly with the 
same section in Fig. 362. SEPARATION OF SUPERIOR MAXILLARY BONES 
639 
The laboratory record shows that all of the puppies in this 
litter, under the same care and with the same food, for a time 
Fig. 363.-Sections of head of puppy, aged six months, with jaws arrested in development across the palate by wiring at eight 
weeks old. These sections show plainly the contracted effect upon the nares, the deviation of the nasal septum, especially the 
section shown in C, the point at which the wire was inserted and development arrested. 
Fig. 362.-Control pup. The same age as the one shown in Fig. 363, upon which no operation was performed. 640 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
thrived equally well, and their growth was about the same. Dur- 
ing the latter portion of the period, when the effect of the compres- 
sion upon nasal growth became apparent, the control dog continued 
to grow and thrive, but those operated upon became emaciated. 
One died shortly before the expiration of the trial period. The 
one shown in the illustration was a mere mass of skin and bone. 
The remaining puppy showed marked congestion of the lungs. The 
late Dr. Willis S. Anderson, of Detroit, by experiments conducted 
in the Parke, Davis & Co. Laboratory, produced partial stenosis 
in dogs by suturing the external nasal openings and by introduc- 
tion of packings in several ways. He demonstrated that the mucous 
membrane of the bronchi of dogs in good health is practically 
immune to pathogenic microorganisms; when breathing is affected, 
however, it becomes susceptible to every sort of infection. Such 
dogs become almost entirely hairless, and the puppies of such 
mothers in some instances lost their hair also. 
As is well known, children who are mouth-breathers because of 
adenoids, enlarged tonsils, or arrested or perverted nasal develop- 
ment, are frequent sufferers from coughs, colds, and other evidences 
of infectious processes in this region. The same is true with older 
persons in corresponding degree. 
Having thus been able to cause deviated nasal septum and con- 
tracted nares by arresting maxillary development, and to correct 
these deformities and their attendant ills by maxillary separation 
it seems fair to assume that our case is complete. 
With the development of knowledge pertaining to the vegetative 
nervous system and the far-reaching effect upon physiological and 
pathological phenomena that are controlled by the counteracting 
adjustment of the balance between the sympathetic and vagus 
systems, much that has hitherto been etiologically and pathologi- 
cally obscure is rapidly coming to be better understood, and this 
is particularly true of treatment by jaw expansion. 
It is well known that "The vagus system supplies the large glands 
of the abdominal cavity, the lower two-thirds of the esophagus, 
the stomach, and the intestines as far as the descending colon. 
The sympathetic supplies the tract from one end to the 
other. 
"The ganglion cells of the walls of the intestines control this 
movement of the intestinal organs, but the sympathetic and vagus 
exercise the regulatory functions of acceleration or inhibition. 
" The vagus nerve through its depressor nerve exercises an inhib- 
itory action on the heart, while the sympathetic through its acceler- SEPARATION OF SUPERIOR MAXILLARY BONES 
641 
ation nerves has acceleration functions. In the digestive tract this 
is reversed. The vagus accelerates. The sympathetic inhibits." 
Higler1 calls attention to the existence of the following structures, 
the enumeration of which is important for an intelligent under- 
standing of our present subject, (a) Ciliary ganglion lying in the 
posterior part of the orbit which supplies the sphincter iridid and 
the ciliary muscle; (6) the sphenopalatine ganglia lying on the 
pterygopalatine fossa which supplies the lacrimal gland and the 
mucous glands of the nasopharynx; (c) the otic ganglia lying under 
the foramen ovale which supplies the parotid gland; (d) the sub- 
maxillary and sublingual ganglia which supply the corresponding 
Fig. 364.-A child, aged eleven years, with chorea and enuresis, winking of the 
right eye and facial spasm of the right side of the face and nose. Recently operated 
upon and much improved. Illustrates the type of face with high-arched palate and 
mouth-breathing for which maxillary separation'is demanded. 
glands; (e) the automatic ganglia (the bulbar part of the vagus 
domain) which lie in organs and which supply the glands and 
muscles of the trachea, the heart muscle, and the gastro-intestinal 
tract from the mouth to the descending colon. (J) The ganglion 
mesentericum inferium, hypogastricum, and hemorrhoidale which 
lie in the upper and lower parts of the pelvis, supplying the 
muscles and glands of the descending colon, the sigmoid, the anus, 
the genital apparatus, and the bloodvessels thereunto belonging. 
With these principles in view it is no longer a matter of wonder 
1 Vegetative Neurology, Journal of Mental and Nervous Diseases: by Heinrick 
Higler, Warsaw; translation by Walter Max Kraus, New York. 642 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
Fig. 365.-Mongolian, aged seventeen years, approximate mentality that of seven 
years. High, narrow palate and mouth-breathing. Improvement since operation 
has been evident in this case, but only time can tell in any of these cases how far- 
reaching the effect may be. 
Fig. 366.-Back of same girl shown in Fig. 365. SEPARATION OF SUPERIOR MAXILLARY BONES 
643 
that adenoids and enlarged tonsils or any other pathologic con- 
dition which might tend to inhibit the great areaway of the clear- 
ing house of vegetative nervous stimulation in nose, pharynx and 
bronchi, should go hand in hand with a typical cast of countenance, 
with tendency to colds, bronchitis and asthma; with dulness of 
comprehension, lack of concentration and apathy where active 
bodily and mental vigor is required and in other cases the opposite 
condition of extreme nervousness; constant desire to overdo in the 
Fig. 367.-Back of girl, aged fourteen years. The form of the back with the 
round flabby appearance due to excess of lymphatic tissue is characteristic of the 
Mongolian type. The distinction may be noted between this and the backs of the 
opposite types of cases shown in Figs. 352 and 358. Two illustrations of letters 
written by this girl give indication of her progress after operation, what the future 
may bring in the way of improvement no one can tell, but her prospects are undoubt- 
edly better than before operation. 
school, or other mental pursuits; poor circulation, irregular or very- 
rapid heart action, insufficient chest development, spinal curvatures, 
choreic and other muscular derangments, etc. 
It also becomes plain that the reason why tonsillectomy and 
adenoidectomy, resections of the nasal septum, and temporarily at 
least even turbinectomy have given such markedly beneficial 
results in so many of these cases is precisely because of the effect 
of better respiration upon the controlling balance of this nervous 644 
NASAL DEFORMITIES AND DISEASES OF MAXILLAE 
and ganglionic interrelationship. In this light also the effective- 
ness of a surgical measure which gives a still greater corrective 
influence by immediate enlargement of both nares and a corre- 
sponding increase of the volume of air at each respiration is readily 
understood. 
The endocrine organ activities are undoubtedly important fac- 
tors in the improvement of these cases as formerly believed, but 
it now seems probable that they are really secondary to the stimu- 
lation of underlying nervous influences which control all the gan- 
glionic and glandular structures. It has been demonstrated by 
Anderson and also by the author's experiments that interference 
with respiration by occlusion of the nares from any cause invari- 
ably affects the adrenals. Relief in this direction by improved 
respiratory conditions combined with better vagus control, easily 
accounts for the marked improvement in the nervous muscular 
control, coordination, spasmodic affections, enuresis, nervous speech 
defects, and other similar conditions that have been so uniformly 
benefited. The application of all these principles and this method 
as a means of opening the door toward constructive upward prog- 
ress for subnormal and even mentally defective children, presents 
a wide field for investigation and study which the author believes 
gives great promise for the future, when better classification may 
bring better recognition and selection of cases. Figs. 365 and 367 
illustrate types of children who have been greatly benefited in this 
way. 
The following case illustrates these possibilities: 
May 12, 1914. Aged eleven years. Previous diagnosis: idiot. 
History.-Premature birth. Slow development. Unable to sit 
until between two and three years old. Began to talk when three 
years old. Began to walk about four years old. Unable to sleep 
well at any time. Mother often saw sunrise while trying to put 
this child to sleep. Eyes were prominent; restless and foolish in 
expression. Coordination not bad except for the erratic nature of 
all movements. Speech: strained nervous tone with defective 
sounds due to imperfect nervous muscular control. Capable of 
learning some things quickly, but want of concentration and self- 
control made teaching almost impossible. Effect of maxillary 
expansion: appliance inserted May 18, 1914. 
Report January 20, 1916.-Enuresis completely overcome dur- 
ing the last two months. Appliance off about one and one-half 
months and no return of old symptoms. 
Wide separation of incisor teeth, with corresponding nasal SEPARATION OF SUPERIOR MAXILLARY BONES 
645 
enlargement-the loud stertorous breathing when asleep ceased as 
regular nasal breathing was accomplished. 
Among the early noticeable effects was the changed appearance 
of the eyes. Mother without suggestion-from anyone asked, "Do 
I imagine it or have my daughter's eyes changed?" The expression 
became quieter, the eyeballs steadier and less prominent in appear- 
ance, and the staring, foolish look disappeared in marked degree. 
She was able to sleep soundly not only at night, but took a long, 
refreshing restful sleep every day in addition to regular sleep at 
night. Better digestion was soon followed by marked growth and 
improved general appearance. When school opened in September 
she was so much quieter and under such good control that it was 
possible for her to attend classes. Her concentration was then such 
that she could take piano lessons for one hour at a time, and was 
willing to continue longer if desirable. 
The following year she was sent to a private school and her 
progress has been gratifying. CHAPTER XII 
MALFORMATIONS, DISEASES, AND INJURIES OF THE 
LIPS. 
MALFORMATIONS OF THE LIPS. 
In perversion of fetal development, closure of. the fissure that 
enters into the formation of the mouth may cause absence of the 
mouth opening, astomia, or partially obliterated mouth opening, 
the result being microstomia, or unduly small mouth. 
Failure to close to the usual degree leads to macrostomia, or 
abnormally large mouth. 
Fig. 368.-Macrocheilia. 
Accidental injuries, cicatricial contractions resulting from 
destructive lesions, surgical operations, and similar agencies may 
cause complete closure of the opening of the mouth. Its size may 
be similarly reduced or enlarged to such an extent as to require 
operative correction. 
Macrocheilia denotes abnormal or excessive size of the lips. 
Lymphangioma of the lips is the usual cause, but it sometimes 
occurs in cretinism, and under certain conditions of abnormal 
trophic changes (see p. 358). Figs. 368, 369 and 370 are photo- MALFORMATIONS OF THE LIPS 
647 
graphs of some of the author's cases of macrocheilia which present 
interesting diagnostic features. Fig. 371, showing angioma of the 
lip, is given to facilitate comparison of these two affections. 
Labial ectropion and deficiency of vermilion border may be 
congenital, or these defects may occur in many ways. 
The author's experience in operations upon the opening of the 
mouth and lips leads him to believe that little could be gained 
by detailed description of the different operations recommended 
for stomatoplasty (plastic surgery of the mouth). In actual experi- 
ence he has found that there is too great variance in the condi- 
Fig. 369.-Lymphangioma of the upper 
lip. 
Fig. 370.-Lymphangioma of the 
upper lip. (Another view of same girl 
shown in Fig. 369.) 
tions and requirements of such cases to warrant reliance upon 
any single method. The principles upon which both selection 
of method and operative technic must depend are included in the 
descriptions of operations upon the lips and restorations of the 
oral opening following operations for the removal of malignant 
growths in the region of the mouth, as elsewhere described (p. 548). 
Fissures of the Face, Lower Lip, and Lower Jaw.-Lip fissures 
are sometimes associated with clefts that extend more or less 
obliquely through the face (Fig. 372). 
Fissure through the lower lip and jaw is rare, but sometimes 648 
MALFORMATIONS, DISEASES, AND INJURIES OF LIPS 
occurs in the region of the first branchial arch. It is due to failure 
of union in the two inferior maxillary arches. It may be simply 
a fissure in the lower lip or extend completely through the lower 
jaw also. 
Fig. 371.-Angioma of the upper lip. (Westmoreland.) 
Fig. 372.-Complete bilateral fissure (coloboma) of face. (Guersant.) 
Clefts of the face and jaw occur too infrequently, and the lives 
of infants with extensive clefts are usually too short to warrant an 
attempt to outline a proper treatment for such cases. If such an 
infant were endowed with sufficient life to continue its existence, MALFORMATIONS OF THE LIPS 
649 
operative procedures might be indicated and would necessarily be 
undertaken to correct the deformity in such form as it might 
appear; but clefts of the upper lip and palate occur so frequently, 
and so much is at stake in the restoration of appearance and speech 
power, that the subject of their correction is worthy of most careful 
consideration. The subjects are so interwoven that it seems best 
to treat them together in a separate chapter. 
Diseases affecting the mucous membrane (see p. 168) affect the 
prolabium, and diseases of the skin may manifest themselves 
upon the surface of the lips. These insofar as they directly con- 
cern our subject have been described in other chapters. CHAPTER XIII. 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
HARELIP AND CLEFT PALATE 
Classification.-In classification of these cases three principal 
divisions require recognition, because they govern operative pro- 
cedures and results. These are the character of the deformity, 
its form, and the age of the patient. They are considered in the 
following classification: 
Character.-(a) Congenital; (b) acquired. 
Form.-(a) Fissure in velum palati only; (b) fissure of the velum, 
including part of the hard palate also; (c) cleft entirely through 
both hard and soft palates; (d) median fissures through both hard 
and soft palates, with bifurcation at the premaxilla; (e) double 
separation divided by the vomer, including the hard palate, with 
wide fissure almost completely obliterating the velum. 
Age.-(a) At birth or during early infancy; (6) six months to 
one year old; (c) two years old and during the period after decidu- 
ous teeth have been erupted, but before their permanent successors 
have caused them to loosen; (d) twelve to eighteen years of age, 
or later years, after permanent teeth have been erupted, but before 
developmental processes have been completed; (e) adults with 
teeth in upper jaws; (J) adults with edentulous upper jaws. 
Either lip or palate may be imperfect without the other being 
affected, although, as will be noted by study of the illustrations, 
it is common for certain forms of lip and palate deformities to be 
associated. 
Congenital harelip deformities are usually either unilateral (see 
Figs. 373,375, 377, 379 and 381) or bilateral (see Figs. 394 to 410), 
although median fissures like that shown in Fig. 340, p. 624, some- 
times occur. The fissures may be of first degree, or little more than 
a notch; of second degree, with a fissure extending completely 
through both lip and maxillary bones; or of third degree, a wider 
separation with unilateral protrusion of the intermaxillary bone. 
Bilateral or double harelip has usually marked deformity of 
the vomer with protrusion of the premaxilla. To these must be HARELIP AND CLEFT PALATE 
651 
added the cases that have been imperfectly operated on in early 
life. These often call for correction, and, although presenting an 
Fig. 373.-Single harelip (first degree). 
Very slight defect without cleft palate. 
Fig. 374.-The same child as shown in 
Fig. 373 after operation. 
Fig. 375.-Harelip (first de- 
gree). This child had fissure 
of the velum, but the hard pal- 
ate was almost complete. 
Fig. 376.-Same child shown in Fig. 375 
after both lip and palate fissure have been 
closed by operations. 
indefinite variety of imperfections, they have nevertheless certain 
characteristic defects that admit of distinct recognition, and may 
be enumerated as follows: (1) Notch at the labial border; (2) 652 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
deflection of the tip of the nose, with deviation of the cartilaginous 
septum and flatness of the ala on the affected side; (3) unsightly 
Fig. 377.-Harelip (second de- 
gree). The fissure in this case 
extended through both hard and 
soft palates. 
Fig. 378.-The child shown in Fig. 377 
after operations. Both lip and palate 
fissures have been closed. 
Fig. 379.-Infant with single harelip (3d 
degree) and wide fissure through both hard 
and soft palates, showing characteristic deform- 
ity of nose and mouth. 
Fig. 380.--Same baby at eight 
months, after lip and hard palate 
have been closed as described. HARELIP AND CLEFT PALATE 
653 
scars; (4) stenosis of one or both nares; (5) marked arrest of develop- 
ment due to removal of the premaxillary portion of the jaw; (6) 
lip too long, and drawn under the incisor teeth, so that it sometimes 
is between the teeth when the jaws are closed. 
Etiology.-The chief recognized etiological factors in harelip 
and cleft palate deformities are direct heredity and hereditary 
tendency, metabolism, maternal impressions and position in utero, 
and pathological affections of the female generative organs which 
may affect the form of the ovum. 
Fig. 381.-Harelip (third degree). 
AVide fissure through both hard and soft 
palates. 
Fig. 382.-The same child shown in 
Fig. 381 after operation upon the 
lip. 
Direct Heredity.-Direct heredity plays a part in the general 
resemblance of the offspring to its more or less immediate ancestors, 
and also in the transmission through various members of the same 
family of peculiar deformities or other variations from so-called 
normal types of both form and mental characteristics, but this fact 
is not so generally apparent as was formerly believed. The author's 
records of a very large number of cases with family history, so far 
as could be secured through three generations, show approximately 
10 per cent, of harelip and cleft palate cases in which one or more 
individuals in the same family had similar defects, either in the 
present or a previous generation. That there is some greater law 
governing development and maldevelopment is apparent. 654 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Hereditary Tendency.-This includes a very much larger group, 
as indicated by maldevelopment in form and predisposition to 
disease through imperfect cell activity. 
Maternal Impressions.-There is reason to believe that maternal 
influences may affect the unborn child, but absolutely authentic 
cases in which this cause might be the true etiological factor appear 
to be comparatively few. The author's records, which seem to 
agree with the records of nearly all others, show almost invariably 
that the accident or occurrence which was alleged to have frightened 
Fig. 383.-Harelip and cleft palate with un- 
usual deflection of the septum for a case in which 
the fissures were not wide. 
Fig. 384.-Same baby as in 
Fig. 383 after operation on 
lip. 
or impressed the mother's mind during pregnancy, and thus 
" marked" the baby, upon investigation was found to have occurred 
much later than would make the production of this particular 
deformity possible. 
Metabolism.-This is always an important influence, though its 
significance depends upon its being subject to or in precedence of 
other factors. 
Position of Child in Utero.-The theory of abnormal crowding 
forward of the head, preventing union of the parts at an early 
stage of development, appears to be difficult of exact proof. HARELIP AND CLEFT PALATE 
655 
Family Histories.-In the majority of cases the family histories 
upon one side or the other, and sometimes both, disclose in direct 
line of descent, diseases, deformities, mental states, or peculiarities 
that are now recognized as indications of unstable nervous systems. 
Many have a neurotic tendency; all betray unequal cell distribu- 
tion either in peculiar mental or nervous habit, or asymmetrical 
bodily development. Consanguinity is undoubtedly important 
when marriage between closely related individuals is shown by the 
family histories of these infants. 
Fig. 385.-Boy, aged fourteen years, 
with harelip and cleft palate. Shows 
the increase of the deformity that occurs 
when such cases are neglected until 
advanced stage. 
Fig. 386.--The same boy as in Fig 
385 after both lip and palate have been 
closed. 
The Hypophysis.-The pituitary body and particularly its 
glandular portion, the hypophysis, appears to bear a more or less 
important relation to this and other deformities. It has been 
demonstrated in many ways that this body exerts an influence 
over body growth and the related structures; other endQcrine 
organs undoubtedly share in developmental control. 
Pathological Affections of the Female Generative Organs.-Prof. 
Bardeen, of the University of Wisconsin, has called attention to 
the effect of deforming the ova in causing monstrosities or lesser 
deformities in animals. He has suggested that any misplacement, 
defective form, or inflammation of the uterus or its appendages, 
that might cause the human ovum to be compressed or otherwise 
distorted, may cause deformity of^the child. 656 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Early Treatment of Infants.-From the very hour of birth the 
question of the manner of treatment of these infants becomes 
Fig. 387.-Infant with very wide fissure through lip and hard and soft palates, also 
marked nasal deformity. 
Fig. 388.-Same child as shown in Fig. 387 at four years of age after the lip and 
palate operations have been completed. The final operation was performed when 
she was two years old. Tendency toward correct development may be noted. 
all-important. There is immediate necessity for determining 
whether early radical operation for closure of the palate first and HARELIP AND CLEFT PALATE 
657 
lip afterward shall be followed, or whether more conservative 
methods will yield greater safety and better results; upon this 
decision rests for good or ill the entire life experience of the indi- 
vidual. The author is convinced that radical operation for the 
purpose of closure of palate fissure in early infancy by immediate 
forcing together of the maxillary bones is exceedingly harmful 
and unnecessarily dangerous. It leads to imperfect future results 
which appear in both defective speech and facial deformity. This 
opinion is based upon the observation at different ages of a very 
large number of cases which have received this early treatment. The 
author's system, to the perfection of which he has devoted many 
years, is designed to accomplish, by gradual steps, the readjustment 
of the malformed facial features and the closure of both hard and 
soft palates sufficiently early to prevent the formation of imperfect 
speech habits. The results of this treatment are shown in the form 
of actual photographs of individual cases, not in drawings. These 
have been chosen to represent the types of congenital deformities 
and defects due to ill-devised operative procedures, with a view also 
to avoid unnecessary repetition.- 
Claims of Advocates of Early Operation Harmful.-The author 
does not agree with the writers who favor early operations upon 
infants' palates. They claim that the most desirable time for 
operation is within three months after birth, and that there is 
less nervous shock because the. nervous system of the child is not 
well developed and the child is not capable of receiving the same 
impressions that it would later in life. This is in a measure true, 
but other adverse conditions incidental to palate operations often 
more than counter-balance purely nervous considerations in new- 
born children. Likewise, he does not believe that in such cases 
the bony and soft tissues develop naturally according to accepted 
types and thus allow speech to follow when the child reaches 
speaking age. The reasons why he considers such statements 
erroneous and harmful are as follows: 
Estimates of Early Infant Mortality under Operation Misleading.- 
While it is admitted that during the first few days after birth, 
before the nervous mechanism has had time to become sufficiently 
organized to transmit pain acutely, little or no anesthetic is neces- 
sary, and that a newly born infant does sustain operation fairly 
well under some circumstances. At the same time it must be 
remembered that estimates of mortality in early operation must 
necessarily be misleading. Many infants do not live beyond the 
periods of infancy, many die from inanition in spite of good care 658 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
and carefully selected nourishment, even though no surgical opera- 
tion be attempted, and it is hardly reasonable to suppose the 
percentage of fatalities would be decreased by the addition of a 
surgical operation in every case. 
In the development of the human embryo there is coincident 
development of other parts at the stage which determines the 
form and character of lip and palate. Causes which lead to arrest 
of development in this particular region frequently cause arrest 
of development in other parts of the individual. Many infants 
placed under the author's care or brought to his notice have had 
additional fingers or thumbs, or they have been totally deaf from 
birth, or otherwise defective. Internal defects are manifested 
in low vitality. One or more of the organs of the body may be 
unable to perform natural functions with sufficient energy to 
sustain life, and this is entirely exclusive of the difficulty in taking 
nourishment, which can be temporarily overcome by the applica- 
tion of strips as described (p. 666), or operation. 
Susceptibility to Toxemias in Infancy.-The total deaths in the 
city of Chicago during one year was 27,212; of these, 5631 were 
under one year, or more than one-fifth of the whole number of 
deaths of all ages and from every cause. 
Certainly grave surgical operations during the first few weeks 
or even months would not have reduced this number of infant 
deaths. Eminent investigators have amply proved that there is 
a vastly greater resistance to disease and injury of every kind 
after one year than previously. 
Order of Closing Lip and Palate when Both are Involved.-It may 
be in a measure true that with lip fissure open operation may be 
more easily performed upon the palate, but no one accustomed 
to operate in this field has serious difficulty in securing all the space 
necessary for rapid use of suitable instruments in cleft palate opera- 
tion after the lip has been properly closed. On the other hand, 
the correct adjustment and fixation of the maxillary bones in their 
right relation, with the additional advantage of better circulation 
for the nourishment of flaps which is secured by proper lip closure, 
are important factors in leading to successful results when the 
palate operation is performed. 
Permanent Deformities of Face.-In addition to the danger of 
early operations, serious permanent disfigurement of the nose and 
face is a matter of some moment, for interference with develop- 
ment of the teeth must affect the form of the maxillary bones and 
other osseous portions of the face, thus directly influencing the HARELIP AND CLEFT PALATE 
659 
shape of the nares, the orbits, and the palate. It is axiomatic 
then that violent injury of any kind in early infancy, even though 
for the good purpose of palate closure, should only be a dernier 
ressort, and at best cannot fail to exercise a very serious and deplor- 
ably ill effect on the appearance, the general health, and the char- 
acter of the voice of the individual so treated (see Figs. 435, 437, 
439, 440, 441, 443, 448, 449, 452, 453, 456, 458 and 462). 
At the fifth week of embryonic life the germs of developing 
teeth have already begun to assume distinctive form, and at birth 
both deciduous and permanent sets are far along toward develop- 
ment. Interference with growth of the maxillary bones affects 
quite seriously the regular eruption of these teeth in due form at 
the proper periods. The successfully erupting dental organs if 
malposed by early disturbance alter the form of the face, the oral 
cavity, the nares, the orbits, and more indirectly the develop- 
ment of the individual in such manner as to demand most careful 
consideration before surgical procedures are attempted. Develop- 
ment of the posterior portion of the palate in such cases through 
the newgrowth of the upper jaw, back of the first molar tooth, does 
sometimes show a tendency to proceed along normal lines. The 
incisor, cuspid, and even bicuspid regions, however, must of neces- 
sity suffer arrest of development in marked degree from the previous 
compression of the maxillae upon each sideof the fissure in early infancy. 
Any injury, in fact, that disarranges the occlusion of the growing 
upper teeth so that they erupt in lingual instead of buccal or labial 
occlusion with their antagonists in the lower jaw will have the 
same effect. 
Nasal Stenosis.-Stenosis of the nares is also a vital matter in 
considering the effect of ill-advised operations upon development. 
Those familiar with the various typical forms of palate fissure know 
that in a large proportion of cases it is physically impossible to 
close the cleft by immediate pressure of any kind without bringing 
the opposite sides of at least one naris in absolute contact, and in 
any case the nasal opening must be very much narrowed upon one 
or both sides (see Figs. 440, 443 and 450). 
The question of partial or complete stenosis of the nasal passages 
and the natural ill-results of mouth-breathing concerns general 
as well as local development and general health besides. Partial 
nasal improvement may occur, but there can never be a normal 
condition in that region. The proof of this statement is at hand 
everywhere, for in otherwise normal individuals the relations of 
contracted dental arches and high palatal vaults to mouth breath- 660 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
ing, enlarged turbinates, spurs, hypertrophic and atrophic rhinitis, 
are too well understood and too apparent in daily rhinological 
practice to admit of further question. 
Effect upon Speech.-This leads to the final claim for better 
speech. Individuals affected by nasal catarrh do not have good 
speaking voices, nor do those who are mouth-breathers with marked 
nasal obstructions, nor do those, as a rule, with contracted irregular 
dental arches and abnormally high, contracted palates. Not only 
is this true because of the very considerable part borne in word 
and sound making by those influences, but in such cases the larynx 
and vocal cords are subject to affections which are not favorable 
to the best speech or oral result. 
The development in form and character of the soft palate is 
not as good as by later operation. More perfect plastic work may 
be done by the surgeon in proportion as he may with safety to his 
patient be deliberate in his effort to secure perfect coaptation of 
surfaces with exact muscular alignment of opposing muscles. 
Probably nowhere in the whole field of surgery is this more impor- 
tant than in staphylorrhaphy. The chief battle at any age is so 
to control hemorrhage and other disadvantageous conditions 
which tend to increase the difficulty of operation in this neces- 
sarily somewhat awkward situation, as to make accuracy prac- 
ticable notwithstanding the radical measures that are impera- 
tively required to secure the best results. 
Reasons Why Skilful Surgeons Often Fail in those Operations.- 
The chief difficulty of present-day surgery of the face, lips, jaws, 
and palate lies in failure to grasp the underlying principles of 
development in this region, and want of appreciation of the proper 
relation of associate parts in their influence upon the form and 
character of these special divisions of this field of practice. 
Large numbers of cases have come to the author with history 
of one or more previous unsuccessful operations. Quite frequently 
it has been evident that the general surgical skill of the operator, 
who nevertheless failed to secure a good result, was of high order, 
but not having recognized some apparently slight though really 
important factor, the postoperative deformity was greater than 
the congenital one. 
SURGICAL TREATMENT OF HARELIP. 
Principles.-1. The first principle of all plastic operations, and 
particularly cheiloplasty in any form, is that it is useless to attempt SURGICAL TREATMENT OF HARELIP 
661 
to secure a good cosmetic result by adjustment of the soft tissues 
alone, because, however perfectly this may be done at the time of 
operation, the future form must inevitably be determined by the 
outline of the underlying supporting structure. 
2. The second and almost equally important principle is, that 
without due recognition and suitable adjustment of muscular 
attachments and care as to the direction of muscular fibers in 
uniting surfaces, the form of the lip will be correspondingly altered. 
3. No matter how great the temptation may be to displace 
tissue for the purpose of closing a lip fissure, such a procedure 
must be avoided if possible. Even though the immediate appear- 
ance at the time of operation may be better by so doing than if 
direct approximation had been secured by forcing the separated 
parts together in what would have been their normal relation, the 
final result will be much more perfect in the latter than in the former 
case. With the parts displaced, as development proceeds, asym- 
metry and the consequent unnatural appearance will be increased. 
On the other hand, even though temporary deformity results, 
when the parts are attached in such manner as to lead to natural 
physiological action, they will continue to improve as time goes 
on because development along right lines is thus made possible. 
The interdependence in such developmental relation of the mouth, 
nares, jaws, and bones of the face, and the coordination of muscular 
action as affecting both function and expression, thus alters not 
only the appearance of the face and lips, but of the eyes as well, 
and in almost equal degree. These facts have been set forth at 
some length in other chapters touching this subject. 
These principles are quite elementary, and are not brought 
forward as being in any sense original, but their application in the 
guidance of operative procedures is not as generally observed as 
it should be, nor is their far-reaching influence upon future devel- 
opment sufficiently recognized by surgeons. All agree that the 
final result absolutely and inevitably depends upon symmetrical 
growth. Examples of this are everywhere noticeable among per- 
sons whose lips bear evidence of operative procedures in closure 
of harelip, and are daily object lessons when one's practice is almost 
wholly confined to patients of this class. Many of the deeply 
scarred lips, deformed noses, and distorted faces, with typical 
staring appearance of the eyes at the time of operation, in infancy 
undoubtedly appeared as though the operation were eminently 
successful, but succeeding years brought steadily increasing 
deformity. 662 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
The final test of a successful lip operation must not alone be a 
smooth skin surface, with the greatest possible freedom from scar 
tissue and nicely adjusted vermilion border, although these are 
matters of vital imporatnce and worthy of the utmost possible 
effort to secure them. In even greater degree it is important that 
the nose be in proper alignment and capable of natural respiratory 
function, that the teeth when erupted be in good form, and that 
muscular attachments be correctly adjusted. The supreme tests 
would then be nasal respiration, and expression when the indi- 
Fig. 389.-Infant with harelip and complete 
cleft palate. The nose has been partially 
straightened, and the fissures made narrower 
by wearing an adhesive strip as described. 
Fig. 390.--The same child as in 
Fig. 389, at the age of two and 
one-half years, after both lip and 
palate have been closed. 
vidual smiles or laughs. It is a notable fact that many lips which 
have a good appearance in repose are distorted during laughter, 
and unless there is an abundance of tissue on the under side of the 
lip, the tightness induced by muscular action under these condi- 
tions renders the defect particularly and often unpleasantly notice- 
able (Figs. 389 to 394). 
The Difficulties in Cheiloplasty.--The adverse conditions to be 
overcome in correction of harelip are: 
Tension.-Tension as the intervening fissure is overcome by 
stretching the parts across. SURGICAL TREATMENT OF HARELIP 
663 
Maldevelopment.-Maldevelopment of the projecting premaxilla, 
which tends to widen the fissure and make its closure more 
difficult. 
Fig. 391.-The same child shown in 
Figs. 389 and 390. Test of the operative 
result during laughter. 
Fig. 392.-Another view of the same 
child as in Figs. 389, 390 and 391. 
Fig. 393.-Later picture of child shown as an infant and at two and one-half 
years old in Figs. 389 to 392. Symmetrical nasal, labial, and facial form gives 
proof of the correctness of the principles herein set forth with regard to early 
treatment. 664 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Nasal Deformity.-Nasal deformity due to distorted develop- 
ment in the maxillary region, which carries with it deflection of 
the attached vomer and nasal septum. Through this agency and 
because of the abnormal muscular action thus engendered, when 
the fissure extends through into the nose, the triangular cartilage 
is also deflected. The abnormal situation of the detached maxil- 
lary bones through adverse muscular action draws the cartilaginous 
wing in such form as to leave it flattened and sometimes curved in 
the wrong direction. 
Irregularity of the Dental Arch.-If the situation of the premaxilla 
is not corrected in early life the maleruption of teeth in this region 
will inevitably increase the deformity. If in an effort to restore 
the premaxilla to its natural position forcible methods are applied 
through traumatic injury to the developing teeth germs, there may 
be failure of certain teeth to erupt, in which case maxillary develop- 
ment will be arrested, or otherwise perverted, and irregularity of 
the teeth will be brought about. In either condition there will be 
deformity which must tend to increase instead of decrease as the 
individual gets older. 
Operative Defects.-Imperfect adjustment of the prolabium, lead- 
ing to the following results: (a) Notch or V-shaped space at the 
lower border of lip; (6) one side higher than the other; (c) excess 
of tissue causing projection beyond the proper line; (d) a white 
surface extending upon the mucous membrane of the prolabium; 
(e) naris upon the affected side unusually large or too small; (J) 
the transverse or other scars which stiffen and mar the appearance 
of the lip; (^) depression along the line of attachment; (A) unusual 
broadness across the base of the nose, excessive development of 
the triangular cartilage leading to marked enlargement, a perpen- 
dicular groove through its central portion or tipping down to its 
under surface; (i) in double harelip cases, depression in the pre- 
maxillary region, flattened appearance of the nose, displacement 
of the parts, so that the small portion of upper lip tissue (the phil- 
trum) which is usually attached to the projecting premaxilla 
becomes part of the nose instead of the lip, unusual length of the 
upper lip, which is then drawn downward and inward and is asso- 
ciated with a beak-like appearance of the nose, unusual length to 
the upper lip with bulging forward in its central portion and a 
tightly drawn appearance at the red border; (j) altered appearance 
of the eyes in all of these cases. The unnatural tension of mahnus- 
cular action causes a strange staring of the eyes. Occasionally this 
is so marked as to affect the supra-orbital tissues also. Thus one SURGICAL TREATMENT OF HARELIP 
665 
eye may appear to be higher than the other, and there is quite 
often an appearance of exophthalmos, which is due to surrounding 
Fig. 394.-Infant with double harelip; shows characteristic projection of the 
premaxilla, and philtrum of the upper lip. 
Fig. 395.-Same infant as in Fig. 394 with adhesive strip adjusted to reduce the 
deformity as described in the test. 
structures rather than to any peculiar form of the eyeball (see Figs. 
435 to 457). 666 
HARELIP, CLEET PALATE, AND DEFECTS OF SPEECH 
Methods for Overcoming Difficulties.-It is the author's purpose 
to present a clear description of his methods of overcoming the 
foregoing difficulties. Part of the technic is original, part the 
adaptation of other methods. 
Operation to Close Lip Fissure on Day of Birth or Soon After.- 
If it be practicable to get the child immediately or within the first 
Fig. 396.-Same infant as in Figs. 
394 and 395. Front view before 
operation shows the benefit derived 
from wearing the adhesive strip for 
about ten days. 
Fig. 397.-Same infant as in Figs. 394 
395 and 396. Profile view before operation 
shows the improvement made by the strip 
of adhesive plaster worn across the lip for 
ten days. 
Fig. 398.-Infant with double harelip deformity reduced by wearing an adhesive 
strip across the lip ready for operation. 
few days after birth, it is of great advantage to perform the lip 
operation at that time. In this way widening of the fissure is pre- 
vented, and a newborn infant sleeps so much of the time, that 
there is very little tendency to disturb the sutures and cause 
irritation or later scars. 
The Use of Zinc Oxide Adhesive Strip.-If very early operation can- 
not be performed then the simplest and most effective method of SURGICAL TREATMENT OF HARELIP 
667 
accomplishing this is by the adjustment of a strip across the lip, as 
shown in Fig. 395. When the fissure had been sufficiently narrowed 
and the premaxilla brought around and backward into approximately 
normal situation, it will be noticed that marked improvement in 
Fig. 399.-Infant with double harelip. 
Fig. 400.-Same infant as in Fig. 399 
after lip operation. In this case, when 
the palate was closed one year later, 
the teeth were found to be erupting 
quite normally. 
Fig. 401.-Double harelip and cleft 
palate. 
Fig. 402.-Same infant shown in Fig. 
401 after both lip and palate have been 
closed, and deformity corrected. 668 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
nasal form has also taken place. Whatever this treatment may not 
have accomplished in the direction of nasal improvement must be 
done at the time of operation. Therefore operative procedures 
must include provision for this result (Figs. 396, 397 and 398). 
Fig. 403.-Infant with double harelip. 
Fig. 404.-Same child after operation. 
Both flip and palate fissures have been 
closed. 
Fig. 405.-Infant with double harelip. 
Fig. 406.-Same case as shown in Fig. 405 
Nasal Splint and Tension Suture.-The author has devised a 
suture (see Fig. 424), which is employed in such manner as to be 
at once a nasal splint and a tension suture to hold the nasal sep- 
tum and triangular cartilage of the nose in correct alignment, the 
cartilaginous wing upon the affected side in proper form and situ- 
ation, and the tissues of the cheek, lip, and facial muscles in such SURGICAL TREATMENT OF HARELIP 
669 
position that when severed and reattached their points of attach- 
ment will be improved. While doing all this, tension from the 
Fig. 407.-Infant showing characteristic 
deformity in double harelip. 
Fig. 408.-Same child as shown in 
Fig. 407 after both lip and palate have 
been closed by operations. Eight months 
after operation on lip. 
Fig. 409.-Boy, aged four years, with double 
harelip and cleft palate. Shows increase of the 
deformity as the child became older. 
Fig. 410.-Same boy as in Fig. 
409 after excision of a section of 
the vomer, and correction of the 
deformity. 
approximated wound surface is relieved. This suture is of the same 
form as that which he uses in cleft palate operations. 670 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Fig. 413.-Nelaton's operation: 
sutures in place. 
Fig. 412.-Nelaton's operation; 
method of adjustment. 
Fig. 411.-Nelaton's operation; 
the incision. SURGICAL TREATMENT OF HARELIP 
671 
Fig. 416.-Malgaigne operation; 
sutures in place. 
Fig. 415.-Malgaigne operation; 
method of adjustment. 
Fig. 414.-Malgaigne operation; 
the incision. 672 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Fig. 419.-Mirault's operation: 
sutures in place. 
Fig. 418.-Mirault's operation: 
method of adjustment. 
Fig. 417.-Mirault's operation 
the incision. SURGICAL TREATMENT OF HARELIP 
673 
Fig. 422.-Double harelip oper- 
ation; the sutures are placed to 
correspond with the incisions and 
method of adjustment as outlined 
in Figs. 420 and 421. This 
method of operation creates an 
ugly deformity by making the lip 
too long, and should be avoided. 
(Author.) 
Fig. 421.-Double harelip oper- 
ation; the method of adjustment 
in accordance with the incisions 
outlined in Fig. 420. 
Fig. 420.-Double harelip oper- 
ation; the incisions as advocated 
with slight variations by von 
Langenbeck, Mirault, Maas, and 
others. 674 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
A needle carrying a silkworm gut, or as formerly used a silk or 
linen ligature attached to a wire suture is passed through from the 
naris upon the opposite side if the case be one of single harelip, 
carried through the affected naris, and brought out upon the cheek 
a little below and beyond the external border of the ala on the 
affected side (Fig. 423). The silver plate that has been previously 
attached to the suture is changed from its usual square shape to 
Fig. 423.-The author's method of harelip operation. The illustration shows 
the author's lip clamp in position. The wire suture with silver plate for septum 
splint, the lead suture of silk or linen, the adhesive square for protection of the 
skin surface and the method of introduction of this suture. 
oblong form, its width and length being adjusted to fit the nose so 
as to prevent buckling or other distortion when drawn into place 
against the septum. At the point where it is drawn through the 
cheek a square of zinc oxide adhesive plaster, somewhat larger 
than the silver plate and having a small hole in the center, is 
slipped over the suture down to the skin surface. A small, square 
silver plate, with suitably perforated holes, is again passed over PLATE XX 
S.C. A., superior coronary artery and its nasal branches; I. C. A., inferior 
coronary artery; F. A., anastomosis of the inferior labial and submental 
branches of the facial arteries; M, M, orbicularis oris and depressor anguli 
oris muscles. SURGICAL TREATMENT OF HARELIP 
677 
the suture and following this are perforated lead shot, which can 
at a proper time be compressed and thus made to hold the parts 
in their proper position (Fig. 424). This simple suture is the key 
to the whole situation. It not only holds the parts in proper rela- 
tion as described, but when tightened gives the necessary pressure 
to control the severe hemorrhage which sometimes follows the free 
incisions. The latter are necessary to sever muscular attachments, 
Fig. 424.-The author's method of single harelip operation. The wire splint 
and tension suture in place with silver plate and compressed lead shot in position. 
Outline of lip incision. Silkworm gut may be substituted for wire, with good result. 
and it is of the utmost importance that they should be thoroughly 
and extensively carried out, thus relieving the tension of muscular 
action during the early part of the healing process and affording 
the readjusted muscular attachment that is so necessary to the 
best final result. 
Compression of Vessels.-The hemorrhage can be materially 
reduced and the operative steps facilitated by making compression 
of the coronary arteries. The author's clamp for this purpose is 
shown in Fig. 423. (See Plate XX.) 
In infant cases the double clamp shown in the illustration is 
unnecessary. Any form of compressor which will not do injury 678 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
the lip upon each side. It serves the temporary purpose of con- 
trolling hemorrhage at this time and holding the wound surfaces 
together, so that more accurate adjustment can be made at the 
lip and nasal borders. This suture is not completely tied at once, 
but is left so that it may be loosened or tightened as required; and 
the ends are temporarily clamped with a forceps. The lip on each 
side is then raised, and with a broad knife or scissors, or both, the 
muscular attachment is freely severed. Upon the side of the fissure 
this must include freeing the cartilaginous wing of the nose as 
completely as possible. The profuse hemorrhage which follows 
these incisions is instantly checked by pressure of the assistant's 
fingers upon the cheeks. The suture through the nose, which up 
to this time has been lightly clamped, is now tightened by forcing 
the silver plate upon the external surface farther in upon this 
suture, and the shot compressed to hold it. This invariably gives 
the necessary compression to check hemorrhage, and may be 
depended upon to control it permanently. 
When this adjustment is completed it will sometimes be found 
that the direction of the first suture is no longer suitable. After 
another suture has been placed, which is carried through the skin 
and muscular tissues upon each side, but does not include the 
mucous membrane upon the buccal side of the lips, which may be 
accurately adjusted and left as one of the tension sutures, the first 
suture may then be removed. 
Before the final adjustment of sutures upon the anterior surface 
of the lip and the prolabium, the lip is everted and catgut sutures 
are placed along the inside of the lip, as shown in Fig. 426. This 
insures against the likelihood of infection from the mouth, because 
the mucous membrane surfaces close quickly when properly approxi- 
mated. It also to some extent takes the strain off of the external 
sutures and prevents the likelihood of their cutting or marking 
the skin. At the same time it serves to fix the outline of the form 
of the lip so that the skin sutures may be accurately adjusted. 
For the approximation of the skin surfaces the author prefers 
interrupted sutures. Notwithstanding the claims that have been 
made for the subcuticular suture, it does not seem to hold skin 
borders with the perfect accuracy required for the least possible 
scar. 
Except where fault has occurred for some other reason, the 
marks of the interrupted sutures have been seldom found such as 
to cause an unsightly appearance of the lip. Usually two catgut 
sutures are placed reasonably well apart to resist the first effect of SURGICAL TREATMENT OF HARELIP 
679 
strain along the line of union. Extremely fine cambric needles, 
the smallest size made, with silk (or 2000 fine linen) fine enough to 
permit their use, are employed to coapt the skin borders accurately. 
At the prolabium and occasionally at points in the skin surface, 
the author uses horsehair. Its chief advantage is that its elas- 
ticity sometimes permits accuracy in its use, which it is difficult 
to secure with a non-elastic suture material. How great or how 
little the importance of this may be, is to some extent a matter of 
conjecture. 
Fig. 426.-The author's method of single harelip operation. Sutures placed along 
the mucous membrane surface of the lip. 
The floor of the nose should be as carefully fashioned as the 
condition of the patient and the circumstances under which opera- 
tion must be performed will permit. It must be remembered in 
this connection that many of these infants are in an extremely 
precarious condition, so much so that the time element is of vital 
importance. By dissecting free the divided tissue upon each side 
along the floor of the mouth at the external opening of the naris, 
one or two sutures can easily be placed just inside and close to the 
external opening. This will not only serve to give greater perfec- 
tion in the external appearance of the nose and lip, but, as explained 
later, will sometimes have a great influence upon speech also. 
The situation and direction of the line of union as affecting the 
later scar should be borne in mind when the incisions are made. 680 
HARELIP, CLEET PALATE, AND DEFECTS OF SPEECH 
The author's preference, wherever possible, is to have the line 
of union slanting, so that the point of junction at the prolabium 
will not be directly under the beginning of the wound at the nose. 
Such a scar as may remain under these circumstances is much 
less noticeable, and is less likely to draw the lip in an unsightly 
way during laughter. Even when it does attract attention it is 
less apt to suggest immediately the thought of harelip. The scars 
of accidental lip injuries are for many reasons less objectionable 
then the mark of a congenital defect, such as harelip (Fig. 427). 
Fig. 427.-Shows diagonal line of approximation. Skin sutures in place. 
Treatment of Double Harelip.-In these cases there is great differ- 
ence in the appearance and corrective requirements. The pre- 
maxilla may project in such manner as to cause great deformity 
and be difficult to place, or the portion of the lip attached to the 
premaxilla may be so small and of such poor character as to make 
its presence difficult to detect. In most young infants the vomer 
and nasal sections are yielding, and it is comparatively easy to 
force the parts into fairly good relation. Occasionally a child is 
met in which even at birth considerable ossification has taken place. 
Figs. 394 to 410 are examples of these cases. SURGICAL TREATMENT OF HARELIP 
681 
Reduction of the Premaxilla.-Were it not that cases are occa- 
sionally met with in which excision of the premaxilla has been 
comparatively recently performed to facilitate the closure of double 
harelip, it would seem unnecessary to warn against this practice. 
Its results may be seen in Figs. 448, 453 and 456, and these 
examples might be repeated almost indefinitely among individuals 
operated upon according to older methods. 
This apparently useless and often embarrassing excrescence pro- 
jecting from the end of the nose, with a detached portion of the 
lip upon the upper or anterior surface even in the newly born, 
contains the germs of both deciduous and permanent central incisor 
teeth, and frequently the lateral incisors also. 
The loss, misplacement, or traumatic injury, which may severely 
injure any growing part of this premaxilla, will cause deformity 
to mar the features of the individual for life. Adjustment of the 
zinc oxide adhesive strip has already been described. Figs. 394 to 
410 show what may be done in this way. When such a strip is 
adjusted for the first time, pressure with the ball of the operator's 
thumb may be employed to force the premaxilla back in the direc- 
tion of its proper situation. In older infants the vomer may be 
split with a periosteal elevator or a strong knife. This separates 
the two divisions due to its double development. Pressure on the 
premaxilla causes folding of the parts, and permits proper place- 
ment of the parts with the least possible deformity. By cutting 
diagonally, the parts may be slid past each other if necessary, as 
adjustment takes place and no tissue is lost. The excision of a 
V-shaped portion of the vomer, as commonly recommended, will 
almost certainly result in a rabbit-shaped mouth that is exceedingly 
displeasing in appearance. 
Only in old cases where the vomer has become thick and alto- 
gether excessive (Figs. 409 and 410) should any of this structure 
be removed, and then with such care as to prevent deformity if 
possible. 
Incisions.-Von Langenbeck's method (Fig. 420), or some 
modification such as the Maas and Hagedorn operations, has been 
most generally followed by surgeons during recent years. 
In this way the premaxilla is preserved, and a portion of its 
labial attachment also, but another kind of deformity is created. 
The characteristic appearance of patients operated on according 
to this plan may be noted in Figs. 449 and 452. 
During infancy the results in these cases may appear to be all 
that might be desired, but with advancing growth a progressive 682 
HARELIP, CLEFT PALATE, AND DETECTS OF SPEECH 
increase in objectionable appearance takes place. The transverse 
scars of the united flaps that have been carried across and joined 
to the lower border of the central lip segment contract or at least 
yield less readily than, the normal structures. The effect of this is 
to cause the anterior portion of the maxilla to bulge forward and 
the scar band to be drawn downward and inward. 
In many patients who have come to the author this had already 
caused the upper lip to become abnormally long, with most unsightly 
convexity on the anterior aspect. 
The author believes that every portion of the lip tissue on the 
anterior surface of the premaxilla should be preserved if possible; 
that even though it be scant in size and thickness, it should, never- 
theless, be treated as though it were the full lip section that it 
represents; that attempts to excise it completely and to create a 
single central line of union almost always fail to give a good result 
in later life, because of the alterations that are created by attempted 
natural growth; that if properly united to the muscle fibers of the 
lateral portions of the lip, the natural function thus made possible 
will lead to proper growth and development. 
There may always be a disproportion between the thickness of 
the central and lateral portions of such a lip, and the lip so treated 
may remain too short notwithstanding its increased opportunities 
for growth, but from wide experience in the correction of lip defects, 
the author unhesitatingly states that such a lip can be improved 
in later life and made to present a more natural appearance than 
a mutilated lip ever can. 
Technic of the Author's Operation for Double Harelip.-The 
same kind of suture that has been described with reference to 
single harelip operations is used in double cases. The needle is 
inserted just outside the ala upon one side, carried through the 
nasal septum, and out upon the opposite side just beyond the ala. 
The skin is protected with squares of zinc oxide adhesive, and a 
silver plate is adjusted with perforated lead shot clamped upon 
wire. This holds nose, cheeks, and lips in correct relation, checks 
hemorrhage, and relieves the principal strain upon the sutures. 
In other respects the operation is performed in the same manner 
as in single cases, except that there are two rows of sutures instead 
of one (Figs. 428, 429 and 430). 
Great care is sometimes necessary in suturing the central divi- 
sion of the lip securely to the lateral portions without traumatic 
injury or interference with circulation sufficient to cause sloughing. 
With perfect control of the situation during operation, and deli- SURGICAL TREATMENT OF HARELIP 
683 
Fig. 428.-Author's method of double harelip operation. Splint suture for 
retention and correction of the deformity of the nasal septum in place. Outline 
of the incisions. 
Fig. 429.-Author's method of double harelip operation. Fissure borders prepared 
for the sutures. First control suture in place. Fig. 430.-Author's method of double harelip operation. The operation completed 
and skin suture in place. 
Fig. 431.-The adhesive strip carried from the cheek upon one side across the 
bridge of the nose to a corresponding point upon the opposite side of the face. 
Another adhesive strip attached upon the cheek upon one side just below the upper 
strip, and carried across the chin to a corresponding point upon the opposite cheek. 
Both of these strips are drawn just tight enough to relieve tension upon the lip 
sutures, and the lower one is so adjusted as to hold the lips slightly apart to favor 
respiration after operation. (Author's method.) SURGICAL TREATMENT OF HARELIP 
685 
cate manipulation with fine needles and sutures, such a result 
may never occur, and never has in the author's experience, except 
years ago in some of his earliest cases in which methods advocated 
by others were used. 
That extensive sloughing may follow either single or double 
harelip operations is shown by Figs. 435, 437, 439 and 440. These 
cases were brought to the author for operation after such failure 
had been allowed to take place. 
Fig. 432.-Dry sterilized gauze laid lightly across the lip and attached at each 
end with short narrow adhesive strips. This dressing can be removed whenever 
necessary without removing the adhesive tension control strips. (Author's method.) 
Postoperative Control Strips and Dressings.-The author's method 
of strapping infants and some older patients after harelip opera- 
tions is illustrated in Fig. 431. 
A strip of zinc oxide adhesive as wide as the nose is long is car- 
ried from the cheek on one side, over the nose, to the cheek upon 
the other side. It is then drawn tightly enough to wrinkle the 
cheek slightly and firmly attached. A second strip is attached to 
the cheek upon one side, carried over the chin to the opposite 
cheek, with care to adjust in such manner that the lower lip will 
be kept slightly open. If the skin surfaces have been cleaned and 686 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
dried with ether, these adhesive strips will hold in position until 
the sutures are removed. The dressing is laid lightly across the 
lip and attached with short, narrow, adhesive strips. This may be 
removed by the nurse whenever it becomes soiled, without dis- 
turbing the retention strips (Fig. 432). 
Treatment of Harelip without Cleft Palate.-When there is 
palate fissure associated with harelip, much more adjustment and 
improvement after operation may be expected than will be found 
to occur in cases in which the hard palate is complete, except for 
the single or double fissures which in accordance with the character 
of the lip deformity extend through the alveolar ridge. 
Fig. 433.-Harelip without cleft pal- 
ate, except fissure through the alveolar 
ridge. The projecting premaxilla in 
these cases is fixed and unyielding. 
Fig. 434.-The same girl after forcible 
correction of the deformity and closure 
of the lip. 
Surgeons who are unaccustomed to these cases usually operate 
in the belief that they are much simpler than the wider and more 
difficult-looking fissures, that include both lip and palate. Error 
in this respect has led to many postoperative deformities. The 
real difficulty is that the premaxilla always projects forward more 
or less in the same manner, though not in such marked degree, as 
with the former class of cases. The solid resistance of the full- 
formed palate behind yields less readily to action of the lip muscles 
than when there is a division which gives greater freedom in 
adjustment of the misplaced parts. SURGICAL TREATMENT OF HARELIP 
687 
When children have passed beyond the period of infancy there 
must always be a definite reduction of the premaxilla and adjust- 
ment in at least approximately correct position accomplished by 
surgical means. 
After the teeth have developed the parts are held in position by 
wires attached to the teeth or metal bands are cemented upon the 
tooth crowns, to which is attached an appliance such as any dentist 
might construct to hold the parts firmly until united. In most 
cases it is better to do this at a preliminary operation and later 
to close the lip perfectly, when-there will be no likelihood of infec- 
tion of the lip from the mouth wound. This was done, in the case 
of the patient illustrated in Figs. 433 and 434. 
A deflected nose is much more likely to persist and cause a less 
perfect facial appearance than in other cases. 
The Removal of Scars and the Correction of Postoperative 
Lip and Nose Defects.- Naris too large. If the floor of the nose 
has not been properly closed in conjunction with lip or palate 
operation, one naris, or even both, may not only be unsightly, but 
may also interfere with speech through allowing the wrong escape 
of air. 
In these cases the tissue at each side of the depression or fissure 
in the floor of the affected naris may be incised sufficiently far back 
to allow the necessary correction. It is then dissected free and 
raised. Usually the septum will be deflected in single cases, and the 
large flattened ala also require reduction. The narrowing effects 
in correction of these associated defects allows the tissues at the 
line of intranasal approximation to be raised in such a manner 
as to make the parts remain permanently in corrected position 
when united, and the floor of the naris to be correspondingly 
benefited. 
The characteristic deflection of the septum resulting from failure 
to care for this defect when the harelip is closed the author cor- 
rects by inserting a suture with splints, as described for harelip, 
from the opposite side of the septum and put through the cheek 
just beyond the cartilaginous wing of the nose. When tightened 
it will draw the septum in the desired direction. The upper lip is 
then raised and a cartilage knife passed through from beneath the 
lip and the septum divided at its attachment with the superior 
maxilla, as far back as may be required to correct the anterior 
deviation. It is then drawn into position and fixed with a wire 
suture. The oral opening is so small that when the lip drops back 
into position it is practically closed. 688 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
The effect of this treatment may be seen in Figs. 435, 436, 437 
and 438. 
Fig. 436.-The result of closure of the lip 
for the little girl shown in Fig. 435. 
Fig. 435.-Child, aged two and 
one-half years. One-half of lip and 
palate almost totally destroyed as a 
result of attempted closure of lip and 
palate at the same time. Forcible 
compression of the side of the palate 
was attempted in early infancy. 
Fig. 437.-Child, aged three years. 
Lip nearly half lost by operation upon 
both lip and palate at the same time in 
early infancy. 
Fig. 438.-Same child shown in Fig. 
437 after closure of the lip fissure. 
In most of these cases operation is performed incidentally to the 
operation for removal of scars and other objectionable features. SURGICAL TREATMENT OF HARELIP 
689 
The Correction of a Notch or V-shaped Space at the Lower Border 
of the Lip and Shortness Resulting from Imperfect Closure of the Lip 
Fissure.-Effort should be made to preserve the prolabium as 
nearly intact as possible. This may not always be accomplished, 
but usually results quite naturally when a transverse incision is 
made and the lower portion of the lip is drawn down until the 
transverse line is converted into a perpendicular one. The length 
Fig. 439.-Front view of boy, aged 
four years, for whom the operation of 
forcibly closing his palate fissure and 
attempting to hold the parts with wire 
and lead plates was performed in early 
infancy. The lip was closed at the same 
operation. Both lip and palate sloughed 
out except for a small bridge of tissue 
which fixed the maxillary bones as 
placed. Not only did he lose almost 
the entire lip upon one side, but the 
deformed shape of his face, which is 
characteristic of the result of these 
operations, remains permanently, as is 
plainly shown in the illustration. 
Fig. 440.-Profile view of the same 
boy as in Fig. 439. The malposition of 
the maxillae and consequent deformity 
of the nose which resulted from forcing 
these bones together to close the palate 
fissure in early infancy are markedly 
apparent. 
of the incision for the elimination of the defect will, as a matter 
of course, be governed by the amount of lengthening the lip requires. 
When One Side of the Lip is Higher than the Other at the Border.- 
Usually a considerable amount of scar tissue must be removed. 
It is the author's custom when removing scars of the lips to follow 
the scar upon each side with a knife until it is dissected out as 
completely as possible. Then incisions are made without regard 690 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
to scar tissue to effect the desired improvement. Almost invari- 
ably, when this scar is dissected out, the lip is much more easily 
Fig. 441.-Infant with double harelip 
and cleft palate. The history of this 
case before coming to the author shows 
that a few days after birth an attempt 
was made to close the palate fissure by 
the use of silver wire and lead plates. 
The wires sloughed out and there was a 
general infection, as a result of which 
the child was in a very critical state for 
several weeks before recovery. 
Fig. 442.-The same baby after the 
lip and hard palate have been closed. 
It will be seen that it was impossible to 
get as perfect a result as might have 
been obtained had the first operation 
not been performed. 
Fig. 443.-Boy whose nose, lip and palate were almost hopelessly deformed by 
compression and wiring his maxillary bones to close a palate fissure in early infancy. 
It will take long patient work to even partially restore the shape of his mouth, and 
• one or more lip operations to improve his appearance. He is a great sufferer from 
nasal disease, as is nearly always the case with such operative results. SURGICAL TREATMENT OF HARELIP 
691 
adjusted to its proper position; therefore not only is the unsight- 
liness removed by excision of scar tissue but the approximation of 
the parts is favored. Care must be taken not to cut completely 
through the lip if it can possibly be avoided, because this invites 
Fig. 444.-Lip, nose and palate de- 
formed by compression in early palate 
operation, and making the lip too long 
by carrying flaps across the philtrum 
as usually performed in double harelip 
cases. 
Fig. 445.--Same boy shown in Fig. 
444 after operation to shorten and re- 
store lip, and forcing the premaxilla 
forward with appliances attached to 
the teeth according to orthodontic 
methods. 
infection from oral secretions and has a tendency to produce more 
scar tissue. With the lip tissue thus set free, the operator must be 
guided in adjustment of the parts as the indications require, and 
this can only be accurately determined by drawing them into con- 
tact and placing and replacing them in the desired position until 
Fig. 446.-Boy, aged nine years. 
Previous history shows that an opera- 
tion was performed in early infancy in 
which an endeavor was made to close 
the palate by the use of wires through 
the jaws and lead retaining plates. 
This failed disastrously, and was fol- 
lowed by four other operations with 
only partial success. The difficulties 
were enormously increased by the effect 
of the early infancy operation. 
Fig. 447.-Same boy as shown in 
Fig. 446, after lip and nose have been 
reconstructed and the palate fissure 
closed by two operations. It was nec- 
essary to' readjust the malposed parts 
and partly close the palate fissure at 
the first operation, and to complete the 
closure one year later. Since this pic- 
ture was taken he has been for several 
years under treatment by his dentist, 
who has been endeavoring to bring the 
malposed teeth into proper alignment. 
(Author's article, Ochsner's Surgery.) 
perfection is secured. Set rules for making incisions in such cases 
are misleading, and implicit obedience to them almost invariably 
results in failure. The operator must be controlled by the guidance 
of his own judgment. 692 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Fig. 448.-Boy, aged seven years. 
Shows the characteristic facial appear- 
ance after the removal of the inter- 
maxillary bone in operation for double 
harelip. 
Fig. 449.-Front view of same boy 
shown in Fig. 448. His palate was 
closed in early infancy with what 
appeared to be a successful operation. 
The result at seven years old may be 
seen. Complete stenosis of left naris, 
right side of nose almost absolutely 
useless for breathing purposes, although 
probe can be passed through. Dispro- 
portion between the upper and lower 
parts of the face and head due to arrest 
of development. Voice shrill, high, and 
by no means perfect in pronunciation. 
Fig. 450.-Front view of same boy 
shown in Figs. 448 and 449 after opera- 
tion for the correction of his lip and 
facial defects. 
Fig. 451.-Side view of boy in Figs. 
448, 449 and 450 after operation for 
the restoration of more natural lines in 
profile. SURGICAL TREATMENT OF HARELIP 
693 
In the Excision of Excessive Tissue Causing Projection Beyond the 
Proper Outline of the Lip Border and the Shortening of a Lip that is 
too Long or Removal of Excessive Size.-Such cases of macrocheilia 
are illustrated in Figs. 368, 369 and 370. Great care must be 
exercised to make the knife follow the exact outline of the proper 
curve of the prolabium at its junction with the skin border. This 
is not so easily done as might appear, because when holding the 
lip taut while the knife is drawn across, the form will be changed 
unless this alteration is provided for. 
Fig. 452.-Face of boy, aged fourteen 
years, showing in front view the result 
of imperfect early operation for double 
harelip which is apparent in deformed 
nasal form; almost complete nasal sten- 
osis; arrest of maxillary developments, 
due to loss of premaxillary structures 
and anterior permanent teeth; upper lip 
too long and badly marked with deep 
scars, and eyes staring on account of 
unnatural muscular tension. 
Fig. 453.-Same boy as Fig. 452. Side 
view of the deformity. 
It is the author's custom to mark the surface with a very sharp 
knife, and then as the incision is deepened the first marking can 
be followed. In most cases sufficient excessive tissue can be removed 
and the mucous membrane so cut as to allow proper restoration 
of the form of the lip when it is drawn up and sutured to the skin 
border. A scar at or just above the junction of the skin and mucous 694 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Fig. 454.-Side view of boy shown in 
Figs. 452 and 453 after operation. 
Fig. 455.-Front view of the same 
boy as in Figs. 452, 453 and 544 after 
operation on lip for the purpose of 
shortening the lip; effecting reattach- 
ment of the parts in more nearly normal 
relation, and the removal of scar tissue. 
The improvement in expression of eyes 
is due to correction of unnatural mus- 
cular action. 
Fig. 456.-A young man whose lip 
was operated upon in early infancy with- 
out due consideration for developmental 
principles. 
Fig. 457.-The same individual shown 
in Fig. 456 after operation upon the lip 
and readjustment of the deformed parts. SURGICAL TREATMENT OF HARELIP 
695 
membrane which properly follows the outline of the prolabium 
will not be distinctly noticeable after operation. Not much can 
be done with transverse scars across the lips except in cases where 
they may be included when the lip is shortened or the lip is so 
Fig. 458. - Characteristic scar with 
notch following harelip operation. 
Fig. 459.-Same young man shown 
in Fig. 458 after correction of the lip 
defect and closure of a wide fissure 
through both hard and soft palates. 
formed as to cause it to have an outward roll, such as is often seen 
in natural lips and which serves to make the transverse marks less 
noticeable. One must always guard against making the lip too 
short. Better leave too much and correct it afterward if neces- 
sary than to take away too much tissue and spoil the lip. 
Fig. 460.-A typical result from com- 
pression and iniury to the premaxilla in 
closing double harelip fissure in infancy by 
the method of carrying flaps across under 
the philtrum as commonly advocated. 
Fig. 461.-The same young man 
(twenty-two years old) who is shown 
in Fig. 460 after operation to cor- 
rect the form of the nose, remove 
scars and readjust the lip outline. 
Depression along the line of union must be avoided in lip opera- 
tions by splitting the tissue upon each side of the wound so that 
there may be thickness enough to overcome the result of cicatricial 
contraction during the healing process. By cutting through the 
skin with his knife on a slant, so that there will be a slight tendency 696 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
to lap when the surfaces are approximated, the author finds that 
there is less tendency to scar appearance than when perfectly 
straight incisions are made. After careful trial, however, he has 
demonstrated that a very great slant, one that would leave an 
exceedingly thin flap of skin upon the upper side to spread over 
the lower one, as has been recommended for skin surface approxi- 
mation, is disappointing because, in spite of all precaution, there 
will often be a tendency for the thin edge of skin to shrivel up and 
leave a greater scar mark than would have resulted from a per- 
fectly straight incision. 
Fig. 462.-Young woman whose face, 
nose, lip and mouth have all been de- 
formed by displacement of tissue in an 
operation for double harelip performed 
in infancy. 
Fig. 463. - Same young woman 
shown in Fig. 462, after parts have all 
been restored to their normal situations, 
and the scars removed. More than all 
else correct muscular action and respi- 
ration have been established. Through 
these agencies there has been a con- 
tinued improvement in her features and 
the expression of the face. 
A Thick, Broad, and Grooved Triangular Cartilage of the Nose.- 
When this is such as to be unsightly it is necessary to remove a 
certain amount of the cartilaginous tissue to give the nose its 
proper shape. The removal of this cartilage should be effected 
from within the nose with fine cutting knives and a fixation suture 
passed completely through the nose from one side to the other, to 
hold the parts in form until union can take place. This is a common 
deformity among adults who were operated upon according to 
old methods of treating harelip and is frequently required to give 
satisfactory results from harelip correction. 
The author has operated upon large numbers of these noses, 
and the results are usually very satisfactory. SURGICAL TREATMENT OF HARELIP 
697 
Situation of Scar.-When choice can be made as to the situation 
of the scar following lip operation it should be remembered that 
with boys it is best upon one side. If a double fissure has existed, 
both scars should be kept well away from the center, so that in 
Fig. 464.-Shows the method of removing the excessive tissue from the triangular 
nasal cartilage in such cases without external incisions. Thus avoiding scar disfig- 
urement. 
Fig. 465.-Fixation suture in place. 
later life a moustache may be grown which will cover the defect 
altogether. With girls or young women the line of union is less 
noticeable in the center, through the philtrum of the lip or along 
one or both of the ridges at each side of the philtrum. 698 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Actual photographs of cases operated upon by the author 
according to the methods advocated are illustrated in Figs. 373 
to 410, and 433 to 463 inclusive. 
These pictures are intended to show that the results are uniform. 
They are presented in considerable number and variety for the 
purpose of demonstrating the clinical, therefore essentially prac- 
tical value of the principles which underlie the operative steps 
that have been recommended. 
Fig. 466.-Notch and scar from im- 
perfect harelip operation in infants. 
Fig. 467.-Same man shown in Fig. 
466 one year after the correction of the 
lip defects by operation to lengthen the 
lip and obliterate the notch, as well as 
to reduce the scar. 
SURGICAL TREATMENT OF CLEFT PALATE 
Definitions.-Uranoplasty.-Plastic surgery of the palate; any 
plastic operation for the cure of cleft palate; usually applied with 
reference to the hard palate. 
Uranorrhaphy.-The surgical closure of a cleft palate, especially 
a hard palate. 
Staphylorrhaphy.-Surgical closure of cleft palate, especially of 
the soft palate. 
The author prefers the use of the terms uranoplasty and uranor- 
rhaphy in the description of operations for the closure of the hard 
palate, staphylorrhaphy for closure of the soft palate, and the term 
uranostaphylorrhaphy for closure of fissure of the hard and soft 
palates. 
Present methods of palate closure are necessarily founded on 
the groundwork constructed by eminent surgeons who have con- SURGICAL TREATMENT OF CLEFT PALATE 
699 
tributed to literature the results of their efforts in this direction. 
Lemonier, in 1776, was probably the first to attempt to close 
palate fissures by surgical means; he was followed by Eustache 
in 1799, von Graefe in 1876, Roux in 1879, Warren, of Boston, 
in 1820. Diffenbach, Liston, Sir William Ferguson, Sedillot, Pan- 
coast, William Garretson, Wolf, Erdman, Billroth, von Langen- 
beck, Trilet, and a host of great surgeons, past and present, who, 
despite great discouragement-for this work is ever discouraging 
to surgical procedures when compared with other fields of operation 
■-have each lent some share of personal skill and ingenuity to aid 
the perfection of the operative technic necessary to insure the 
ultimate success of the work. 
Necessary concentration of the results of study of the literature 
of cleft palate operation prevents detailed consideration or mention 
by name of many other authors who have from time to time brought 
forward suggestions with regard to these operations. 
[I Types of Operation.-The recognized distinct types of operation 
from which one may choose in deciding upon a method of palate 
closure may be summed up as follows: 
Fig. 468.-Brophy's method of wiring for cleft palate: 0, orbital cavity; M, upper 
jaw; L, lower jaw; T, tongue; W, W, silver wire (note its relation to the teeth sacs 
which must be damaged) ? (After Treves.) 
Compression.-By this is meant crowding together the segments 
of a palate divided by fissure in such a manner as to force the 
1 Treves: Operative Surgery, Fig. 281, p. 173. 700 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
parts into contact. This method was recommended for young 
infants by Garretson and Brophy (Fig. 468). 
Turning over the Flaps.-The soft tissues upon one side of the 
palate surface are reversed and attached to the opposite side. 
The method is recommended by Lane for young infants, and by 
Ferguson, of Chicago, for persons of more advanced age (Figs. 
469 to 472). 
Fig. 469.-Lane's method of removing 
mucoperiosteal flap from hard and soft 
palate upon one side of the cleft, and 
tucking the edge of this flap under the 
mucosa through a slit upon the opposite 
side of the cleft. (After Eastman.) 
Fig. 470.-Edge of flap tucked under 
slip upon opposite side of cleft and 
sutured. (After Eastman.) 
Carrying in and Attachment of Outside Flaps.-The flaps are 
taken from lips, cheeks, skin, or other extrapalatal surfaces, and 
the attachment of a finger or other expedient of this character 
is designed to bridge the fissure. 
Fracture of Palate Bones.-This method consists in sawing through 
the palate bones from behind forward, fracturing with forceps, 
and wiring in such a manner as to approximate the bony fragments 
sufficiently to bring the soft parts together. It was devised by 
Ferguson, and earnestly advocated for many years by J. Ewing 
Mears, of Philadelphia, who did so much for the advancement of 
oral surgery which, after having become practically obsolete, was 
improved by Roe (Fig. 473) who by the use of a specially formed 
needle holder and needles was able to introduce an E string banjo- 
wire suture in such manner as secured very good results. SURGICAL TREATMENT OF CLEFT PALATE 
701 
Anterior Ends of Flaps Detached.-Detachment of a flap from 
the anterior portion of the palatal mucoperiosteum and carrying 
it across the fissure, as advocated by Davies-Colley (Figs. 474 
to 476), has undoubtedly a field_of usefulness in certain cases. 
Fig. 471.-Ferguson's method: A, 
incision upon nasal side of palate for 
turning down flap; B, incision upon oral 
side for loosening of mucoperiosteal flap. 
(After Ferguson.) 
Fig. 472.-Ferguson's method; the 
nasal and oral mucoperiosteal flaps with 
raw surfaces apposing, leaving a mucous 
covering upon the nasal and upon the 
oral side of the new palate. (After 
Ferguson.) 
Fig. 473.-Fissures of the hard palate: A, preliminary punctures with awl to 
give line for chisel; B, incision through bone completed by chisel; C, holes bored 
through hard and soft palates for sutures; D, junction of hard and soft palate; E, 
lateral openings subsequently filled up by granulation.1 (Bryant.) 
Mucoperiosteal Flaps.-They are closed by lowering the palatal 
arch and sliding the flaps on the bone surface in such a manner 
as to bring them in contact, as brought forward by von Langen- 
1 American System of Dentistry. 702 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
beck, and improved and altered from time to time by other 
operators; this method may be useful. 
Retention Sutures and Appliances.-Subdivisions of these methods 
bring us to the consideration of various expedients for aiding the 
Fig. 474. - Davies-Colley operation 
for cleft of the hard palate with flaps 
(a, b, c, d and e) marked out.1 (After 
Treves.) 
Fig. 475. - Davies-Colley operation 
for cleft of the hard palate. Flaps in 
position. (After Treves.) 
Fig. 476.-Mucoperiosteal flaps are turned inward to cover the fissure and sutured 
with the periosteum upward toward the floor of the nose. Another flap is raised 
with anterior end free and its posterior end attached by a pedicle, this is carried 
across the palate and laid with its raw surface upon the previously attached flap 
and united to a flap carried from the opposite side. (After McCurdy.) 
retention of sutures, such as the tape-ribbon of Mayo (Fig. 477), 
the wax tape-ribbon of Sherman (Fig. 478), the lead-plate and 
silver-wire attachment of Brophy, rubber or aluminum plates 
for protection of the palate, as recommended by several writers, 
1 Treves: Operative Surgery, p. 169. SURGICAL TREATMENT OF CLEFT PALATE 
703 
silver plates and wire as used by the late Dr. Fillebrown and modified 
by other operators. 
Conclusions.-The author's consideration, observation, and ex- 
perience, as applied to selection from these methods, lead to the 
following conclusions: 
Palate Compression.-The first of these methods is unhesitat- 
ingly to be condemned. Such compression necessarily contracts 
the parts in such manner as to narrow the nares and crowd the 
erupting teeth out of place or totally destroy them. Thus it leads 
not only to later disfigurement through disarrangement of the 
Fig. 477.-Charles Mayo's method. 
Unwaxed tape passed under flap. Tape 
is tied with single turn and secured by 
silk ligature. (After Eastman.) 
Fig. 478.-Sherman's technic, relaxa- 
tion incisions, mattress sutures, tape 
impregnated with wax and iodine encir- 
cling the flaps to prevent tension upon 
sutures. Relaxation incisions packed 
with 5 per cent, iodoform gauze. The 
ends of the tape and silk ligature cut 
short and turned around to nasal surface 
out of reach of patient's tongue tip. 
(After Eastman.) 
dental arch, but also to loss of growth and development of mouth, 
nose, and face, making impossible the best speech when adult life 
is reached, and preventing the fullest possibility of good appearance. 
Unfortunately these cases, when apparently successful and so 
reported, sometimes in later years prove to be more seriously 
damaged than the unsuccessful cases in w'hich the parts have 
drawn apart at an early date, and thus to some extent overcome 
the contraction. 
Large numbers of children and young persons who have had 
palates closed in early infancy by direct compression are living 704 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
examples of the truth of this statement (see Figs. 441 to 449). 
Deviated nasal septa, contracted nares, and diseases attendant 
upon these conditions, extending in various degrees throughout 
the extent of the nasal mucous membrane; affections of the middle 
ear; mastoiditis with associated deafness; contracted palates with 
teeth developing toward the central portion of the mouth, with 
almost hopelessly deformed dental arches and insufficient space for 
tongue movement in speech, fully attest the truth of this conclusion. 
Operation on Puppies.1-Additional evidence is given by sec- 
tions through the heads of puppies aged six months. They have 
been sectioned so as to show definitely and with absolute perfec- 
tion exactly what does occur in alteration of intranasal form when 
growth of the upper maxillary bones is arrested so as to interfere 
with the normal width across the palate. It is immaterial whether 
it occurs through adenoids, enlarged tonsils, mouth-breathing, 
the malocclusion incidental to irregular dental arches, or through 
forcible compression and the introduction of retaining wires or 
otherwise. In greater or lesser degree the same results are in- 
evitably produced, and there is the invariable chain of pathological 
conditions which affect not only the local structures, but general 
health and development as well. 
Much less compression was applied than would under any 
possible condition be necessary to force the sides of a palate fissure 
in contact with cleft palate cases. Therefore the ill-results which 
are apparent in the sections in the heads of these dogs (see Figs. 
362 and 363, p. 639) might reasonably be expected to be much 
greater and more disastrous from such palate operations than with 
this slight compression. 
Flaps Inverted-Th.e second type of operation (Figs. 469 to 472) 
the author also believes to be objectionable. The disturbance of 
the natural anatomical arrangement of the tissues, occasioned by 
turning the periosteum upside down, is hardly likely to cause 
bone growth to take place, as it might if the periosteal surfaces 
were merely moved across and brought together in natural position. 
He believes that all such operations, even though successful in 
giving a covering to the palate, cause formation in that region.of 
more or less thickened fibrous tissue. While this tissue may yield 
to normal expansion as growth proceeds, and thus not seriously 
contract the width of the palate or nose, when developed it will 
not have the firm, resounding properties of a bony palate, nor will 
1 For description see page 636. SURGICAL TREATMENT OE CLEFT PALATE 
705 
it have the fixed resistance to the attachments of the muscles that 
is necessary for proper speech function. 
The author's belief is founded upon observation of a consider- 
able number of cases in which there was not and never had been 
fissure through the palate, beyond a few instances of bifid uvula, 
and yet these individuals had all the speech defects of patients 
with complete fissures through both hard and soft palates. Not 
only was this the case, but the inability to profit by speech training 
seemed to be fully as great. Careful examination disclosed in every 
instance that though union of the soft tissues of both hard and soft 
palates was complete, there had been an arrested development 
of the palate bones. This left the hard palate short or with the 
outlines of a notch in the median portion, which would have been a 
cleft palate had it not been covered by soft tissue. Such cases were 
not previously, and are not now generally recognized, as is evidenced 
by the fact that in several instances more or less persistent electric 
and other treatment had been used to stimulate what was believed 
•to be an insufficient action of the palate muscles due to partial 
paralysis. As a matter of fact, the real cause lies in the alteration 
of the fixed attachments of the muscles of the velum palati at the 
hard palate, so that proper function in lowering and raising is 
impossible, and for this reason development of the soft palate as a 
whole is incomplete. Operation in a number of these patients has 
led to considerable improvement, but the trouble is so insidious 
and yet so difficult to overcome that any operation which at the 
outset contemplates producing a similar condition should be avoided. 
Transplantation of Tissue.-The introduction into the mouth of 
extraneous tissue of any character is now known to be absolutely 
unnecessary. Even the worst forms of palate fissure can be closed 
without resort to such expedients and with better hope of function 
than would be possible even if operative attempts at transplanta- 
tion had been more successful. 
Methods of Retention.-In the selection of methods of retention, 
such as are included in our subdivision, the author's experience 
leads to the conclusions that certain principles must be observed 
in all palate operations, and that without provision for them no 
retention expedient can be successful. If these operative principles 
are duly provided for, it makes little or no difference how reten- 
tion is accomplished or what agent is used. A plan which may be 
successful for one operator may in no way appeal to or be produc- 
tive of good results for another. A mucoperiosteal flap, unless 
relieved of the chief elements of tension by operative means, cannot 706 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
be successfully held by any retention appliance, suture or other 
similar assistance. If there be tension upon the sutures, they will 
tear out; if there be undue strain upon a broader surface which 
cannot tear out, there will at least be pressure which will interfere 
with circulation and cause sloughing; thus the result is likely to 
be the same. 
Rubber or aluminum plates, or other similar appliances to 
protect against pressure after operation, are quite unnecessary 
and should be avoided on the ground that all things that may 
be cumbersome, uncomfortable for the patient, or difficult to 
keep clean are contra-indicated. Lead plates kept for any con- 
siderable length of time in mouths of patients are not desirable; 
moreover, the covering of large surfaces of mucous membrane 
of the mouth by any substance which prevents cleanliness is 
inadvisable. 
The author's conclusions as affecting operative methods may be 
summed up in the statement that the real basis for improvement 
in the results of palate operation lies not so much in a new method 
as in the perfection of technic and the steps of operation, so that 
the purpose toward which all the different plans are directed might 
be better accomplished. 
Throughout all cleft palate treatment, from the first care of 
young infants until the final closure, whatever the age may be, 
the nasobuccal relation should be a foremost consideration, for 
upon favorable nasal conditions both speech and development 
depend. 
Decision as to the Method of Procedure.-If, therefore, the surfaces 
of the palate of an adult on each side of the cleft are broad enough, 
and the angle of their slant sufficiently acute to enable the borders 
to be brought together in the median line without tension, after 
making due allowance for incisions, then a plastic operation alone 
is indicated. If these conditions are unfavorable, then the bony 
parts should be corrected before the division in the soft tissues 
is closed. 
Reduction of Wide Palate Fissures by Maxillary Operation.- 
Since direct compression without modifying preparation would 
narrow the nares, the author has devised the method shown in 
Fig. 479. By cutting through the malar ridge on the external 
surface of the upper maxilla, and again behind its tuberosity, 
with additional grooving of the bone through the denser external 
wall between these points (Fig. 479), the parts will yield under 
pressure and narrow the palate fissure without affecting the nasal SURGJCAL TREATMENT OF CLEFT PALATE 
707 
region to any marked extent. The form of splint shown in Fig. 
479, a, b, holds all parts firmly as long as required to give security. 
Fig. 497 is a photograph of the mouth of a patient after this opera- 
tion has been performed, and shows the splint in place. 
Operative Essentials in Plate Closure.-The chief considera- 
tions to be observed in uranoplasty and staphylorrhaphy are: (1) 
Position of the patient; (2) anesthesia; (3) control of immediate 
hemorrhage; (4) provision for control of secondary hemorrhage; 
(5) access to field of operation; (6) avoidance of injury to tissue, 
particularly the periosteum; (7) preservation of blood supply; 
Fig. 479.-The author's method of bone operation to reduce the width of unusually 
unfavorable fissure: a, b, nut and screw bar, and bands cemented upon the teeth; 
c, lines of cutting to weaken the bow resistance. It is only in very unusual cases 
that this treatment is required. 
(8) relief of tension; (9) character and adjustment of sutures; 
(10) control of adverse muscular action; (11) prevention of septic 
conditions; (12) preparatory treatment; (13) postoperative care. 
Position.-With the patient in a recumbent position and the 
shoulders raised with a pad, the head tipped backward and to one 
side, a good view of the field of operation is obtained; blood collects 
in the pouch formed by the pharynx where it is least likely to 
be inspired and most easily cleansed. The author finds this more 
favorable than the Rose position, in which the head hangs over 
the table, because the parts are viewed directly, and this makes 708 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
it easier to get correct approximation than if viewed upside down. 
Moreover, patients sometimes complain of much discomfort from 
the neck muscles after long operations when the head has hung 
over the table and not been properly supported. 
Fig. 480.-Cleft through hard and soft palate. Whitehead's mouth gag as 
modified by the author with bar across the front of the mouth removed, bow over 
the nose and arms clasping the teeth on each side. 
Anesthesia.-Ether, vaporized by heat, and blown through a 
tube into the back part of the mouth, as by the Gwathmey apparatus 
(Fig. 13, p. 34) can be made to give just the delicately poised anes- 
thesia that is so exceedingly desirable to avoid the danger of blood 
inspiration, which might easily occur with the reflexes entirely 
abolished in profound unconsciousness. This method also makes 
it possible to keep a patient on the border-land, sufficiently quiet SURGICAL TREATMENT OF CLEFT PALATE 
709 
and insensible to pain, with a minimum of danger and of tendency 
to postoperative or other ill effects of the anesthesia. 
Access to Field of Operation.-To obviate the disadvantage 
of the bar across the Whitehead gag, which interferes with work 
in the anterior part of the mouth, the author has had this gag 
Fig. 481.-The author's self-retaining fixation forceps attached to hold the soft 
palate taut to favor perfect operative work upon the fissure border. Paring the 
border of the fissure. The author believes that a palate border pared and split is 
more dependable for a secure line of union than one split and not pared. 
improved by removing the objectionable portion and substituting 
two arms which rest upon either side of the palate close to the 
teeth. They occupy practically no space, hold the appliance 
rigidly in place, and leave the entire field absolutely free (Figs. 
480 to 488). 
The tongue holder attached to the gag is to some extent 710 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
adjustable, since patients at different ages and sizes require tongue 
holders of different lengths. 
Another improvement is the addition of two little parts that 
slide down over the horns that rest against the palate. These 
additions make the gag fit the mouths of exceedingly young infants, 
and the guards upon each side give a very desirable degree of steadi- 
ness (see Figs. 489 and 492). 
Fig. 482.-Raising the mucoperiosteum with the author's periosteal elevator, the 
knife being passed under it to sever resisting attachments. 
Preservation of Blood Supply.-Perhaps no part of staphylor- 
rhaphy or of uranoplasty requires so much judgment as the decision 
with regard to sufficiency or insufficiency of vascular supply to 
sustain the tissue when carried to its new position. 
If the operator does not do an extensive and radical operation SURGICAL TREATMENT OF CLEFT PALATE 
711 
involving the free loosening up of all tissue upon the palatal surface, 
he is almost certain to suffer failure through pulling apart of the 
wound surfaces. If, on the other hand, he does his work very 
thoroughly, making free incisions and completely separating all 
tissue adherent to the palate surfaces, the danger confronts him of 
Fig. 483.-Mucoperiosteum raised while the author's knife, safe on the upper 
side and bent to a suitable angle, is used to sever the tissue attachments at the 
posterior border of the hard palate. 
having extensive sloughing through want of nourishing blood 
circulation. Great care and judgment are also required to avoid 
undue injury to vessels. Plate I (frontispiece) is designed to give 
accurate guidance in dealing with all important anatomical struc- 
tures in this region. 712 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Tension Relief Incisions.-Incisions in line with and near the 
gingival borders of the palate upon each side should, if possible, 
be above the line of the palatal artery, and in using the periosteal 
elevator it should pass under the vessel, and effort should be made 
to raise it intact, so that there may not only be less hemorrhage, 
but better circulation in the flap as well (Fig. 484). 
Fig. 484.--A straight periosteal elevator passed through the lateral incision 
under the mucoperiosteum, and a curved one simultaneously forced from the border 
of the fissure to raise the flap with the least possible traumatic injury. 
It is not always practicable to do this, especially where cases 
have been previously operated upon and the parts disarranged, 
but it should be borne in mind and accomplished, if possible. In 
the same way, the vessels passing through the foramina at the 
anterior palatine fossa should not be severed in the effort to separate 
tissues from the bone in that region. SURGICAL TREATMENT OF CLEFT PALATE 
713 
These incisions are only called for in more or less extreme cases. 
Objections that have been made to this plan of relieving tension 
fall to the ground when confronted with conditions in which through 
scarcity of tissue failure must inevitably result unless the tension 
be relieved. 
Fig. 485.--The author's method of inserting the principal wire retention suture. 
The illustration shows the bronze wire suture with silver plate, attached to the 
leading suture as inserted with the author's needle and caught at the point with a 
hook for this purpose. 
Incisions upon each side of the soft palate should be a series 
of slight incisions in the same line, with the tissue held on the 
stretch, rather than a single deep continuous incision which would 
increase the danger of hemorrhage. Care should be taken to 
make these in such form that a packing, if it is necessary to insert 
one, would be retained and effective (see Fig. 486). 714 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Sutures.-The author uses formalized pyoktanin gut for coap- 
tation sutures. He has found it better than silk, inasmuch as 
it does not take up the oral secretions, and, though resisting for a 
sufficient time to serve its purpose, it is easily absorbed, and unlikely 
to make a channel down which the nasal secretions can find their 
way and thus create infectious disturbance. 
Fig. 486.-Wire tension suture in place with silver plate slipped over its free end 
down to the palate surface and followed by four lead shot. Method of freeing 
the soft palate tissue, and forcing it toward the center through the lateral incisions. 
Pad inserted as used to control hemorrhage. 
Retention sutures are of silkworm gut or as formerly used 
aluminum bronze wire. This the author believes to be preferable 
to silver wire, because it has a slight degree of stiffness which pre- 
vents its pulling taut and in that way cutting the tissue at each side. 
This wire is passed through silver plates which serve to relieve the SURGICAL TREATMENT OF CLEFT PALATE 
715 
tension. No matter what the form of plate or button suture may 
be, it is well to remember that, after all, the wire itself would cut 
through the tissue if any considerable amount of strain were placed 
upon it. While the silver plates covering a broad surface upon each 
side do assist in this respect, these sutures, or any other similar 
ones, do not give absolute security against tension. 
Fig. 487.-Fissure borders coapted with pyoktanin gut and horsehair sutures, 
Tension suture in place and the last shot being compressed to hold the plates. 
The fact, however, that a plate upon each side of the palate 
makes it unnecessary for the wire to cross the palate again, thus 
leaving the tissue free, reduces the danger of cutting out very 
considerably, and does not interfere with circulation, as it other- 
wise might (Figs. 486, 487 and 488). 
The sutures, as the author inserts them, are a modification of 716 
HARELIP, CLEET PALATE, AND DEFECTS OF SPEECH 
those used by Dr. Fillebrown, who first called his attention to the 
use of the silver plates. The change that has been made is in 
the use of perforated lead shot, which are slipped over the wires 
and pinched down upon the plate (Fig. 487). By using a series 
of four of these, they can be readjusted and tightened a little 
from time to time, as the operation progresses. Thus the exact 
pressure on the retention plates and the resistance they have to 
overcome are easily and accurately adjusted. 
Fig. 488.-The operation completed and the final clipping of tension causing 
fibers being made to give not only freedom from tension but a broader palate surface 
for better speech purposes. Relief incisions such as are shown in this illustration 
are only required in comparatively rare cases in which the tissue is very scant. 
During recent years the author has used .silkworm gut almost 
entirely instead of wire. It has been found to be much more easily 
handled than any kind of wire, and is quite as reliable for this 
purpose in every way. It is used with the silver plates, and shot 
the same as described for the wire suture. SURGICAL TREATMENT OF CLEFT PALATE 
717 
Author's Operation.-The method of operation is shown in 
Figs. 480 to 488. It covers quite closely in a general way what 
might be known as the old method of performing staphylorrhaphy, 
with certain modifications which have from time to time been 
adopted. 
Separation of Mucoperiosteum.-If in the separation of the peri- 
ostium from the bone surface the membrane of the overlying 
tissues which form the mucoperiosteal flaps suffers undue trau- 
Fig. 489.-The author's method of palate operation for infants. The attachment 
slipped through the arm of the modified gag clasps the anterior part of the alveolar 
ridge as shown. The incisions as used for these cases are as described. 
matic injury, the danger of sloughing is very materially increased. 
In order that this may be accomplished with as little bruising 
or damage as practicable, the author has had his own periosteal 
elevators made for delicate manipulation. These are in different 
sizes and angles, with very smooth, slightly convex surfaces (see 
Figs. 490 and 491, C, C, D, E, F, G, II, I). The reason for this 
is that palates not only differ in size, but also have different angles, 
and even slight force applied in a direction which would easily 
separate the periosteum from the bone in one case might bruise, 718 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Fig. 490.-The author's set of staphylorrhaphy instruments: A, self-retaining tenaculum 
forceps for holding the soft palate taut; B, retractor; C, C, right and left periosteal elevators; 
D, E, F, G, periosteal elevators; Q, wire cutter; S, needles. SURGICAL TREATMENT OF CLEFT PALATE 
719 
Fig. 491.-The author's set of staphylorrhaphy instruments: a, self-retaining tenaculum 
forceps; H, I, periosteal elevators; K, L, M, N, knives of different angles; O, P, straight knives; 
R, lead shot compressor; >S, needles of different sizes and curves; T, hook. 720 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
tear, or break it with serious injury in another. By having the 
angle of the instrument regulated to the slope of the palate wall, 
this difficulty is to some extent obviated and more delicate manipu- 
lation made possible. 
It is frequently necessary to cut the bands of scar tissue and 
unusually resisting attachments that prevent the periosteum from 
being lifted easily. This difficulty is overcome by a set of knives 
with angles corresponding to the form of the periosteal elevators, 
so that, with the elevator making tension upon the tissue, the 
Fig. 492.-The hard palate closed and the tissue of soft palate brought close 
together but not sutured as advocated for infants when the hard palate is cleared 
first, and the soft palate one year later as described in the text. 
knife can be passed under it (Fig. 482) with perfect safety and be 
depended upon to cut the resisting attachment without inadver- 
tently damaging the periosteum (Fig. 491, K, L, M, N): 
Needles.-The needles are of different curves, shaped something 
like a corkscrew, so that when passed in upon one side it can easily 
be calculated where the point will show upon the other (Figs. 490 
and 491). With these the author finds it possible to work at greater 
advantage than with a needle holder, because his hand is not in the 
way to obscure the line of vision. SURGICAL TREATMENT OF CLEFT PALATE 
721 
Postoperative Changes in Palate Form.-Observation of the 
changes that take place in the form of palates, both hard and 
soft, not only during the first few weeks immediately following 
closure of clefts by operation, but during at least several years 
afterward, brings to notice a number of facts that should have a 
direct bearing upon operative procedures. 
The first strain upon sutures occurs at the time of the operation, 
when the flaps are moved over to be brought into contact. If 
properly relieved and the sutures securely placed, this quickly 
disappears. In natural order it occurs that the healing of the 
incisions made to relieve tension, and the tension on the flaps 
which have been brought down from the bone surfaces caused 
by the periosteum seeking its normal situation, gives rise to a 
tendency to pull apart in the median line, which, if unanticipated, 
is very apt to bring disaster just when the surgeon is beginning 
to congratulate himself upon success. 
Many patients have come to the author with histories of pre- 
vious unsuccessful attempts to have their palates closed. In them 
the operation appeared to be perfect for several days, and then 
the palate opened up again. 
Ten days to two weeks is about the time during which reten- 
tion must usually be provided for, before all sutures can safely 
be removed. 
From this time on, during several months, there is a gradual 
rounding of the palate surface, the arch becoming higher and 
the pillars of the fauces more directly outlined. Future form of 
the palate depends upon natural growth as influenced by respira- 
tion and its use in speech. 
In nearly all cases the velum has much the same appearance 
after operation, but some of the author's patients who have made 
more than ordinary speech or vocal effort, and who have made the 
greatest strides toward speech improvement, have had their soft 
palates become lined and creased by developing muscles, and have 
lost much of the smoothly outlined surfaces that were observed 
a few weeks after closure. 
Among these patients, with ages varying from fourteen to fifty 
years at the time of operation, are a number who show almost 
no speech defect that would be noticed in ordinary conversation, 
especially among strangers, as an indication of cleft palate, yet the 
appearance of their palates would be disappointing if compared 
with others in whom the speech results are not as good. 
The cause of this is that great effort is required to coerce the 722 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
newly adjusted and but partly developed palate muscles to per- 
form their parts in speech office, and unusual development is the 
natural result. 
Fig. 493.-Palate view of typical 
case of double harelip and cleft 
palate showing the characteristic 
deformities of the nose and palate. 
Fig. 494.-Photograph of girl, showing 
fissure in the velum palati. 
Fig. 495.-Picture of mouth of the 
same patient as in Fig. 494 after oper- 
ation. 
Fig. 496.-Photograph of the mouth of a 
patient with cleft through both hard and soft 
palates. 
Muscular Alignment.-The lesson to us as influencing operative 
methods is to emphasize the necessity of perfect alignment with 
the uvula in the center, in order that the detached muscles at 
each side may form as perfectly outlined arches as possible, that 
the back of the tongue may find, as nearly as may be, the natural SURGICAL TREATMENT OF CLEFT PALATE 
723 
outline when it meets the posterior border of the palate, and the 
postnasal space be closed as readily as conditions will allow, and 
all muscles of the palatal region coordinate with at least reason- 
Fig. 497.-Same patient as in Fig. 496, with the appliance used for reduction of the 
bone deformity in place. 
Fig. 498.-Photograph after fissures through both hard and soft palates have been 
completely closed. 724 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
able perfection. Figs. 493 to 498 are examples of different forms 
of palate fissures and the results of operations performed by the 
author according to the methods here described. 
SPEECH RESULTS OF CLEFT PALATE OPERATION. 
In consideration of what may safely be promised to those who 
contemplate surgical operation for the closure of cleft palates, 
and the more or less complete correction of the defects from which 
such persons suffer, there are many elements that must be taken 
into account. 
1. Above and beyond all else is the individual feeling on the 
part of those afflicted. No normal person can fully comprehend 
this. None can know what this means save those who have reached 
sufficient age to suffer the scoffs and jibes of school children, the 
heart-trying struggle to keep up in school or college with the 
handicap of imperfect speech, or the bitterness of social ostracism, 
even though largely self-inflicted through supersensitiveness, and 
the untold trials of wage earning or other battles of life in com- 
petition with the anatomically perfect though often less gifted 
mentally. 
2. More healthy conditions of nose and pharynx mean, in 
greater or lesser degree, better general health, and particularly 
protection against deafness due to the middle-ear disease that 
so commonly results from unusual Eustachian exposure through 
open palate fissures. 
3. No plates, obturators, or any sort of mechanical appliance 
could give either of the two foregoing benefits. 
4. There is the infinite satisfaction of knowing that throughout 
life continued speech improvement is possible, and that whatever 
may be accomplished in this direction is permanent, not subject 
to uncertainties of accidental loss or breakage, or change in per- 
fection of adjustment through absorption or growth of surround- 
ing structures, with attendant difficulties of reconstruction, and 
necessity of again becoming accustomed to the new or altered 
appliance. All this must in the natural course be expected with 
artificial appliances, to say nothing of the cleanliness of natural tissue 
as compared with uncleanliness of plates under these conditions. 
5. There is some degree of immediate improvement in speech, 
for almost invariably speech becomes easier and is effected with 
less effort; but beyond this, progress is dependent upon a number of 
modifying factors. SPEECH RESULTS OF CLEFT PALATE OPERATION 
725 
Fig. 499.-Illustration prepared to 
represent as nearly as possible the un- 
equal division of the soft palate which 
frequently results from the destructive 
processes following imperfect early oper- 
ations, and which makes operative con- 
ditions much more difficult. 
Fig. 500.-Illustration representing 
the condition of the mouth of a boy, 
aged twelve years. His first operation 
was performed in infancy. Following 
this several other unsuccessful opera- 
tions were made in attempt to close the 
palate fissure before he came under the 
author's care. The unequal muscular 
activity had been militating against 
success. This fibrous band of tissue 
was freed with the underlying perios- 
teum and muscular readjustment accom- 
plished when these openings were closed. 
The result is that at his present age, 
seventeen, this young man can speak 
almost without speech defect. 
Fig. 501.-Cast of the mouth of a 
child, showing the contraction and loss 
of teeth from a compression in early 
infancy operation and the loss of tissue 
which makes closure exceedingly diffi- 
cult. 
Fig. 502.-Drawing from the cast of 
the mouth of a young woman, aged 
twenty-eight years. Palate was closed 
by compression in early infancy. Her 
upper dental arch is so narrow and the 
palate so high that the freedom of the 
tongue in speech is so inhibited as to 
make good speech sounds practically 
impossible. She has also a correspond- 
ing contraction of the nares with marked 
deflection of the septum. 726 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Conditions which Govern Speech Progress after Operation.- 
Postoperative results show that, although there is always more or 
less noticeable defect present in speech sound, some patients gain 
marked improvement almost immediately, and this with compara- 
tively little conscious effort or speech training. In other cases voice 
change for the better is exceedingly slow and can be acquired only 
after long and patient effort. In considering the different factors 
that must necessarily play a part in this condition of results, one 
element of purely etiological character is of primary importance. 
The Influence of Etiological Factors.-As previously stated, it is 
the author's custom wherever practicable to trace as accurately 
as possible the family history of each patient through at least 
three generations. In approximately 10 per cent, a history of 
direct heredity in the family appeared, and upon one side or the 
other ancestors affected by either harelip or cleft palate or both 
were found. The number in which maternal impressions play 
a part is so small as to be of little significance. Many of the stories 
told by mothers and relatives of shock, fright, or other maternal 
impressions during pregnancy, when analyzed, are found to have 
occurred too late. Little thought is commonly given to these 
matters earlier than the fifth, seventh, or eighth week, and it is 
during this period only that this factor would be of etiological 
importance. Careful study of the family histories, however, quite 
often reveals the fact that relatives have been subject to mental 
peculiarities, nervous affections, diseases of the heart, aneurysm, 
tuberculosis, cancer, or paralysis. These and other affections occur 
with astonishing regularity. Usually there is comparatively little 
difficulty in tracing upon either the paternal or maternal side, and 
sometimes both, these evidences of an unstable nervous system and 
irregular or insufficient bodily or mental development which indicate 
arrest of development during the early embryonic period. 
The bearing of this upon the subject is chiefly made apparent 
by an important fact which the author has been unable to find 
noted by other writers, but which he has so frequently met in 
dealing with these cases as to warrant mention. 
By no means invariably, but quite frequently, he has noticed 
that either the father or the mother of a cleft-palate patient had 
some peculiarity of speech. In none of these cases has the pecu- 
liarity been noticed or associated in any way with cleft palate, 
and though he has been unable to examine all cases, it is fair to 
assume that in the outward appearance of the palate there was 
no defect. Nevertheless, careful attention has demonstrated that SPEECH RESULTS OF CLEFT PALATE OPERATION 
727 
there was unquestionably, in greater or lesser degree, tendency to 
nasal or imperfect speech sounds such as are more markedly notice- 
able with cleft-palate patients. It would seem, then, that there 
must be in. these individuals either a nervous inefficiency in the 
speech mechanism or a slight imperfection of anatomical develop- 
ment, either of which in the next generation has become exag- 
gerated into complete fissure and consequent speech difficulty. 
Many persons whose palates are only slightly imperfect, the 
uvula being bifid and both velum and hard palate apparently 
complete, have marked speech defects. These cases are more 
specifically described under the heading of Speech Defects without 
Cleft Palate. 
Significance of Corrective Influences in Embryo.-That nature does 
repair both harelip and cleft palate in embryo is quite frequently 
demonstrated by individuals who have a mark extending the full 
length of the lip with notch at the labial border. Such lips have 
the appearance of having been imperfectly operated upon in early 
infancy, although no such operation has been performed, because 
the lip was in this condition at birth. 
Speech Defects Directly Due to Postoperative Imperfections.- 
Observation of cases after operation, and particularly those in 
which, on account of imperfect operative methods, there has been 
little or no improvement, speech progress under training being 
slow, leads to the following conclusions in explanation of these 
difficulties in many instances. 
Ill-advised Operations in Early Infancy.-Where forcible means 
have been employed in early infancy to bring the sides of the 
fissure into direct or too close approximation, the arrested 
development of the maxillary bones makes the anterior portion 
of the mouth too small for accommodation of the tongue in the 
utterance of word sounds. This disadvantage is increased by the 
fact of the early disarrangement of developing germs of teeth 
through forcible compression of the parts. Not only are the in- 
cisors, cuspids, and bicuspids erupted in such position as to reduce 
the size of the dental arch, but frequently one or more teeth erupt 
almost in the central portion of the palate. 
Under these conditions, words beginning with c, d, g, h, j, k, I, 
n, r, s, t, x, z, all of which the tongue utters principally behind the 
teeth and with little or no assistance from the lips, are exceedingly 
difficult, if not practically impossible, to utter correctly. 
Disarrangement of the anterior teeth, since the teeth are more 
or less involved in pronunciation of all letters, widens the range of 728 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
defective sounds materially. Where any portion of the protruding 
premaxilla has been removed for the purpose of facilitating lip 
closure in infancy the non-eruption of teeth in this region is also 
a very serious disadvantage. 
Scars that stiffen and distort the lip, and which are so commonly 
noticeable on account of improper operative treatment in infancy, 
affect all words beginning with b, f, m, p, v, w. 
Maldevelopment of Nasal and other Parts Accessory to Speech.- 
Imperfections from wrong methods of early treatment, such as 
noses that have the characteristic appearance of leaning to one 
side, with the cartilaginous wing more or less flattened, usually 
have deflection of the septum with tendency to unequal develop- 
ment amounting to partial stenosis upon one or both sides, or 
one naris may be unusually large with corresponding enlargement 
of the turbinal bodies. Hypertrophy of the nasal mucous mem- 
brane and other pathological conditions that are in natural sequence 
to these conditions tend to nasal speech sounds even in persons 
otherwise normal, and are obviously more disadvantageous when 
other speech difficulties incident to cleft palate speech habits act 
as a still greater complication. 
Hard Palate too Short and too Flexible.-Shortening of the hard 
palate in its anteroposterior measurement, such as often occurs 
from wrong operative methods and failure to develop cartilaginous 
or bony tissue of sufficient firmness to act as a sounding board, 
or to give the degree of stiffness required for proper muscular 
action from points of attachment thereto, is a matter of much 
importance, since physiological action of the muscles of the soft 
palate depends upon the outline and character of the posterior 
border of the hard palate. Methods of operation by which the 
periosteum is carried over accurately and with as little injury as 
possible, to be united in the central palatal line, are advisable 
because they favor formation of bone. Conversely, methods by 
which flaps are turned over and the relation of the periosteal and 
mucous membrane surfaces is altered, while they may be successful 
in closing the palate fissure, are ill-advised because a membranous 
yielding tissue covering the region of the hard palate cannot give 
as good speech results as one more firmly resistant may be expected 
to produce. 
Velum Insufficient through Abnormal Hard Palate Borders, Scars, 
etc.-On account of ill-formed hard palate at the posterior border, 
or because of its own insufficiency, the velum palati, after being 
closed by operation, is sometimes too short, drawn too tightly, or SPEECH RESULTS OF CLEFT PALATE OPERATION 
729 
too stiffened by scars to enable it to be made to approach the 
pharyngeal wall, or meet the base of the tongue with sufficient 
readiness properly to perform its speech function in governing 
escape of air through nose and mouth in sound making. 
Possibilities of Improvement of These Cases.-A study of the 
principal difficulties that stand in the way of speech improvement 
-for those who have had cleft palates closed by operation leads 
naturally to the conclusion that corrective treatment must be 
along two distinct lines. The author's experience has shown that 
almost incalculable assistance may be given such patients by 
(1) improved operative methods, and (2) better speech training. 
The lesson to be read from the unfortunate results of imperfect 
or ill-advised treatment, as evidenced in results of operation upon 
this unfortunate class of patients, is not alone that exceedingly 
great care should be exercised in order that no unnecessary violation 
of natural processes of development in early infancy or later develop- 
mental periods should be allowed, but also that through operative 
means much may be accomplished by an effort to undo the damage 
that has been done by reconstruction, readjustment, and improve- 
ment of the malformed parts by surgical operation. 
Reconstruction of Deformed Lips.-Because of reconstruction 
of the lip which is often too long, or scar contraction upon the 
inside, the lip has a tendency to curve inward instead of having 
the natural outward roll. It may also be that the lip is too short 
or distorted through wrong muscular attachment. These, as 
well as other lip deformities, can be much improved and the lip 
made more useful for labial speech office (see Figs. 443 to 463, 
pp. 692 to 696). 
In many instances, through destruction or injury to the pre- 
maxilla, there is no development of the dental arch anterior to the 
cuspid teeth, or, if the incisors be erupted at all, they are in such 
form as to be of little practical assistance in restoring the contour 
of the face and giving necessary labial support as well as speech 
assistance in the utterance of dental sounds. 
Correction of Deformity of the Dental Arch.-The dental arch 
must be restored to its natural form and relation to both the lips 
and occlusion with the lower jaw. The simplest, most direct, 
and satisfactory means of accomplishing this is by the insertion 
of teeth arranged in proper form and attached to teeth in the 
jaw by means which dentists fully understand and commonly 
practice. 
In the next class of cases the teeth are erupted, in malposition, 730 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
with the upper dental arches contracted. These arches may be 
expanded and the teeth placed in proper relation so that the tongue 
may have sufficient room to give proper speech assistance while both 
buccal and labial tissues are held in better form. This should only 
be attempted with exceeding great care and due control of pressure, 
so that no separation of the line of palate union may occur and 
unfortunate reopening of the palate be brought about. For this 
reason methods usually employed in correction of dental irregu- 
larities must be avoided or carefully modified. 
The results of correction under these conditions have been very 
gratifying in large numbers of cases. In one case recently, where 
the velum after closure was less flexible than seemed desirable, 
through the fact that the patient was thirty years old before the 
author performed the operation, and though no scar stiffening 
interfered with movement, the tissue was so scant through want 
of development as to give this result. A new operation was per- 
formed by making incisions upon each side and carrying tension 
sutures of wire through from one side to the other without in 
any way interfering with the central portion of the palate, allow- 
ing granulation to fill the division in the tissue thus made, and in 
that way gaining additional freedom for the soft palate. The 
speech results in this case are exceedingly good. 
Correction of Defects by Operative Assistance.-The question 
of reoperation in the region of the hard palate, where tissue cover- 
ing fissure has remained too flexible, is one that requires careful 
consideration, for fear of doing injury to what has already been 
accomplished in the closure of the fissure with tissue. Under favor- 
able conditions, however, the mucoperiosteal flaps can be separated 
from the bone surfaces and carried to the center as for the original 
palate operation, thus gaining an increase of the surface which best 
promises cartilage or bony development. This operation the 
author has usually performed coincidently with an operation 
demanded for some other purpose, but the results were such as 
to indicate that there is hope for future improvement of many 
otherwise comparatively hopeless cases from this method of 
treatment. 
Conclusions from Phonographic Speech Records.-Phonographic 
records that the author has taken of speech before and after opera- 
tion in all of the different degrees of palate fissure, as might naturally 
be expected with a large number of cases, have demonstrated some 
curious facts. The cases ranged from a slight separation at the 
posterior border of the velum on through partial and complete SPEECH RESULTS OF CLEFT PALATE OPERATION 
731 
clefts of both hard and soft palates varying in width of the 
separation. Chief in point of interest is the evidence that some- 
times an individual with only a bifid uvula, the rest of the palate 
being intact and apparently normally developed, will speak more 
imperfectly and with greater exaggeration of the nasal and other 
defective sounds common to persons with cleft palates than 
others whose fissures are much more extensive. Some, in fact, 
with complete fissure through both hard and soft palates are able 
to speak more clearly than those with almost imperceptibly defec- 
tive ones. 
Many individuals with practically no palate sing quite well, 
even though unable to speak words with sufficient correctness 
to be understood. 
Case I.-This was that of a girl, aged fourteen years, who had 
only a fissure in the soft palate before operation. It was impos- 
sible to distinguish speech sounds sufficiently for unaccustomed per- 
sons to understand what she said. Therefore a phonographic 
record would have been a mere jargon of unintelligible sounds. 
She had been unable to get beyond the fourth grade in the public 
schools because teachers could not understand her. Immediately 
after operation marked improvement was noted by record. Later 
records showed remarkable change for the better, and on one or 
two occasions, after training, she has recited before large audiences, 
with much clearness and a very good approximation of perfection 
of sound, verses in which she had been drilled, but in general con- 
versation her progress was not in proportion to that of better 
educated patients, as was noted in records of other cases. Eager- 
ness in conversation always tended to cause lapses into old speech 
habits, and in this case such difficulty was hard to overcome; a 
difference being apparent if she were allowed to associate for a time 
with people who themselves spoke incorrectly or carelessly or the 
reverse. 
Case II.-Another girl, aged twenty-two years, with the same 
character of fissure, but who had a high-school education, could 
speak much better than the preceding one before operation, the 
range of her intelligible, even though somewhat nasal, sounds being 
much less limited. After closure of the cleft, though operative 
results were quite perfect in both cases, her progress in the line of 
improvement in conversational sounds was shown by the record 
to be much more marked. 
Case III.-Patient, aged thirty-eight years, was the mother of a 
grown-up family. The cleft in soft palate was the same as Cases 732 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
I and II. She was not well educated, but not ignorant and of less 
nervous temperament than the other two. Speech, as might be 
expected, was better than Case I and not so good as Case II. Soon 
after operation, therefore, without training, her record was found 
to be surprisingly good, due in a considerable measure, no doubt, 
to freedom from nervousness. Later reports of improvement 
were much more favorable than was expected. 
Case IV.-This patient, a girl, aged sixteen years, in whom the 
fissure was confined to the velum, as in all the preceding cases, 
was as uneducated as the first patient, but with less natural intelli- 
gence. Scarcely a single word in her first record could be under- 
stood. Later and after much training she was able to recite simple 
rhymes before large audiences quite well, but she has never acquired 
good speech. Notwithstanding this deficiency, she can repeat 
after another person, sentence by sentence, even most difficult 
combinations of words, with little noticeable speech defect. 
Case V.-A girl, aged twenty-two years, who had an acquired 
fissure of the velum, due to hereditary syphilis, was operated on 
after preparatory administration of potassium iodide, with success- 
ful results so far as closing the opening was concerned. It was 
not perfect in the sense that the preceding cases were, because 
cicatricial contractions, due to previous ulcerative processes, had 
stiffened the tissue. Notwithstanding the fact that this deformity 
was acquired at about the age of fourteen years, and the patient's 
education was above the average, there was less improvement after 
operation than in any of the other cases. 
Case VI.-In contradistinction to these other cases, a little boy, 
aged nine years, whose congenital cleft in the velum was like that 
in Case V, with very imperfect speech, was able to improve so 
rapidly that between the months of May and November defects 
were so overcome that his school-teacher did not notice unusual 
difference from other children of the same age. 
Case VIL-A girl, aged twenty-two years, fairly well educated, 
with opening in velum palati alone, in whom speech sounds were 
very bad before operation, was able, by reason of good ear and 
singing practice, to improve sufficiently to be able to pray and 
sing alone at Salvation Army meetings within a few months from 
time of closure. In this case, undoubtedly, religious zeal helped 
to overcome self-consciousness, together with other mental and 
nervous hindrances, while constant attendance on the meetings 
of the Army gave the best possible training to the vocal apparatus. 
Case VIII.-A young man, aged eighteen years, had a complete 
cleft of both hard and soft palates. He is a graduate of a high SPEECH DEFECTS WITHOUT CLEFT PALATE 
733 
school. Before operation he was almost impossible to understand, 
yet in repeating the alphabet unusual ability to pronounce each 
letter was noted, even the g, k, and c being more than ordinarily 
good. Stammering was the prime cause of his speech difficulty. 
The record, taken two days after the last stitches were removed, 
complete union by first intention having taken place throughout, 
even to the tip of the uvula, showed an almost astonishing result, 
since his voice from the graphophone, singing the "Holy City," 
sounded better, perhaps, than many of our own would if a similar 
record were taken. 
Case IX.-A young man, aged nineteen years, with a fair educa- 
tion, had fissure through both hard and soft palates. The first 
speech record was better than Case VIII, on account of freedom 
from nervous habit, but ability to make separate sounds was less 
perfect. He could sing "Rock of Ages" quite well, and showed 
great speech improvement in later records as a result of two weeks' 
singing and drill exercise. 
Case X.-A boy, aged nine years, for whom only the preparatory 
operation had been performed, has given two interesting records. In 
one he recites the "Lord's Prayer" with an obturator in his mouth, 
and the next equally well without it, yet with cleft through both 
hard and soft palates. It must be understood that he could not 
have learned to speak so well had he not had the mechanical 
assistance in the beginning. 
Case XL--A girl, aged twenty-two years, highly educated, but 
with wide cleft through both hard and soft palates, made worse by 
having had several previous unsuccessful operations, improved so 
rapidly after the normal form of the palate had been restored 
by operation that she successfully passed an examination to teach 
in an eastern law school. The fact that she afterward filled an 
important position and transacted the telephone business of a large 
establishment is sufficient proof of her improvement. Undoubt- 
edly her rare intelligence and persistence have been assisting 
factors. 
Hundreds of similar examples of clinical results confirm the 
correctness of the findings of these phonographic records. 
SPEECH DEFECTS DUE TO IMPERFECT DEVELOPMENT 
WITHOUT CLEFT PALATE. 
Speech is an index of individual sex, character, mental capacity, 
training, state of mind, nervous conditions, general bodily health, 
and past or present developmental influences. 734 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
Etiology.-The causes of defective speech, according to Cohn, 
are stammering, stuttering, nasal defects or malformations of hard 
and soft palates, deaf-mutism, and defects of speech due to diseases 
of the central nervous system. 
Ballenger's enumeration of causes is as follows: nasal origin, 
epipharyngeal and faucial origin, lingual origin, laryngeal origin, 
thoracic and abdominal origin, deaf-mutism, malformations of 
palates, and central origin. 
From the foregoing classifications the causes of defective speech 
may be grouped with advantage to the oral surgeon into nervous, 
anatomical, and mechanical influences. Radical divisions of this 
character, which will readily be understood, cannot be arbitrarily 
insisted upon, because factors belonging to each one of these classes 
are inseparably dependent upon and associated with those that 
might be classed in another division. Congenital absence of the 
sense of hearing or defective brain development or nervous affec- 
tions common to defectives, insofar as they may prevent or mili- 
tate against speech, are for the greater part beyond any surgical 
or medical control. Certainly their control lies outside the field 
of oral surgery. 
A considerable number of nervous affections are, however, sus- 
ceptible to improvement by the treatment of buccal conditions, as 
may be noted by reference to the chapter on Nervous Diseases. 
All of the methods suggested in this connection should be 
employed when indicated to assist such individuals toward the 
establishment of more stable nervous conditions, and to aid speech 
improvement. 
In undertaking the treatment of these cases the most difficult 
feature often rests upon the decision as to whether the condition 
is susceptible of improvement or is due to causes that cannot be 
corrected. 
The Correction of Anatomical Defects.-This has already been 
provided for in the description of the prevention and correction 
of nasal, palatal, lingual, maxillary, and other oral malformations; 
with the single exception of the operative treatment of cases having 
defective speech from imperfectly developed palates, that are not 
cleft, and which upon casual examination give no evidence of the 
imperfection. These palates have been from time to time referred 
to in the discussion of other divisions of the subject. 
The author's method of treatment is based upon the belief that 
when there is no nerve lesion or congenital motor insufficiency in 
the control of the movements of the soft palate, the reason why SPEECH DEFECTS WITHOUT CLEFT PALATE 
735 
there is wrong escape of air through the nose, with an imperfect 
sound such as that which is characteristic of cleft palate cases, is 
because it is impossible for such patients perfectly to approximate 
Fig. 503 
Fig. 504 736 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
the posterior wall of the pharynx and the soft palate at the proper 
moment, as is shown in Fig. 503, which illustrates the contact of 
the velum with the projection in the pharynx formed by the pharyn- 
goconstrictor muscles whereby closure of the nasal openings takes 
place. This occurs with slight variations in the pronunciation of 
the elementary vowel sounds and the consonants p, b, t, d, v, s, 
z, c, h, j, th, r, sh, I. Fig. 504 shows the impact of the tongue against 
the soft palate required in k, g, and ng.1 Kingsley's palatograms 
(Fig. 505) indicate the points of contact of the tongue and palate 
in articulation of speech sounds. 
Fig. 505.-Kingsley's palatograms. Show tongue and palate contact in vocalization 
of letters indicated. 
Obviously, if the hard palate is short, the levator and tensor 
palati muscles will not have the same leverage as would be the 
case with a perfect outline at the posterior border of the hard 
palate. Moreover, the angle at which the velum is suspended will 
be such as to make it necessary for it to be carried farther upward 
and backward in order to complete physiological speech function 
in relation to the pharyngeal wall. 
More is therefore required of muscular action that is necessarily 
deficient. The difficulty is still further increased because the 
natural effect of this condition upon the palatoglossi muscles is to 
cause them to be shorter than would be expected if their antago- 
nists of the velum were operating from points of attachment farther 
back, as would be the case with a normal hard palate. 
1 American System of Dentistry. SPEECH DEFECTS WITHOUT CLEFT PALATE 
737 
When the soft palate is unusually short, either because of its 
own incomplete development or because of the shortness of the 
hard palate, the difficulties of proper contact with the base of the 
tongue and also with the pharyngeal wall are increased. For cases 
in which the uncontrollable conditions previously referred to have 
been completely and sometimes partially excluded by diagnosis 
the author has undertaken to remedy the condition of the velum 
by operation. 
Incisions are made as shown in Figs. 486 and 488 upon each 
side of the velum in line with the molar teeth. The tissues are 
separated with the fingers and a retention suture inserted, as 
shown in Fig. 486 for staphylorrhaphy. This suture is allowed to 
remain until the healing process has taken place in such a manner 
as to insure an increase of palate tissue in this region. By this 
method greater freedom may be given the soft palate in its central 
portion, and a certain amount of rigidity upon each side, which is 
believed to be beneficial in assisting function under these conditions. 
Division of the palatoglossi muscles, as described for cases of 
cleft palate and shown in Fig. 485, when the suture is inserted, 
also gives a measure of freedom in this direction. 
In some cases the author has found it necessary to draw together 
tissues from the ends of the transverse sutures and close them 
with fine catgut sutures in a vertical line, thus preserving the 
increased length of these muscles permanently. The operation 
which naturally suggests itself of causing an increased bone devel- 
opment at the posterior border of the hard palate by raising the 
mucoperiosteum and carrying it over to a point which will allow 
the periosteal borders to meet in the center, and retention in this 
position by sutures, as in closing cleft palate, might be warranted 
in some cases. Except under unusual circumstances, the danger, 
however, of creating palatal defects which might result disadvan- 
tageously rather than the reverse is too great. 
The number of cases operated upon by the author as described 
has been limited, and the result of speech training which must 
necessarily be depended upon to supplement the anatomical correc- 
tion have been undertaken too recently to permit positive state- 
ments as to the degree of benefit given. 
Sometimes a marked improvement immediately following the 
operation is noted. At other times the change for the better is 
less apparent, and the progress of speech training is such that it 
is impossible to say if progress is more rapid because of the opera- 
tion than might otherwise be expected. Personally the author has 738 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
no doubt of the necessity of surgical assistance in such cases the 
same as with other forms of palatal defects. 
Simple Methods of Speech Training Best.-In the matter of 
speech training, simplicity of method is extremely desirable. Due 
recognition must be given to all factors incident to individual 
adaptability and talent, to which attention has been called in 
earlier descriptions of conclusions drawn by the author from phono- 
graphic records of patients, which mark the tendency in this as 
in any other education to slow or rapid progress. 
After an experience of many years, during which there has 
been unusual opportunity to observe the results of speech training 
under widely different conditions, the author feels called upon to 
urge most strongly the avoidance of all methods of instruction 
that are unnecessarily technical or complicated. They may be 
alluring from the theoretical standpoint of a more or less limited 
observation of certain aspects of this many-sided question, but it 
is certain that the easier and more naturally the directions given 
to such persons may be followed, the earlier will improvement be 
noticed. 
As an example of this, two cases, both boys, aged about four- 
teen years, may be cited. Each had had his palate closed in infancy, 
both suffered in almost the same degree from contraction and 
ill-development of both hard and soft palates, with eruption of 
the teeth well in toward the central portion of the palate. With 
both the author used successfully the same method of correction 
by gradual expansion and reshaping of the palates and dental 
arches. One of these had had constant instruction from his earliest 
days not only in English, but also in French, the latter with a 
view of assisting him in English, as the learning of foreign lan- 
guages for such patients is one of the accepted forms of favoring 
speech improvement. The other little patient had had practically 
no training at all. His parents wisely considered that unless the 
anatomical defects from which he suffered could be corrected, it 
were better that he be saved the trials of comparatively useless 
effort to improve. As might have been expected, the boy who 
had been taught French and who could not make English sounds 
correctly was unable to do any better in French. Therefore he had 
acquired wrong speech habits in two languages instead of one. 
This is a point that should be borne in mind by others who may 
feel inclined to undertake this means of improvement. The won- 
derfully complicated studies of consonant sounds upon which he 
had apparently spent many hours that could have been more 
beneficially employed out of doors, gaining health and strength, SPEECH DEFECTS 
739 
only tended to confuse his mind and lessen the quickness of response 
of the many elements of speech mechanism. The difference was 
markedly apparent because the boy without previous training 
made much more rapid progress as soon as conditions were favor- 
able, while the other, though quite equal in general intelligence, 
was found to be exceedingly slow and effort toward improvement 
was very difficult. 
General Principles.-Better understanding of these differences 
depends upon due appreciation of the general principles which 
have been so well explained by Scripture in the following manner: 
1. Reflex Tonus.-Tonus is a faint muscular contraction due to 
continuous weak nerve stimulations, easily subject to fatigue, ill 
health, and other demoralizing conditions, lack of or disarrange- 
ment of which causes marked change of voice in both speaking 
and singing. 
2. Force of Movement.-This depends on the amount of stimulus 
sent to muscles, movements of which includes not only those 
directly involved, but also their antagonists. This requires an 
excess of effort over what might be expected, but when the inner- 
vations are properly coordinated this excess is not necessarily large 
and fatiguing. 
3. Accuracy of Movement.-Inaccuracy of movement is a funda- 
mental source of inaccurate and wrong sounds. 
4. Precision of Movement.-This refers to regularity and even- 
ness of execution and depends on nervous control. 
5. Accuracy and Precision of Coordination.-This represents the 
nervous control over shmdtaneous muscular movements. Some 
forms of thick speech of alcoholic intoxication and incorrect adjust- 
ments during excitement are caused by defective coordination in 
speech effort. 
6. Quickness of Response.-This is action of the nervous centers 
that tends to become automatic. One object in vocal training 
should be to render speech and song automatic. 
7. Quickness of Muscular Movement.-This depends on both 
muscular and nervous quickness, and must be properly balanced; 
otherwise speech appears labored or slurred. 
8. Auditory Motor Control.-The learning of speech sounds con- 
sists largely in forming connections between motor and auditory 
sensations. 
9. Ideomotor Control.-Sounds occurring simultaneously with 
sights, touches, tastes, smells, emotion, act of will, etc., tend to be 
connected with them, so that when any one of a complex group 
occurs again, the others are revived more or less clearly in con- 740 
HARELIP, CLEFT PALATE, AND DEFECTS OF SPEECH 
sciousness. It is in this way that speech movements become 
associated with printed letters. 
10. General Voluntary Control.-This is subject to changes of 
nutrition, fatigue, emotion, and general habits, on all of which 
vocal control must place its dependence. 
The author is indebted to Prof. Carberry, of the Wisconsin 
Conservatory of Music, for the following suggestion, which has 
proved to be exceedingly useful in the management of postoper- 
ative speech-training cases. As vocal instructor, he is accustomed 
to teach that the Italian a is the basal tone, modification of which, 
with but slight alteration of physiological action, allows sufficient 
change to utter clearly each of the other vowels, and even the 
consonants. With the organs in position to make this tone at the 
beginning of the sound, all parts are under the least possible strain. 
The resultant sound effect therefore will be most natural, and 
for this reason can be carried on up through the various registers 
of the voice to higher notes without sacrificing purity, as must 
necessarily be the case if there is the least strain upon the voice 
or the sound-producing mechanism connected therewith at the 
moment of inception. 
Applications of this principle to speech training show that the 
confusing and complicated systems which involve special direction 
of the attention to lips and tongue for each particular letter of the 
alphabet are not only largely unnecessary, but in some instances, 
at least, most unadvisable. For with overanxiety causing undue 
nervousness and tendency to unconscious contraction of all muscles, 
and the added difficulties of other speech defects induced by 
nervous conditions, that so commonly affect these patients as to 
make additional complication, there can be no question that the 
simpler form of training and the more devoid of multiplied rules 
of procedure such instructive methods may be, the more easily 
and rapidly speech improvement will take place. The easiest and 
the most natural way to overcome these unfortunate speech habits 
seems to be the use of the voice in singing. 
Conclusions.-No individual with cleft palate, no matter how 
bad the condition, need be utterly discouraged. 
In every case (age being no contra-indication) operation for 
closure of palate fissure should be performed. 
No unnecessarily forcible methods should be employed in early 
infancy. Defects of lip, nose, and palate due to imperfect operative 
results, which are frequent causes of slow speech progress, may 
be much benefited by corrective operation. 
Avoid complicated methods of speech training. BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE. 
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Operationen, Gottingen, 1885. 
Ayasse, M.: Etude Historiques et critique des procedes de restauration 
du rebord alveolaire dans le bec-de-lievre complique, Paris, 1897. 
Bein, G.: Zweiundfiinfzig Faile von Hasenscharten, Bern, 1890. 
Berendsen, G.: Die Esmarchsche Methode der Hasenschartenoperation, 
Kiel, 1883. 
Bidalot, J. F.: Observations de varietes rares de bec-de-lievre, Strass- 
burg, 1867. 
Bosch, B.: Ueber das Schicksal der Hasenschartenkinder, Erlangen, 
1892. 
Brandt, L.: Zur Uranoplastik Staphylorrhapie und Prothese, Berlin, 
1888. 
Briinck, W.: Systematische Untersuchung des Sprachorgans bei ange- 
borenem Gaumendefect in ihrer Beziehung zur Prognose und Therapie, 
1906. 
Butcher, R. G. H.: Operative Measures Necessary in the Treatment of 
Harelip, 1856. A description of operations on different types of harelip. 
Chaussier, F.: Description et usage d'un bandage pour le bec-de-lievre, 
Paris, 1803. 
Courmont, F.: Des Operations applicables an bec-de-lievre complique, 
Paris, 1875. 
Denise, A.: Traitement du bec-de-lievre simple et complique, Paris 
Thesis, 1884. 
Deye, S.: Ueber Wolfsrachen, Jena, 1904. 
D'Hour, L. H.: Traitement du bec-de-lievre, Lille, 1894. 
Dobberkan, L. J.: Ueber Gaumenspalten, Berlin, 1898. 
Ehrmann, C. H.: Dissertation sur le bec-de-lievre, Strassburg, 1812. 
Eigenbrodt, K.: Ueber die Hasenscharte, ihre operative Behandlung 
und deren Erfolge, Halle, A. S., 1885. 
Fillebrown, T.: Reports of Operations on Harelip and Cleft Palate, 
Boston, 1898. 
Fronhofer, E.: Die Enstehung der Lippen-Kiefer-Gaumenspalte in 
Folge amniotisches Adhasionen, Berlin, 1896. 
Garretson, J. E.: System of Oral Surgery, Philadelphia, Fifth Edition, 
1890. Chapter XLIX, Cleft Palate; Chapter LIV, Harelip; favors early 
operations. 
Garretson, J. E.: Treatise on the Diseases and Surgery of the Mouth, 
Jaws and Associated Parts, 1869. Chapter XXXV, Harelip; Chapter XL, 
Cleft Palate. Discusses the proper time for operation and the operations. 
Gourdon, J. J. M. L.: Traitement du bec-de-lievre complique, Bordeaux, 
1897. 
Kiel, 1883. 742 
BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
Grant, H. H.: Text-book of Surgical Principles and Surgical Diseases 
of the Face, 1902. Chapter XXIII, Harelip and Cleft Palate. Describes 
operations. 
Greiner, 0. H. W.: Zur Aetiologie und Therapie der Hasenscharte, 
Leipzig, 1866. 
Groll, 0.: Beitrag zur Statistik der Hasenscharte, Wurzburg, 1888. 
Henne, 0.: Zur Operativen Behandlung der angebornen Gaumenspalte, 
Leipzig, 1904. 
Hermann, E.: Beitrage zur Statistik und Behandlung der Hasenschar- 
ten, Breslau, 1884. 
Hosack, A. E.: Memoir upon Staphylorrhaphy, New York, 1833. 
Hullen, M.: Le Pronostic des Urano Staphylorrhapies pour Fissures 
congenitales, Paris Thesis, 1904. 
Hullihen, S. P.: Harelip and its Treatment, 1844. Twelve-page 
pamphlet. Age for operation, preparation for operation, and method of 
operation. 
Jourdain Berchillet, A. L. B.: Treatise on the Diseases and Surgical 
Operations of the Mouth, 1851, p. 227. Congenital Defects of the Palate 
and Harelip. 
Kolliker, T.: Ueber das Os intermaxillare des Menschen und die 
Anatomie der Hasenscharte und des Wolfsrachens, Halle, 1882. 
Lane, G. F.: Cases of Complicated Cleft Palate, London, 1854. 
Lane, W. A.: Cleft Palate and Harelip, 1905. Causes; best age for 
operations; technic of operation. 
Lane, W. A.: Cleft Palate; Treatment of Simple Fractures, etc. Chap- 
ter I, Cleft Palate, Harelip, and other Complications. 
Liessner, E.: Zur Kenntniss der Kiemenspalte, Dorpat, 1889. 
Lorthior, J.: Operations plastiques de la bouche, Brussels, 1901. 
Lowy, A.: Die an der Kbniglichen Chirurgischen Klinik, Breslau, 1891 
bis 1901, behandelten Faile von Hasenscharten, Breslau, 1903. 
Marshall, J. S.: A Manual of the Injuries and Surgical Diseases of the 
Face, Mouth, and Jaws, Philadelphia, Second Edition, 1902. Chapters 
XLHI and XLIV. Congenital Fissures of the Lip and the Vault of the 
Mouth, and their Surgical Treatment. 
Mason, F.: On Harelip and Cleft Palate, 1877. Harelip: Types and 
complications; causes and heredity; different methods of operation. Cleft 
palate: Types; feeding of infants with cleft palates; causes and hereditary 
character; age for the operation; different methods of operation; improve- 
ment in voice. 
Mason, F.: Surgery of the Face, 1879. Chapter HI, Harelip: Differ- 
ent types; hereditary character; method of operation. Cleft Palates: 
Langenbeck's operation; Dieffenbach's operation. 
Muller, E.: Die Hasenscharten der Tiibinger Chirurgischen Klinik, 
1843-1885, Tubingen, 1886. 
Murray, R. W.: Harelip and Cleft Palate, 1902. Causes and types 
of harelip; the operation for harelip; operation for double harelip; types 
of cleft palate; age for operation; technic of operation; after-treatment. 
Mutter, T. D.: Report on the Operation for Fissures of the Palatine 
Vault, Philadelphia, 1843. 
Napleson, J.: Observations of the Treatment of Cleft Palate, London, 
1851. BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
743 
Neveu, N.: La Voute Palatine en Ogive, Paris Thesis, 1905. 
Owen, E.: Cleft Palate and Harelip, 1904 (Medical Monograph Series). 
The development of palate and lips and the causes of cleft palate and 
harelip; varieties of harelip; technic of the operations; operation for harelip 
in infancy and after infancy; care after the operation; the operation for 
harelip, and the subsequent treatment. 
Owen, E.: Surgery of the Mouth, Teeth, and Jaws. In Keen's Surgery, 
1908, vol. iii, p. 614. 
Petaeu, G.: Contribution a 1'etude du Traitement du bec-de-lievre 
double complique, Blois, 1875. 
Preiswerk, G.: Atlas and Text-book of Dentistry, including Diseases of 
the Mouth, Philadelphia, 1906. Harelip and Cleft Palate, pp. 169 to 174. 
Rawdon, H. G.: Operative Treatment of the Cleft Palate in Children, 
Liverpool, 1880. 
Ricketts, B. M.: Surgery of Cleft Palate, Toledo, O., 1891. 
Ricketts, B. M.: The Surgery of Cleft Palate, 1891. A paper read 
before the Mississippi Valley Dental Society at Cincinnati, 1891. 
Roberts, John B.: Surgical Treatment of Congenital and Pathological 
Disfigurements of the Face (Mutter Lectures, College of Physicians of 
Philadelphia, 1900). Lecture VI, Harelip: Different forms; causes; opera- 
tive treatment; later minor operations to improve appearances. 
Scheck, P.: Diseases of the Mouth, Throat, and Nose, Edinburgh, 1886, 
p. 89, Cleft Palate. 
Schmitz, E. F. J.: Contribution a 1'etude du role de 1'heredite, et du 
role de l'amnois dans la pathogenie du bec-de-lievre, Paris Thesis, 1904. 
Sinan, A. L. M.: Du procede de Mirault d'Angers pour 1'operation du 
bec-de-lievre simple, Paris, 1904. 
Texier, Jean.: Du Traitement du bec-de-lievre simple, Paris Thesis, 
1905. 
Trabold, K. A. M.: Schadelform un Gaumenhbhe, Freiburg u. Br., 1903, 
Ueberholz, F. B.: Ein Beitrag zu den Operationen der angeborenen 
Gaumenspalten, 1887. 
Warren, J. M.: Fissure of the Hard and Soft Palate, Philadelphia, 1865. 
Wheeler, W. I.: Operative Treatment of Harelip, London and Dublin, 
1887. 
Wolff, J.: Ueber fruhzeitige Operation der angeborenen Gaumenspalten, 
Leipzig, 1901 (Sammlung klinischer Vortrager, No. 301). 
PERIODICALS.1 
Abbe, R.: Harelip and Cleft Palate, Post Graduate, 1895, vol. x, p. 15. 
Anderson, C. M.: The Author's Needle for Acutely Arched Cleft Palate, 
New Zealand Medical Journal, 1907, vol. v, p. 1. Application de la 
prothese dentaire a la reduction des becs-de-lievre compliques, Revue 
ondotologique, 1906, vol. xxv, p. 387. 
Baldwin, K. W.: Cleft Palate and Harelip, Laryngoscope, 1907, vol. 
xvii, p. 506. 
Barnhill, J. F.: The Repair of Harelip and Cleft Palate, Laryngoscope, 
1908, vol. xviii, p. 814. 
1 For earlier periodical literature consult the United States Surgeon-General's 
Catalogue under Harelip and Palate, Cleft. 744 
BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
Berger: Le bec-de-lievre, Revue general de clinique et de therapeutique, 
1905, vol. xix, p. 326. 
Billhaut, M.: Bec-de-lievre Annales de chirurgie et d'orthopedie, 1904, 
vol. xvii, p. 33. 
Bradford, T. G.: Surgical Operation of the Labium Frenum, Texas 
State Medical Journal, 1907, vol. ii, p. 234. 
Broca: Bec-de-lievre complexe de la levre superieure. Revue generale 
de Clinique et de Therapeutique, 1906, vol. xx, pp. 1 to 81. 
Brophy, T. W.: Anatomy of the Palate, Normal and Cleft, Journal of 
the American Medical Association, 1907, vol. xlix, p. 662. 
Brophy, T. W.: Surgical Treatment of Palatal Defects, Dental Cosmos, 
April, 1901. 
Brown, G. V. I.: Clinical Results in the Surgical Treatment of Harelip 
and Cleft Palate, Dental Cosmos, 1908, vol. i, p. 123. 
Brown, G. V. I.: Conservatism in the Treatment of Infants with 
Harelip and Cleft Palate, Journal of American Medical Association, 1907, 
vol. xlviii. 
Brown, G. V. I.: Surgical Correction of Malformation and Speech 
Defects Due to or Associated with Cleft Palate, Journal of American 
Medical Association, 1902, vol. xxxiii, p. 169. 
Brown, G. V. I.: Surgical Correction of Malformation and Speech 
Defects Due to or Associated with Harelip and Cleft Palate, Journal of 
American Medical Association, January 18 to 25, 1902. 
Brown, G. V. I.: A System for the Surgical Correction of Harelip 
and Cleft Palate, Journal of American Medical Association, 1905, vol, xliv, 
p. 848. 
Brown, G. V. I.: Speech Results of Cleft Palate Operation, Journal of 
the American Medical Association, 1908, vol. 1, p. 342. 
Calvin, W. D.: Etiology of Harelip and Cleft Palate, Dental Digest, 
1908, vol. xiv, p. 1508. 
Carmody, T. E.: Cleft Palate, Colorado Medicine, 1908, vol. v, p. 313. 
Case, C. S.: Mechanical Treatment of Congenital Cleft Palate, Trans- 
actions of the International Dental Congress for 1905, p. 129; also in 
Dental Cosmos, 1905, vol. xlvii, p. 1037. 
Chauveau, C.: Anomalie Palato-Staphylienne, Archives International 
de Laryngologie, 1907, vol. xxiii, p. 297. 
Coomes, M. F.: Malformations of the Mouth and Cleft Palate; Ameri- 
can Practitioner and News, 1908, vol. xlii, p. 97. 
Craig, A. R.: Repairing of Clefts of the Palate and the Lip, Pennsyl- 
vania Medical Journal for 1907-1908, p. 214. 
Delangeniere, H.: Du veritable precede de Mirault, d'Angers pour 
1'operation du bec-de-lievre, Archives provinciales de chirurgie, 1903, 
vol. xii, p. 717. 
Dumont, J.: A propos de 1'operation du bec-de-lievre, Presse medicale, 
1905, p. 517. 
Dunham, T.: Operation for Harelip, Post-Graduate, 1897, vol. xii, p. 
603. 
Dunham, T.: Retention Method after Harelip Operations, Annals of 
Surgery, 1905, vol. xlii, p. 593. 
Eastman, J. R.: Newer Conceptions of Operative Technic in Cleft 
Palate and Harelip, Annals of Surgery, 1909, vol. xlix, p. 35. BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
745 
Ferguson, A. H.: Harelip and Cleft Palate, Transactions of the South- 
ern Surgical and Gynecological Association, 1908, vol. xx, p. 278. 
Fillebrown, T.: A Study of Harelip and Cleft Palate, Proceedings of 
the Massachusetts Dental Society, 1897, vol. xxxiii, p. 68. 
Gaucher: Bec-de-lievre, Journal Medecine Interne, 1908, vol. x, p. 21. 
Graddy, L. B.: A Satisfactory Operation for Harelip, Medical Brief, 
1905, vol. xxxiii, p. 713. 
Haug, G.: Beitrag zur Statistik der Hasenscharten, Beitrage zur 
klinischen Chirurgie, 1904, vol. xliv, p. 254. 
Haymann, T.: Amniogene und erbliche Hasenscharten, Archiv fur 
klinische Chirurgie, 1903, vol. Ixx, p. 1033. Also reprint, Berlin, 1903. 
Hentze: Ueber Hasenscharten und Wolfsrachen und deren Behandlung, 
Deutsche Monatsschrift fiir Zahnheilkunde, 1905, vol. xxiii, p. 539. 
Kirmisson: Le bec-de-lievre et son Traitement, Medecine moderne, 
1904, vol. xv, p. 185; also, Annales de Medecine et chirurgie infantiles, 
1903, vol. vii, p. 472. 
Kirmisson: Traitement du bec-de-lievre double et complique, Gazette 
de maladies infantiles, 1903, vol. v, p. 81. 
Kiister: Zur Operation der complicierten Hasenscharte, Zentralblatt 
fiir Chirurgie, 1905, vol. xxxii, p. 713. 
Lane, W. A.: Modern Treatment of Cleft Palate, Lancet, 1908, vol. i, p. 6. 
Lorenz, R.: Eine neue Operations methode fiir doppelseitige Hasen- 
scharte, Deutsche Zeitschrift fiir Chirurgie, 1907, vol. Ixxxvii, p. 410. 
Lowman, W. H.: Median Harelip, British Medical Journal, 1904, vol. 
i, p. 892. 
Lucas, R. C.: On an Ill-developed Upper Lateral Incisor Tooth as a 
Forerunner of Harelip or Cleft Palate, Report of Society for the Study 
■of the Diseases of Childhood, London, 1905, vol. v, p. 31. 
McGraw, T. A.: Unsettled Questions in the Treatment of Harelip and 
Cleft Palate, Detroit Medical Journal, 1908, vol. viii, p. 1. 
McKernon, J. F.: Congenital Cleft of the Palate . . . the Opera- 
tive Technic and its Results, Laryngoscope, 1903, vol. xiii, p. 97. 
McKernon, J. F.: Contribution to the Technic of Modern Uranoplasty, 
New York Medical Journal, 1900, vol. Ixxi, p. 933. 
Makuen, G. H.: Cleft Palate and its Relation to Speech, American 
Medicine, October 5, 1901. 
Makuen, G. H.: Operations for Cleft Palate and their Results, especi- 
ally in the Improvement of Speech, New York Medical Journal, 1907, 
vol. Ixxxvi, p. 146. 
Manley, J. H.: Harelip: Its Causes and Treatment, International 
Medical Magazine, 1893, vol. ii, p. 209. 
Morris, R. T.: Harelip, American Journal of Surgery and Gynecologv, 
1899, vol. xiii, p. 139. 
Muller, W. B.: Die Operation der Hasenscharte, Kinderarzt, 1908, 
vol. xix, p. 49. 
Mumford, J. G.: Medical and Surgical Treatment of Harelip, Boston 
Medical and Surgical Journal, 1898, vol. cxxxviii, p.198. 
Murray, R. W.: At What Age Should a Cleft Palate be Closed? Pedi- 
atrics, 1907, vol. xix, p. 73. 
Murray, R. W.: Geographical Distribution of Harelip and Cleft Palate, 
Lancet, 1904, vol. i, p. 1423. 746 
BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
Peck, C. H.: Operative Treatment of Cleft Palate, Annals of Surgery, 
1906, vol. xliii, pp. 5 and 126. 
Piechaud, T.: Un point du technique sur 1'operation du bec-de-lievre. 
Putnam, C. H. L.: Harelip and its Treatment, Pediatrics, 1904, vol. xvi, 
p. 81; also Post-Graduate, 1903, vol. xviii, p. 868. 
Rachford, B. K.: Harelip, Archives of Pediatrics, 1902, vol. xix, p. 100. 
Reiss, W. A.: A Harelip Operation, Dental Grief, 1906, vol. xi, p. 83. 
Roberts, J. B.: Modern Method in the Repair of the Cleft Palate, 
Laryngoscope, 1907, vol. xvii, p. 501; also American Journal of Medical 
Sciences, New Series, 1907, vol. cxxxiv, p. 87; also reprint. 
.Rocher: Quelques Considerations embryologiques sur la pathogenic du 
bec-de-lievre, Journal de Medecine de Bordeaux, 1904, vol. xxxiv, p. 530. 
Sherman, H. M.: Some Technical Points in the Cleft Palate Operation, 
Surgery, Gynecology and Obstetrics, 1908, vol. vi, p. 644; also, Transac- 
tions of American Surgical Association, 1908, vol. xxvi, p. 609. 
Singley, J. De V.: Operative Treatment of Cleft Palate and the Causes 
of Failure, American Medicine, 1905, vol. x, p. 490. 
Smith, D. T.: Cleft Palate, Surgery, Gynecology and Obstetrics, 1907, 
vol. xxix, p. 223. 
Starr, F. N. G.: Cleft Palate and Harelip, International Clinics, 18th 
Series, 1918, vol. iii, p. 171. 
Starr, F. N. G.: New Method of Dealing with Cleft Palate, Canadian 
Journal of Medicine and Surgery, 1907, vol. xxi, p. 349. 
Stone, J. S.: Harelip and Cleft Palate, Bryant and Buck, American 
Practice of Surgery, 1908, vol. v, p. 500. 
Taylor, A. S.: A Dressing after Harelip Operation, Journal of American 
Medical Association, 1907, vol. xlvii, p. 209. 
Tomlinson, E. S.: Cleft Palate: Its Origin, Effect, and Treatment, 
Dental Cosmos, 1906, vol. xlviii, p. 658. 
Vance, A. M.: Points in Technic of Cleft Palate, Surgery, Gynecology 
and Obstetrics, 1907, vol. iv, p. 343. 
Warnekros: Gaumenspalten, Archiv fiir Laryngologie und Rhinologie, 
1908, vol. xxi, p. 144. 
Waugh, G. E.: Operation for Cleft Palate, Lancet, 1905, vol. ii, p. 1504. 
Wharton, H. R.: Cleft Palate, Pennsylvania Medical Journal, 1906, 
vol. x, p. 99. 
Whitehead, W. R.: Report on the Best Methods of Treatment for 
Different Forms of Cleft Palate, Transactions of American Medical Asso- 
ciation, 1869; also reprint. 
Wies, H.: Prognose der Hasenscharten Operationen, Annalegen der 
stadtischen der allgemeinen Krankenhauser zu Munchen, 1901, vol. xi, p. 
245. 
Winternitz, A.: Operation der Gaumenspalte mittelst Platennaht, 
Archiv fiir klinische Chirurgie, 1908, vol. Ixxxvi, p. 643. 
Woollcombe, W. L.: Mandibular Processes Associated with Double 
Harelip and Cleft Palate, Lancet, 1905, vol. i, p. 357. 
Young, J. K.: Treatment of Harelip, International Medical Magazine, 
1900, vol. ix, p. 821. BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
747 
RECENT LITERATURE. 
Ambridanne: Restauration d'un bec-de-lievre Complet Avec Fente du 
Palais et du Voile, Chez un Enfant de Deux Jours, Bulletin et Memoires 
de la Societe de Chirurgie de Paris, 1913, vol. xxxix, p. 1506. 
Barge, J. A. H.: Hazenlip en Scheeve Gesichtsplect Volgens Nieuwere 
Onderzoekingen. Tydscher V. Geneesk Amst., 1914, vol. ii, pp. 1416-1498. 
(Full name of periodical unknown.) 
Bater: Hagendorn's Operation for Harelip and Cleft Palate, Lancet, 
1916, vol. i, p. 136. 
Berry, J.: Surgery of the Cleft Palate, Surgery, Gynecology and Ob- 
stetrics, 1915, vol. xx, pp. 85-87. 
Blader, W. F.: Heredity as a Factor in Congenital Harelip and Cleft 
Palate, Dental Cosmos, Philadelphia, 1914, vol. Ivi, pp. 1241-1245. 
Blakeway, H.: The Treatment of Harelip and Cleft Palate, Practitioner, 
London, 1914, vol. xcii, pp. 219-239. 
Blakeway, H.: The Effects of Cleft Palate Operations on the Dental 
Arch, Practitioner, London, 1915, vol. xcv, pp. 145-169. 
Brophy, T. W. The Late Results of Cleft Palate Operations, Surgery, 
Gynecology and Obstetrics, 1915, vol. xx, pp. 98-100. 
Brown, G. V. L: The Principles Which Govern the Ultimate Results 
of Harelip and Cleft Palate Operations, Lancet, London, 1914, vol. ii, pp. 
587-691. 
Brown, G. V. I.: The Principles Which Govern the Ultimate Results of 
Harelip and Cleft Palate Operations, Surgery, Gynecology and Obstetrics, 
1915, vol. xx, pp. 87-91. 
Bryan, W. A.: Operative Correction of Harelip and Cleft Palate, South- 
ern Medical Journal, 1915, vol. viii, pp. 218-222. 
Carmody, T. E.: Cleft Palate, Colorado Medicine, 1914, vol. ii, pp. 
90-106. 
Carmody, T. E.: (Title not listed) Southern Medical Journal, vol. ix, 
p. 744. 
Cole, H. P.: Harelip Surgery; Essentials in the Production of Scarless 
Incisions, Southern Medical Journal, 1915, vol. viii, pp. 790-796. 
Drachter, R.: Zur Frage der Verschliisse der Kieferspalte bei "Einseitig 
Durchziehender Gaumenspalte," Zentralblatt f. Chirurgie, 1914, vol. xli, 
pp. 497-499. 
Drachter, R.: Die Gaumenspalte und Deren Operative Behandlung, 
Deutsche Zeitschrift fiir Chirurgie, 1914, vol. cxxxi, pp. 1-89. 
Drachter, R.: Die Gaumenspalte und Deren Operative Behandlung, 
Miinchener medizinische Wochenschrift, 1914, vol. Ixi, p. 1624. 
Eastman, J. R.: Factors of Safety in Cleft Palate Surgery, Lancet, 
London, 1914, vol. ii, pp. 312-315. 
Eastman, J. R.: Factors of Safety in Cleft Palate Surgery, Surgery, 
Gynecology and Obstetrics, 1915, vol. xx, pp. 91-95. 
Eastman, J. R.: The Surgical Anatomy of Cleft Palate, Journal of 
American Medical Association, 1915, vol. Ixv, pp. 915-920. 
Eifert: Herstellung von Obturatoren fiir den Weichen Gaumen (Eigene 
Methode). Deutsche Zahnheilkunde im Vortrag, 1914, Heft, 33, S. 49-56. 
Emerson, L.: Operations for Clefts of the Hard and Soft Palate, Journal 
of American Medical Association, 1915, vol. Ixiv, pp. 301-305. 748 
BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
Farr, R. E.: The Management of Harelip and Cleft Palate Cases, 
Journal-Lancet, Minneapolis, 1914, vol. xxxiv, pp. 481-489. 
Froschels, E., and Klein: Wolfsrachen und Hasenscharte, Wiener 
klinische Wochenschrift, 1914, vol. xxvii, p. 587. 
Hazemann, R.: Eine Zweckmassige Modifikation des Heftpflasterver- 
bandes bei Hasenscharten Operationen, Zentralblatt f. Chirurgie, 1914, 
vol. Ixi, p. 884. 
Hans, H.: Zur Operationstechnik der doppelseitigen Hasenscharte, 
Zentralblatt f. Chirurgie, Leipzig, 1914, vol. xli, p. 1357. 
Helbing, C.: Zur Frage der Heftpflasterverbandes bei Hasenscharten- 
Operationen, Zentralblatt f. Chirurgie, Leipzig, 1914, vol. xli, p. 1385. 
Holfelder: Heftpflasterverband bei Hasenschartenoperationen, Zentral- 
blatt f. Chirurgie, Leipzig, 1914, vol. xli, p. 1145. 
Kaerger, E.: Die Brophysche Gaumenspaltenbehandlung, Deutsche 
medizinische Wochenschrift, Leipzig and Berlin, 1913, vol. xxxix, p. 2552. 
Kaerger, E.: Brophysche Gaumenspaltenbehandlung, Deutsche medi- 
zinische Wochenschrift, Leipzig und Berlin, 1913, vol. xxxix, p. 2573. 
Kaerger, E.: Ueber die Behandlung der Angeborenen Kiefer und Gaumen- 
spalten unter Besonderer Berucksichtigung der Friih-Operation und der 
Methode nach Brophy, Archiv. f. klinische Chirurgie, Berlin, 1914, vol. 
ciii, pp. 255-349. 
Keynon, E. L.: The Speech Aspects of a Case of Cleft Palate, Journal of 
Ophthalmology and Oto-Laryngology, Chicago, 1915, vol. ix, pp. 102-104. 
Keynon, E. L.: The Speech Aspects of a Case of Cleft Palate, Illinois 
Medical Journal, Chicago, 1914, vol. xxvi, p. 622. 
Ladd, W. E.: Modification of Technic for Harelip Operation, Boston 
Medical and Surgical Journal, 1915, vol. clxxii, pp. 54-56. 
Lenormant, C.: Le Traitement der Divisions Congenitales du Palais 
par la Methode de Brophy, a Propos d'une Statistique Recente, Presse 
Medicale, Paris, 1914, vol. xxii, pp. 167-169. 
Levi, G.: A Proposito di una Fessura Labio Maxillo Palatina in un 
Giovane Embrione Umano, Ginecol. Mod. Geneva, 1914, vol. vii, pp. 
260-276. 
MacKenty, J. E.: Operative Treatment of Cleft Palate, Transactions 
of American Laryngological Association, 1914, vol. xxxvi, pp. 273-291. 
Matti, H.: Zweckmassiger Verband nach Hasenschartenoperation, 
Zentralblatt f. Chirurgie, Leipzig, 1914, vol. xli, pp. 1386-1388. 
Meige, H.: Un bec-de-lievre en Peinture et Quelques Remarques sur la 
Conformation des Levres, N. iconog. de la Salpetriere, Paris, 1914, vol. 
xxvii, pp. 57-60. 
Mitchell, V. E.: Artificial Restoration of Lost or Missing Tissues in 
Congenital Cleft Palate, New Device, American Journal of Surgery, March, 
1917, vol. xxxi, p. 57. 
Nicholl, J. H.: Operative Treatment of Cleft Palate and Harelip, 
Glasgow Medical Journal, January, 1917, vol. Ixxxvii, p. 16. 
Nicholl, J. H.: Operations for Harelip in the Out-patient Department, 
Edinburgh Medical Journal, 1913, vol. xi, pp. 419-421. 
Neumann, W.: Die "Normierung" des Oberkiefers bei Kompletter 
Kieferspalte, Berliner klinische Wochenschrift, 1914, vol. li, p. 294. 
Riegner: Die Prothesenbehandlung der Gaumenspalten, Beitrage zur 
klinischen Chirurgie, 1914, vol, xci, pp. 569-577. BIBLIOGRAPHY FOR HARELIP AND CLEFT PALATE 
749 
Schoemaker, J.: Zur Technik der Uranoplastik, Zentralblatt f. Chir- 
urgie, 1914, vol. xli, p. 1514. 
Smith, Herbert L.: Apparatus for Use after Operations, Surgery, 
Gynecology and Obstetrics, November, 1916, vol. xxiii, p. 628. 
Soyder, F. W.: On the Treatment of Cleft Palate, Surgery, Gynecology 
and Obstetrics, 1915, vol. xx, pp. 95-97. 
Thompson, G. S.: Nasal Flap and Modified Langenbeck Operations 
for Cleft Palate, Lancet, London, 1915, vol i, p. 1288. 
Todd, A. H.: Case Showing Bilateral Harelip without Cleft Palate, 
and also Congenital Bilateral Mucous Fistulae in the Lower Lip, Proceed- 
ings of the Royal Society of Medicine, 1913-14, vol. vii. Section on the 
Study of the Diseases of Children, p. 132. 
von Tothfalussy, E.: Die Hasenscharte, Ergebnisse der Chirurgie und 
Orthopadie, 1913, vol. vii, pp. 409-453. 
Welch, Rowe, and Lehnhoff: Complete Unilateral Harelip and Cleft 
Palate, Nebraska Medical Journal, February, 1917, vol. ii, p. 246. 
Wilkinson, 0.: The Use of Aluminum Plates in Cleft Palate Operation, 
Virginia Medical Semi-monthly, 1913, vol. xviii, p. 481. 
Witherspoon, L. G.: Harelip and Cleft Palate, Bulletin of El Paso 
County Medical Society, 1913, vol. v, pp. 18-26. CHAPTER XIV. 
THE TREATMENT OF WOUNDS UNDER WAR 
CONDITIONS. 
The experiences of the war in Europe with wholesale destruction 
of tissue by an infinite variety of projectiles and the ever-present 
dangers from battlefields planted with pyogenic microorganisms 
through centuries of fertilization with manure, the diseases of the 
trenches, the inhalation of poisonous gases, the burns of flames 
sent broadcast among the soldiery, frost-bite, the diseases of expo- 
sure and unsanitary conditions have so changed the order of rou- 
tine treatment of wounds that had previously been found to be 
satisfactory under ordinary conditions, that a work of this charac- 
ter would be incomplete without at least a brief reference thereto. 
Tetanus.-The horrors of tetanus whenever the antitetanic 
serum could be procured have been largely prevented by the early 
injection of the serum in all cases of serious wounds. 
Infection by Gas-producing Organisms.1-According to Mac- 
kenzie Forbes, "these are of the anaerobic variety. The bacillus 
of malignant edema is the most common. More rarely found is 
the Bacillus aerogenes capsulatus (Welch). Infections by these 
organisms are characterized by their virulency. It is necessary to 
recognize them early, because at first the infection is local, although 
usually of a deep wound, and practically always of the lower 
extremity. 
"A wound so infected is dirty in appearance. It contains pus, or 
pseudopus, with a fecal-like odor, which is similar to liquid feces 
in color and consistency. The parts about it are swollen and con- 
gested, but at this stage no characteristic crackling can be elicited 
by palpating the surrounding tissues; thus it may be difficult to 
differentiate it from an infection by the colon bacillus. Later there 
may be localized gangrene around the wound about which crack- 
ling can be elicited on careful palpation. In some cases this latter 
may be noticed without a suggestion of gangrene. The condition 
at first is really one of cellulitis. The patient's general condition, 
which is due to toxemia, is often far worse than is suggested by the 
1 Notes on War Surgery, British Med. Jour., p. 369. INFECTION BY GAS-PRODUCING ORGANISMS 
751 
local lesion. In those cases where crackling is found on palpation 
there can be no doubt as to either diagnosis or treatment. In the 
earliest stages, where there is doubt as to the diagnosis, open freely 
and drain. Where crackling is found, treat at once as for a fulmi- 
nating cellulitis, where the freest incisions and drainage are indi- 
cated. At the same time hydrogen dioxide may be injected into 
the surrounding subcutaneous tissues in an attempt to limit the 
infection. The infected area must be kept under constant sur- 
veillance, always remembering that to save life, amputation in the 
case of a limb may be necessitated at any time. When gangrene 
has appeared, amputation is necessary. This may be done through 
the emphysematous tissues if the open methods to be described 
later are employed. 
"In dealing with infections by gas-forming organisms it is 
necessary to keep in mind that the patient's life is endangered from 
the very beginning, and, although early and very free incisions 
may relieve the patient even in cases where we are dealing with a 
cellulitis alone, amputation with free drainage may often have to 
be resorted to in the end in order to save the patient's life." 
Morriss1 calls attention to the fact that "modern trench war- 
fare created an unexpected situation, and at present the military 
surgeon faces problems which in some respects are novel. A major- 
ity of the wounds are caused by pieces of shell and shrapnel balls, 
and generally these are infected. Even rifle wounds are rarely 
aseptic, for the range is short and the explosive violence corre- 
spondingly increased. Shattering of the bone and hernia of muscle 
are common. These conditions, resembling those in wounds caused 
by low-velocity projectiles, nearly always lead to suppuration. 
Accordingly all wounds are treated from the first as if infected, 
and antiseptics are used with Listerian rigor." 
Bull has recently elaborated a gas gangrene bacillus antitoxin, 
by the injection of which he claims both growth and toxic absorp- 
tion are inhibited.2 
Antiseptics.-Since practically all wounds are infected and great 
enlargement usually is necessary because clothing, foreign bodies 
of various kinds and other infective agents are driven into the 
tissues by projectiles, and especially because the frightful slough- 
ing and edematous conditions of the tissue require extensive 
incisions for relief and drainage, as well as large exposed areas 
where portions of the body have been torn away, the problem 
1 The Military Surgeon, xxxviii, 131. 
2 Report of Demonstration before the National Council of Defense. 752 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
of combating infections by the use of antiseptics is a very serious 
one. A natural result of this has been the trying out in the various 
base and other hospitals of practically all known antiseptic agents. 
The net result of this has been the general adoption of the use of 
Dakin fluid. 
Dakin's Solution.-A. W. Hornbogen1 states that the antiseptic 
developed by Dr. Dakin, and tried out in a thoroughly convincing 
manner at the Carrel Hospital, is an aqueous solution of 0.5 per 
cent, concentration of sodium hypochlorite and is made as follows: 
Dissolve in a large bottle 140 grams of dry carbonate of soda, 
with 10 liters of sterile water. Add to this 200 grams of chloride 
of lime (bleaching powder) and shake well. After half an hour 
siphon off the clear fluid into another bottle through a cotton plug 
or filter paper and then add 40 grams of boric acid to the clear 
filtrate. This solution is neutral to litmus, is non-irritating and is 
the proper strength for wet dressings and irrigations. A stronger 
stock solution of 4 per cent, may be made, but the quantity of boric 
acid to be added must be determined exactly, so that the solution 
is just acid to phenolphthalein suspended in water; otherwise the 
solution decomposes very quickly. The solution should be made 
fresh every three or four days, and the dry stock ingredients should 
be kept in covered receptacles. Besides its proved efficiency 
another point worthy of consideration is that this solution can be 
made up, even in small amounts, at a cost of only about five cents 
for 10 liters. 
Dalton says the results obtained by the use of sodium hypo- 
chlorite in the present war have been so remarkably satisfactory 
that he believes it should be the method of choice. The advan- 
tages observed from the use of sodium hypochlorite solution in the 
treatment of septic wounds are: (1) The simplicity and cheapness 
of preparation of the antiseptic. (2) Being non-toxic and non- 
irritating to the tissues, when properly prepared according to 
Dakin's formula, the hypochlorite solution may be safely used in 
large quantities over long periods of time without ill effects. (3) 
The deodorant action of the solution is remarkable. The fetor 
from gangrenous tissue usually disappears in twenty-four hours. 
(4) The rapidity with which sloughs separate and clean granula- 
tion tissue is forced in a wound under its influence. (5) The infre- 
quency of redressing required by cases treated with hypochlorite 
compared with the constant change of dressings required in large 
* Jour. Michigan State Med. Soc., September, 1917. HYPERTONIC AND ISOTONIC SALT SOLUTIONS 
753 
wounds with other forms of antiseptics. (6) The fact that injec- 
tions of the hypochlorite solution into rubber tubes used in the 
dressings may with safety be entrusted to very imperfectly trained 
orderlies without fear of ill results, once the case has been adequately 
dealt with by the surgeon. 
Dichloramine-I, Dakin's latest antiseptic solution, twenty times 
as powerful as the watery solution used in the Carrel method, is 
dissolved in oil of eucalyptus and applied by a spray.1 
Earl V. Morrow, M.D., chief surgeon, American Red Cross in 
Belgium {Northwest Medicine, 1916), gives the following descrip- 
tion of his experience with the Carrel method and the action of the 
Wright hypertonic and isotonic salt solutions: 
Carrel's Method.-"As to Carrel's sodium hypochlorite solution 
I cannot say too much. I am thoroughly convinced it is one of the 
greatest that has been found. It is hard for me to determine which 
has given the best results, the salt solutions or Carrel's. The Carrel 
tube is used, it being made by placing a common perforated rub- 
ber tube one-quarter of an inch in diameter in cloth of coarse 
material, as rough toweling. One thickness is placed around the 
tube and sewed. Made in different lengths, these tubes are placed 
in the tract made by the missile, sometimes a single tube and 
sometimes two, one through the wound of entrance and one through 
the wound of exit, lying alongside of each other in the tract. The 
solution is then injected every two, three or four hours or can be 
used continuously. Dr. Carrel advises that in the wound there 
should not be any effort made on the part of the surgeon to clean 
out the foreign particles of dirt; in fact, no disturbance of the wound 
in any way, but it has been our custom to clean out all blood clots. 
This solution seemed to give the best results in cases that had 
received their injury only a few hours previously. The tubes were 
generally left in the wound from twelve to fourteen days and upon 
removal the wounds seemed to heal very rapidly. The exudate 
was never as abundant as in the other cases and did not have the 
appearance of pus but that of a thin, colorless jelly-like substance." 
Hypertonic and Isotonic Salt Solutions.-The attempts on the 
part of the surgeon to increase the combative forces of the body 
are at times very discouraging and there are several things that 
have to be taken into consideration. The one word stimulation will 
cover a great deal of it; first, the stimulation of the physiological 
forces; second, that of the protective elements, and, third, that of 
1 Le Conte: Report of the National Counsel of Defense. 754 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
the action of the white blood corpuscles (phagocytosis). It may be 
said that the action of salt solutions has been known for many 
years, but the use of solutions of different strengths for different 
bacteria is comparatively new. For instance, the hypertonic solu- 
tions have a very pronounced effect upon the pyocyaneus and 
greatly stimulate the action of the white blood corpuscles. The 
isotonic act best in the streptococcus infection and also show a 
tendency to dilute the lymph, and in this way make it possible for 
the white blood corpuscles to enter the wound and carry on their 
work. It is known that they are the most deadly enemy of the 
streptococcus, while this organism does very well in lymph. 
The record of wounds in the base hospital work in Russia, 
reported by Major H. H. Snively,1 N. G. Ohio, late director-in- 
chief of the American Red Cross in Russia, shows a proportion of 
fractures of the jaws to other fractures: 
RELATIVE FREQUENCY OF JAW FRACTURES IN WAR WOUNDS. 
Grand total. 
Cranium 78 
Face 114 
Mandible 205 
Hyoid 6 
Vertebra 19 
Ribs 78 
Pelvis 28 
Clavicle 60 
Scapula 68 
Humerus 235 
Ulna 176 
Radius 153 
Carpals 64 
Metacarpals 77 . 
Phalanges 160 
Femur 163 
Patella 26 
Tibia 123 
Fibula 70 
Tarsals 38 
Metatarsals 26 
Phalanges ■ . 31 
Total 1998 
AMERICAN AMBULANCE HOSPITAL METHODS OF TREATMENT 
OF JAW FRACTURES. 
Dr. Harvey Cushing,2 M.D., Medical Reserve Corps, U. S. A. 
(Inactive), surgeon-in-chief to the Peter Bent Brigham Flospital, 
Boston, Mass., pays this tribute to the American Ambulance of 
1 The Military Surgeon, xxxviii, 634. 2 Ibid., xxxviii, 605. AMERICAN AMBULANCE HOSPITAL METHODS 
755 
Paris: "A practical example of the value of surgical specialization 
in warfare is afforded by the experience of the American Ambulance 
in Paris, where, owing to the brilliant reparative work on patients 
with fractured jaws, inaugurated by Dr. Hayes and his colleagues, 
of all inmates some 20 per cent, were victims of wounds of this 
type. A general surgeon can set a broken jaw, but as a rule just 
badly enough so that the teeth are not in exact alignment, and a 
soldier who cannot masticate coarse food is about as ineffective as 
one who has crippled feet. If Napoleon's army marched on its belly, 
Joffre's holds on with its teeth, and only experts can make 50 per 
cent, of lacerated faces and jaws capable again of army crusts." 
Dr. Benjamin Jablons,1 pathologist of the American Ambulance 
of Paris, gives the following summary: The cases treated may be 
divided into two general classes. First, gunshot injuries; a large 
majority of which have involved compound and multiple fractures, 
and, second, gunshot wounds of the face involving the maxillae, 
and requiring the intervention of dental surgery. This latter class 
has greatly increased in number, owing to the unique facilities of 
the American ambulance for their treatment. The number of 
patients received during the year ending August 31 has been 2622, 
of whom 1968 have been discharged, cured, or improved; 117 have 
died and 536 remained under treatment. The death-rate has been 
4.46 per cent. 
Dr. Francis Wilson, of the American Ambulance Hospital in 
Paris, with his associates Drs. Hayes and W. Davenport and others, 
during three years of faithful service, took personal charge of an 
enormous number of cases of fractures of the jaws. The restora- 
tion work accomplished by these men and other Americans scat- 
tered throughout the hospitals of Europe will long continue to be 
a matter of national as well as professional pride. Dr. Wilson 
writes: "As Neuilly was more a front line, we were often obliged 
to evacuate our wounded before they were cured. For example, in 
September, 1915, I had 52 cases of fracture of the maxillae enter 
the hospital in one afternoon; of these I saw only 2 completely 
cured-all the others were sent to hospitals away from the war 
zone some ten days later. Among these 52 cases were some of the 
worst that have ever come under my observation. In fact, it would 
be difficult to imagine how many of these could have been worse. 
One poor fellow had the entire face below the eyes blown off, noth- 
ing remaining of the inferior maxilla. Among the simpler cases a 
1 New York Med. Jour., civ, 552. 756 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
great many multiple fractures, particularly of the lower jaw, some 
fractured in five, six, seven, or eight places. My work was to wire 
these together so the man could eat soft food besides being more 
comfortable. The mouths were washed' out with a mild antiseptic 
or normal salt solution as many as six or eight times a day. When 
the inflammation subsided sufficiently, we took impressions, 
extracted useless roots and made cast splints which were cemented 
to place. I might mention that very often portions of the inferior 
maxilla would be found missing ranging in size from slight splints 
to even half or all of the jaw. We find with a good interdental 
splint that nature furnishes bone substance in many of the cases. 
A case in mind brought in February, 1916, was wounded in the 
lower maxilla in the region of the right canine by a splinter of shell. 
The lower right lateral and central incisors were carried away 
together with a portion of maxilla the same width as the combined 
width of the teeth above mentioned. I put on a splint allowing 
for the space between cuspid and left central and from three weeks 
to a month after he had an osseous union of the two portions. 
Figs. 514 to 521, pages 766 to 769, show interesting results of the 
wonderful work done at this hospital. 
OPERATION IN INFECTED FRACTURES. 
Joseph Rilus Eastman, M.D., F.A.C.S., Indianapolis, Indiana, 
formerly chief surgeon, Reserve Hospital No. 8, Vienna, Austria, 
has written especially for this chapter these conclusions from his 
war experiences: 
It need hardly be said that infected gunshot fractures do not 
tolerate open operative interference. Practically all gunshot 
fractures are infected, therefore the field of operative surgery in 
war fractures is relatively small. 
In the case of gunshot fracture of the lower jaw, the experience 
of this war has proved that primary bone suture or wiring is to no 
good purpose. It has been shown in these cases that primary bone 
suture is rarely effective, that primary healing never occurs, and 
that suppuration and sequestrum formation always follow. In 
other words, the primary bone suture in jaw fractures does only 
harm and no good. 
The experience of the present war has demonstrated that for 
weeks after apparently complete healing of gunshot fracture wounds, 
the infection lurks in bone and soft tissues about the site of fracture, 
making any open operative procedure a dangerous undertaking. OPERATION IN INFECTED FRACTURES 
757 
Fractures plated two months after the disappearance of every dis- 
coverable vestige of infection or inflammation have reacted with 
what bore every evidence of a recrudescence of the old infection. 
The arrays in these cases revealed no signs of inflammation and 
none were found during the operation itself. 
A gunshot fracture healed but harboring a dormant infection, 
could hardly be subjected justly to operation, especially a plastic 
operation, except upon the erroneous assumption that the infection 
had entirely disappeared. As it is almost impossible to learn before 
Fig. 506.-Diagram of a fractured lower jaw illustrating the inlay bone graft in 
place imbedded in the gutter cut in both fragments by the twin motor saws. The 
graft has been procured from the antero-internal surface of the tibia cut by the twin 
motor saws adjusted at the same distance apart as when cutting the gutter in the 
jaw fragments. Note the drill holes and that the graft is fixed in place by kangaroo 
sutures. (Albee.) 
or even during operation of the presence of infection in healed cases 
and in so much as the infection often persists for months with no 
manifestations whatever, it follows that open operation in healed 
gunshot fractures should not be undertaken without due sense of 
the dangers of lurking infection. The manipulation required to 
complete a bone plastic operation without much doubt stirred up 
latent infections in several of our cases. Fortunately, frequent 
continuous irrigation with Dakin's solution permitted good approxi- 
mation of the fragments and sufficed to control the infection, which 758 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
was from the beginning of its flare-up in an attentuated form, the 
discharge being made up largely of lymph and containing relatively 
few pyogenic bacteria and pus cells. Such experiences teach a 
lesson which although in a sense generally understood, is perhaps 
not sufficiently appreciated, i. e., that open operation in gunshot 
fractures with deformity is not indicated before two months at 
the very least have elapsed after the disappearance of every sign 
of infection. Then the operation should take the simplest form 
possible under the circumstances, which means simple osteotomy 
with splinting in a large percentage of cases. 
In completely healed infection-free gunshot fractures, the auto- 
genous bone graft represents the ideal method of holding fragments 
in alignments and coaptation. If an autogenous graft cannot be 
obtained the bones of a dog or those of a calf may of course be 
Fig. 507.-Diagram showing a cross-section of the inlay bone graft implanted 
for a fracture of the lower jaw and showing the method of securing the graft in posi- 
tion by the kangaroo-tendon suture passed through the drill holes and over the graft 
holding it securely in position. (Albee.) 
utilized, but far greater safety and greater convenience consist in 
using bone pencils cut from the edge of the tibia or from some other 
bone easily accessible. Judging from a limited experience in the 
use of autogenous grafts for the retention of fragments in good posi- 
tion it has appeared that such grafts cause less irritation and have 
less tendency to provoke recurrence of infection than do plates or 
other metal devices. 
Whether the transplanted bone heals in as a foreign body and later 
disappears by resorption, as held by Ollier, Gebhardt, and Ullmann, 
or whether a part continues to live as stated by Marchand and 
Axhausen, is an old question of no great importance in this connec- 
tion. The important clinical fact for us is that if laid in correctly 
the graft unites in some manner with the surrounding bone and OPERATION IN INFECTED FRACTURES 
759 
serves as a support. As advised by Shaffer no more bone should be 
transplanted than is absolutely necessary, and care of course should 
be taken that the osteoblastic periosteum is intact along one side 
or margin of the peg or intramedullary graft. Moreover, the grafts 
should be so cut as to contain as little compact bone as possible for 
the generally admitted reason that compact bone after transplanta- 
tion requires a longer time for resorption than does spongy bone, 
the porosity of which allows the ingrowth of vascular connective 
Fig. 508.-Diagram of a fractured lower jaw so badly shattered as to leave a gap 
where a proper position of the remaining fragments is maintained. This gap can be 
satisfactorily spanned and the fragments securely united through the inlay method 
with a graft and gutter produced by the twin motor saws adjusted at the same dis- 
tance apart, producing an accurate fit of the graft which is held in position by kan- 
garoo-tendon sutures passed through drill holes in jaw fragments. This is a frequent 
condition in the present war, resulting from the trench warfare. (Albee.) 
tissue and lime-bearing osseous trabeculae. Care should also be 
taken that no blood or devitalized tissue is interposed between the 
intramedullary pencil and the endostium of the fragments, since 
the resorption of such foreign matter must of course precede the 
ingrowth of vascular connective tissue into the graft. 
It is probable that in our cases the intramedullary pencil serves 
merely as a support. The dowel graft, however, if inlaid so that the 
periosteum of the graft lies in contact with the periosteum of the 760 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
fracture fragment and with the other bone layers in normal relation 
actually grows into the surrounding bone. In the case of the intra- 
medullary pencil it is practically impossible to bring the periosteum 
of the graft into contact with that of the fracture fragment. How- 
ever, as above stated, the matter of chief importance is that the 
autogenous intramedullary splint provides good support during 
the process of union of the fragments, and this it seems to do much 
better than a dowel graft insofar as our cases were able to illus- 
trate. Though the dowel graft with proper apposition of histological 
layers grows in, and the intramedullary autogenous bone splint 
remains in most instances as a foreign body, nevertheless, in 
fractures with obstinate tendency to angulation, the bone peg 
in the medulla gives the best possible support, the thing most 
desired. 
In view of the danger of arousing latent infections in healed gun- 
shot fractures with shortening, Finsterer, of Vienna, has advised 
that all open operations made during the first year after healing of 
the wound should be made at the site of the fracture but remote 
from it. 
In treating infected wounds the following resources are employed 
in the American Hospital in Vienna: 
1. Removal of infected bits of clothing or other infected foreign 
matter. 
2. Wide incision and drainage. 
3. Immobilization. 
4. Continuous irrigation by the drop method with Dakin's solu- 
tion of sodium hypochlorite, or continuous immersion in hot anti- 
septic solutions, as acetate of aluminum. 
5. Stimulation of lymph drainage with Wright's solution of sodium 
citrate 1 part, sodium chloride 4 parts, and water 95 parts. 
6. Regular and prolonged daily exposure to the rays of the sun. 
7. Continuous exposure of all wounds to the air without dressings 
whenever possible to avoid foreign-body reaction. 
We have not made use of Clumsky's solution of camphor and 
phenol. 
Small superficial slightly infected tangential wounds are rinsed 
with normal salt solution or hydrogen peroxide and covered with 
Peru balsam, or Mickulicz's salve. 
Of these agents those which have proved of greatest value are: 
(a) Solar therapy. 
(6) Open treatment without dressings to promote drying and to 
prevent foreign-body reaction. WOUNDS AND FRACTURES OF FACE AND JAWS 
761 
(c) Continuous irrigation with sodium hypochlorite solution, 
composed of dry sodium carbonate, chlorinated lime, boric acid, 
and tap water. 
Naturally the method of treatment and the agents to be employed 
in each case are determined by the nature of the infection and the 
character of the wound. For our own convenience we have made 
the following simple classification: 
GUNSHOT WOUNDS AND FRACTURES OF FACE AND JAWS.1 
The leading features to remember are the extraordinarily rapid 
union of wounds in this region and the importance of not uniting 
the wound in the soft parts over shattered bone and pieces of 
impacted metal. This is especially likely to occur in the antrum 
and nares. The bone destruction may be terrible. In one young 
soldier I removed the upper jaw, half the lower jaw, the palate, 
part of the ethmoid and the pterygoid plates. The soft parts were 
united over the huge gap, and the resulting deformity was far less 
than might have been expected. It is important to preserve the 
orbital plate of the maxilla, or, if this is impossible, to maintain 
intact the periosteum and suspensory ligament of the eyeball, or 
the latter gets displaced downward. In the "rush" of early cases 
I had to treat some bad fractures of the jaw without any special 
apparatus. I had recourse to the old molded splint of gutta-percha 
and jaw bandage which I had not applied for many years. All 
loose fragments were removed with forceps, and Mr. Acland gave 
his aid for the loose and injured teeth. The results in these cases 
were excellent, and an indication of what can be done with very 
simple measures in very difficult cases. In fractures of the jaw 
extensive comminution is very frequent. I think it well to expose 
the parts by an incision along the inferior border and remove all 
the fragments of shattered bone. This is very important, or after- 
suppuration and obstinate sinuses are sure to persist. Pus is very 
apt to burrow down the neck under the cervical fascia, and I think 
it well to drain through the submaxillary incision. In past days I 
have drilled and wired the bones, but I am not sure the results 
were better than when simply treated by a splint. In these cases, 
however, the aid and skilful appliances of the dental surgeon and 
mechanism are very essential, and molded metal or wire splints 
very advantageous. In all instances the mouth should be constantly 
washed out with an antiseptic lotion. Permanent facial paralysis 
1 A. Marmaduke Shield, M.B., F.R.C.S.: Injuries of War, Lancet, p. 968. 762 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
is often found in wounds of the face, and is very unsightly. When 
the soft parts are extensively blown away the most hideous and 
distressing deformities ensue. What plastic surgery cannot effect 
must be remedied by skin-colored masks. These can often be 
advantageously supported on a spectacle frame. It is fortunate 
that an institution is to be opened where the patient and surgeons 
get the advantage of mechanical skill and appliances, which are 
only to be found among trained and ingenious surgical mechanisms, 
and they alone can cope with such cases as these. 
The following interesting cases are described by Major G. E. 
Meyer, D.D.S., R.A.M.C., Oral Surgeon of the Twenty-third 
General Hospital, British Expeditionary Force, France: 
Sergeant James Brown, Regiment No. 8336, Unit 1, York 
Lancers. Service ten years. Single, aged twenty-seven years. 
Place of Action.-Near Verlines, about 2 p.m., October 1, 1915. 
Injury or Illness.--Compound fracture of lower maxilla. Mandible 
blown away from right lateral to about one-half inch above the 
angle of the jaw and the whole face, including part of the tongue. 
The part missing on face extended from center of chin down to 
lower border of neck, back to ear, and almost up to nose. . 
Immediate Symptoms -Profuse hemorrhage; no pain; first aid by 
stretcher bearers. Tetanus antitoxin administered at first dressing 
station. When patient arrived his face wound was in a horrible 
condition; patient running a temperature of 103°; much gangrenous 
tissue; could smell it a block away. Fig. 509 shows when patient 
entered hospital. 
Treatment and Operation.-Cut away gangrenous tissue and 
dressed with a solution of eusol, diluted two-thirds, and irrigated. 
Pulse being very weak, gr. strychnin was administered hypo- 
dermically every six hours. After ten days' treatment wound began 
to granulate in nicely. Patient had to be fed with tube. Diet: 
eggs, milk, orange-juice, stout, and custard. Wound irrigated every 
four hours with 1 to 10000 solution of potassium permanganate. 
November 1, 1915. Removed piece of necrosed bone one-half 
inch square. For the upper and lower teeth on the left side German 
silver plates were swaged, covered with silver solder and a wire 
soldered to the buccal surface with several loops. On the buccal 
surface of the lower plate a heavy piece of German silver plate was 
Soldered which glided on surface of upper plate when patient closed 
jaw, throwing jaw over to left in its normal position. The first 
plastic operation was performed three months later. The piece of 
the mandible lost was replaced by a graft from the tibia. A small WOUNDS AND FRACTURES OF FACE AND JAWS 
763 
vulcanite splint was made to fit between swaged upper and lower 
plates which were laced together through loops that were made on 
the buccal surfaces, holding the patient's jaw open about one- 
half inch and immovable. 
Private L. P., Regiment No. 2632, Unit 8, Sherwood Foresters. 
Aged twenty years. Service fifteen months. Single. 
Place of Action.-Loos, about 2.15 p.m., October 13, 1915. 
Injury or Illness.-Compound fracture of the lower jaw and 
shrapnel wound in right arm. 
Present Findings.-Lower jaw fractured between the cuspid and 
bicuspid. Four lower central incisors and jaw-bone between cus- 
pids completely shot away. Bullet passed down and made its exit 
two inches below the angle of right jaw on neck, making an opening 
on neck three inches in diameter. 
Fig. 509.-Condition when entering 
hospital. 
Fig. 510.-After six months just 
after bone graft was placed. 
Doctor's Deport.-The patient entered the hospital with a tem- 
perature of 103.5°. The temperature was of the septic types, 
reaching 104° at times and lasting fourteen days. Since the last 
of October he has had a normal temperature. At the time of his 
illness, dulness.with tubular breathing and numerous rales were 
found in left chest over region of lower lobe. The patient coughed 
severely and expectorated a copious mucopurulent secretion. This 
was never blood-tinged. Respirations were rapid. The heart was 
rapid, irregular, and considerably dilated, and pulse was very weak. 
The heart condition improved very slowly and recovery has not 
been complete. It was thought at the time that patient had an 764 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
aspiration lobar pneumonia. The wound was heavily infected, but 
discharged. 
At one point during the battle of Loos the British had captured 
two trenches and were attacking the third, when this young 
private was hit (Fig. 511). He was carrying sixteen bombs at the 
Fig. 511 
Fig. 512 
time. A bullet entered his open mouth and passed through the 
neck, carrying with it that part of the mandible between the cuspids. 
The a;-ray (Fig. 512) shows the splint applied to hold the two 
portions of the mandible in their proper position until a bone 
graft could later be placed between them. Very few of the cases 
coming to us had sufficient teeth properly to place such a splint. WOUNDS AND FRACTURES OF FACE AND JAWS 
765 
This same patient developed septic pneumonia. He entered the 
hospital with a temperature of 103.5° F. Generally such cases die 
before they can be brought to the base hospital. The condition of 
the wounded during a big offensive is terrible. At the battle of 
Loos the dead could not be quickly removed from between the 
firing lines. At night the soldiers would crawl out, drag the 
bodies back to the trenches,, and then throw dirt over them. Thus 
many dead were buried right in front of the trenches. When a 
shrapnel hit such a spot the horrible mess was spread in all direc- 
tions. Can you wonder that shrapnel wounds are so septic? 
Fig. 513.-After four months. 
The treatment in this case was that used successfully in many 
others, and was as follows: German silver pinch bands were placed 
on a number of the lower teeth on either side of the fracture. The 
ends of these pinch bands were allowed to project outward. Then 
the upper and lower teeth were wired together, thus bringing them 
to normal occlusion and reducing the fracture. Next an impres- 
sion was taken of the buccal and labial surfaces of the teeth, together 
with the ends of the pinch bands. This impression was removed, the 
pinch bands were taken from the teeth and properly placed in the 
impression, and an investment was made with the bands in posi- 
tion. After cutting off the projections of the pinch bands a heavy 
German silver wire was soldered to the bands on both the buccal 
and lingual surfaces. The wiring was then removed from the teeth, 
and this splint was cemented in place. 766 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
Fig. 514.-Case of Dr. C. W. Bouchet, Dr. 
C. J. Koenig, and Dr. W. S. Davenport. 
Shrapnel wound with fracture of the maxilla 
involving the septum of the nose and a loss 
of the right half of the upper lip. (Dental 
Cosmos.) 
Fig. 515.-Same case as shown in Fig. 514, 
with prosthetic restoration of teeth and jaw. 
(Dental Cosmos.) 
Fig. 516.-Same case as shown in Figs. 514 
and 515, after plastic operation to restore lip 
and nose. (Dental Cosmos.) 
Fig. 517.-Same case as in Figs. 514, 515 
and 516, showing the final result of both plastic 
and prosthetic restoration. (Dental Cosmos.) WOUNDS AND FRACTURES OF FACE AND JAWS 
767 
Fig. 518.-Case reported by Dr. R. B. 
Greenough, surgeon, and Dr. W. S. Daven- 
port, dentist. Bullet entered the right cheek 
and tore away two bicuspid and the left first 
molar teeth and other teeth, and fractured 
the mandible. The splints are in place. 
(Dental Cosmos.) 
Fig. 519.-Splints used in the case shown in 
Fig. 518. (Dental Cosmos.) 768 
TREATMENT OF WOUNDS UNDER WAR CONDITIONS 
Fig. 520.-Radiographs of case shown in Figs. 518 and 519. A shows the fractured 
jaw; B, a Sherman four-hole metal plate fastened by two screws in the posterior 
fragment, to bridge the defect in the jaw-bone. (Dental Cosmos.) WOUNDS AND FRACTURES OF FACE AND JAWS 
769 
Fig. 521.-Radiographs of the same case illustrated in Figs. 518, 519 and 520. 
B shows the jaw after the removal of the metal plate and the successful union of a 
bone graft taken by Dr. Greenough from the fifth rib slightly anterior to the sternal 
cartilage. SELECTED LIST OE EXAMINATION QUESTIONS. 
(Be particular to know the answers to the questions indicated in italics.) 
ANESTHESIA. 
1. Define anesthesia, page 17 
.2. Define analgesia, page 17 
3. Define hyperesthesia, page 265 
4. Define paresthesia, page 266 
5. Give two principal forms of anesthesia, page 17 
6. Name the agents most commonly used for inducing general anesthesia, 
pages 17, 18 
7. What local anesthetic agents are most frequently employed? pages 
18/19, 20, 21 
•8. How may careless use of local anesthetics in the mouth lead to serious 
results? page 18 
9. Describe the technic of infiltration anesthesia for the roots of the anterior 
teeth, pages 22-24 
10. Describe the injection to block the inferior dental nerve at the lingula 
according to the modified Braun method, pages 24, 25 
11. Give the method of conduction anesthesia for the upper jaw, page 28 
12. How may the sphenopalatine injection be accomplished? page 29 
13. For what purpose are local anesthetic agents sometimes used in combina- 
tion with other anesthetics for surgical operation, page 18 
. 14. Is it advisable to give an injection of morphin and atropin before 
surgical operation, and why? page 35 
15. Describe infiltration anesthesia, page 20 
16. What conditions should govern the choice of a general anesthetic? pages 
20, 30-33 
17. What is the relative safety in administration of chloroform, ether, nitrous 
oxide gas and somnoform? pages 30-33, 36 
18. Describe the desirable conditions for anesthesia for mouth operations, pages 
34, 35, 36 
19. Describe the preparation of a patient for general anesthesia, pages 36-40 
20. Ima general way give the relative values of the preparations most used for 
infiltration and conduction anesthesia, pages 20-29 
HEMORRHAGE. 
1. Define hemorrhage, page 40 
2. Name the recognized forms of hemorrhage, page 40 
3. What are the causes of hemorrhage? page 40 
4. Give classification of the principal forms of hemorrhage, page 40 
5. Define epistaxis, hemoptysis, gastrorrhagia, hemorrhagic infarcts, hema- 
toma, enterorrhagia, metrorrhagia, menorrhagia, ecchymosis, page 40 
6. What is meant by primary hemorrhage, reactionary hemorrhage, and 
secondary hemorrhage? page 40 
7. What are the local symptoms of hemorrhage? page 40 
8. What are the general symptoms of Severe hembfrhag~eTpages 40, 41 
9. Describe fifteen methods of arresting, hemorrhage, page 41 
10. Describe the following terms as applied to. the arrest of hemorrhage: ligation, 
forcipressure, tourniquet, Esmarch's bandage, styptics, constitutional treatment, 
direct' transfusion of blood, intravenous infusion, proctoclysis, hypodermoclysis, 
heat, cold, position, pressure, page 41 SELECTED LIST OF EXAMINATION QUESTIONS 
771 
11.. What preparatory treatment may be employed in preparation to avoid grave 
results from hemorrhage during surgical operation? pages 41, 42 
12. Describe the treatment of grave hemorrhage and give the remedial measures 
in accordance with the indications of the symptoms, pages 42, 43, 55, 56 
13. Is human blood transfusion beneficial in cases of hemophilia? pages 
51, 52, 53 
14. Describe a method of indirect blood transfusion and give the dangers 
to be avoided in the procedure, pages 47-50 
SHOCK. 
1. Define shock, page 55 
2. Enumerate some of the psychic and operative causes of shock in surgical 
conditions, pages 56, 57 
3. Name some of the predisposing and also important direct factors in 
shock, pages 56, 57 
4. Describe the symptoms of shock in a graduated way from simple to grave 
conditions, page 59 
5. Describe coma, page 59 
6. What prophylactic treatment may be given in anticipation of shock to reduce 
its severity? page 59 
7. Give postoperative treatment of surgical cases with reference to shock, pages 
■60, 61, 62 
PATHOLOGICAL DENTITION. 
1. Name and classify the principal causes of pathological dentition, page 63 
2. Give the local and general symptoms of difficult dentition in infants and 
adults, page 65 
3. How may serious general symptoms occur in infant cases during tooth 
eruptions? pages 63, 64 
4. How may malposed or unerupted teeth be diagnosticated? pages 66-70 
5. Describe the principles governing treatment of delayed or difficult eruption 
of teeth in infants and adults, pages 71, 73, 74, 75 
6. Describe the steps in operation for the removal of malposed third molars 
with reference to anesthesia, asepsis, position of patient, control of field of 
operation, and exposure of the embedded tooth crown, pages, 75, 77, 78-81 
7. Describe the symptoms and preliminary treatment of a case of impacted 
third molar tooth and tell what other affections the symptoms may simulate and 
how they may be differentiated in diagnosis, pages 71, 74, 75 
8. What are the chief dangers to be avoided in the surgical removal of impacted 
teeth? pages 75, 76, 77 
WOUNDS. 
1. Define a wound, page 81 
2. Give classification of the different varieties of wounds, page 82 
3. Describe the repair of wounds, page 82 
4. What is meant by the terms immediate union, healing by first intention, 
by second intention, and by granulation surface? page 82 
5. Describe six steps in the treatment of wounds in the order of their impor- 
tance, page 83 
6. Describe the treatment of wound^ of the mouth, with special reference to 
local conditions, pages 85, 86, 87 
7. What essential properties must dressings for wounds of the mouth possess? 
page 84 
8. What has been the influence of the use of antitoxin in preventing tetanus 
in the present war? page 751 
9. What is Dakin's solution? page 752 
10. Give the Carrel method of using Dakin's solution, page 753 772 
SELECTED LIST OF EXAMINATION QUESTIONS 
INFECTIOUS DISEASES. 
1. Define septic intoxication, infection, poisons, toxemia, sapremia, septi- 
cemia, mycosis, pyemia, bacteriemia, auto-intoxication, pyrexia, pages 88, 89, 90 
2. Describe aseptic fever and septic fever, page 91 
3. What are the causes of aseptic wound fever? page 91 
4. Describe the symptoms of aseptic wound fever, page 91 
5. Give the causes, symptoms, and treatment of septic fever, pages 92-97 
6. Differentiate by their symptomatic indications toxemia, true septicemia, 
and pyemia, pages 92, 93 
7. What is the purpose of vaccine therapy? pages 96, 97 
8. What is meant by autogenous vaccine? page 97 
9. Define anaphylaxis, page 97 
10. What foundation is there for the theory of the transmutation of micro- 
organisms? page 158 
11. How may focal infection of oral origin be a factor in the causation of 
remote diseases? page 159 
12. Describe the diagnostication of blind abscesses, and their importance, 
page 162 
TETANUS. 
1. Define tetanus, page 97 
2. Give the etiology of tetanus, page 98 
3. What is the approximate period of incubation in tetanus? page 98 
4. What are the symptoms of tetanus? pages 98, 99 
5. What are the recognized forms of this affection? page 99 
6. Describe the symptoms of acute, chronic, and cephalic tetanus, page 99 
7. What diagnostic indications differentiate tetanus from other spasmodic 
affections? pages 99, 100 
8. Describe the prophylactic treatment that should be given in grave accidental 
injuries if tetanus is apprehended, page 102 
9. What kind of injuries most frequently result in tetanus? page 98 
10. Describe the treatment of tetanus, pages 100-102 
11. What is the primary cause of death in tetanus? page 100 
TUBERCULOSIS. 
1. Define tuberculosis, page 102 
2. What are the portals of entrance of tubercle bacilli into the human body? 
pages 103, 104 
3. What are the principal forms of tuberculosis? page 105 
4. Describe the treatment of tubercular necrosis, page 113 
5. Give the symptoms of tuberculosis, pages 108, 109 
6. Describe the methods of diagnosis in tubercular cases, pages 109-111 
7. Describe Koch's tuberculin test, the cutaneous reaction, ophthalmic 
reaction, pages 109, 110 
8. Describe the basal principles of some of the most important measures for 
the prevention of tuberculosis, pages 111, 112, 113, 116, 117 
1. Define syphilis, page 117 
2. What is meant by the hereditary and acquired forms of this disease? pages 
117, 121 
3. How may syphilis be transmitted by heredity? pages 117, 118 
4. Describe Hutchinson's teeth, page 119 
5. Is extragenital inoculation a frequent cause of syphilis? page 121 
SYPHILIS. SELECTED LIST OF EXAMINATION QUESTIONS 
773 
6. What are the dangers to be apprehended from this cause in dental practice 
and how may they be avoided? page 122 
7. Describe the symptoms of acquired syphilis according to stages, page 123 
8. What is the period of primary incubation and how long does it last? pages 
122, 123 
9. Describe the secondary incubation period and give the approximate time 
of its duration, page 124 
10. Describe the tertiary symptoms and tell how early they might be expected 
to appear, and how long after infection they may be manifested, page 125 
11. Describe chancre, chancroid, mucous patches, gumma, pages 127, 130, 131 
12. Give the cardinal symptoms of the three stages of syphilis, pages 123-126, 
131, 132 
13. Describe the Wassermann test, page 134 
14. Differentiate diagnostically between chancre and chancroid, page 129 
15. Describe the prophylactic treatment of syphilis and tell when it must be 
instituted in order to be effective, page 136 
16. Describe the treatment of chancre and tell why it differs from the treatment 
of chancroid, pages 137, 142 
17. Give in a general way the treatment of secondary and tertiary syphilis, pages 
139-141 
18. Give the prognosis of syphilis, pages 117, 118, 120, 123, 126, 137 
19. What is salvarsan and how is it administered in syphilitic treatment? page 140 
20. May destruction of the maxillary bones occur as with other structures through 
the extension of lesions affecting the soft tissues in the early stages of tertiary syphilis? 
page 133 
21. What general instructions should be given syphilitic patients, especially 
when the disease is first recognized? page 136 
22. How may mercury be administered in the treatment of syphilis? pages 
137-140 
23. What mouth indications would be important in detecting mercurialism? 
pages 130, 140 
ACTINOMYCOSIS. 
1. Define actinomycosis, page 142 
2. Give the etiology of actinomycosis, page 143 
3. Describe the symptoms of actinomycosis of the cervical facial regions, pages 
143, 144 
4. What are the diagnostic indications of actinomycosis? pages 146, 148 
5. Describe the treatment of actinomycosis, pages 147-149 
GLANDERS. 
1. Define glanders, page 149 
2. Define farcy, page 149 
3. Give the etiology of glanders, page 149 
4. Describe the diagnosis of glanders, pages 150, 151 
5. What treatment may be employed in these cases? page 151 
antiIrax. 
1. Define anthrax, page 151 
2. Give etiology of anthrax, page 152 
3. Describe the symptoms and treatment of this infection, pages 152, 153. 
LEPROSY. 
1. Define leprosy, page 155 
2. Describe the tubercular and anesthetic forms of this disease, page 156 774 
SELECTED LIST OF EXAMINATION QUESTIONS 
DISEASES OF THE MUCOUS MEMBRANE OF THE MOUTH. 
1. Define stomatitis, page 168 
2. Describe the etiology, symptoms, and treatment of gingivitis, page 168 
Describe interstitial gingivitis (pyorrhea alveolaris), page 168 
Describe stomatitis simplex, page 172 
Describe aphthous stomatitis (stomatitis aphthosa), page 173 
Describe Bednar's aphthae, page 174 
Describe ulcerative stomatitis, pages 174, 175 
Describe gangrenous stomatitis, pages 176-178 
Describe parasitic or mycotic stomatitis {thrush), pages 178, 179 
Describe foot-and-mouth disease, page 179 
Describe pseudomembranous stomatitis, page 180 
Describe phlegmonous stomatitis, page 180 
Describe tubercular stomatitis, pages 108, 111, 112, 181 
Describe actinomycotic stomatitis, pages 143, 147, 148 
Describe leukemic stomatitis, pages 181, 186 
3. May stomatitis be a symptom of glanders and leprosy? pages 186, 187 
4. Describe the etiology, symptoms, and treatment of Ludwig's angina, 
pages 187, 188 
5. Give the etiology, symptoms and treatment of Vincent's angina, page 190 
6. Have the diphtheroid bacillus and spirillum of Vincent's angina been 
found in gangrenous stomatitis (noma)? page 190 
7. Describe gonorrheal ulcerative stomatitis, pages 190, 191 
8. Define pemphigus, page 191 
9. What forms of pigmentation may affect the mucous membrane of the 
mouth? pages 191-193 
10. Tell some of the reasons why traumatic injuries of the mucous membrane 
of the mouth due to nervous habits may bear an important relation to serious patho- 
logical conditions, page 193 
11. Describe the terms, first, second, and third degree as applied to burns and 
scalds of the mucous membrane of the mouth, page 194 
12. Describe erythema endemicum {pellagra), pages 198, 199 
13. Define urticaria, page 199 
14. Define herpes simplex, page 200 
15. Define lichen planus, page 200 
16. Define purpura, pages 204, 205 
17. Describe eczema labialis, page 204 
18. Give etiology, symptoms, and treatment of scorbutic stomatitis, pages 205, 206 
19. Give etiology, symptoms, and treatment of infantile scorbutis, pages 206-212 
20. Give etiology, symptoms, and treatment of blastomycosis, pages 212-213 
21. Give etiology, symptoms, and treatment of erysipelas, pages 213, 214 
22. Give etiology, symptoms, and treatment of leukoplakia, pages 202-204 
N. B.-{Be particular to know thoroughly the affections indicated in italics.) 
1. Define neuritis, page 216 
2. Give the principal causes of neuritis, page 216 
3. Describe the symptoms of neuritis, page 217 
4. In the treatment of cases of neuritis without direct injury to the affected 
nerves what measures may be employed to give relief? pages 218, 219 
5. Define neuroma, page 219 
6. Name five reasons why diseases of the spinal cord may bear an important 
relation to buccal affections, pages 220, 221 
7. Define syringomyelia, page 221 
8. What are the most notable symptoms of syringomyelia? pages 221, 222 
9. Define acute anterior or infantile paralysis or poliomyelitis, pages 222, 223 
10. Should mouth disinfection be rigidly maintained during treatment in cases 
of infantile paralysis, and why? page 225 
DISEASES OF THE NERVOUS SYSTEM. SELECTED LIST OF EXAMINATION QUESTIONS 
775 
11. Describe chronic anterior poliomyelitis, pages 225, 226 
12. Define amyotrophic lateral sclerosis, page 226 
Define muscular dystrophy, page 228 
Define acute progressive paralysis, page 237 
Define locomotor ataxia, page 238 
Define Friedreich's ataxia, page 238 
Define spinal meningitis, page 241 
13. Describe bulbar paralysis, pages 222, 225, 253 
DISEASES OF THE BRAIN. 
1. What are the chief reasons why cerebral diseases, particularly cerebral 
hemorrhage, cerebral embolism, and cerebral thrombosis, are sometimes of diag- 
nostic importance to the oral surgeon? pages 241, 242 
2. Describe the symptoms of intracranial pressure, page 242 
3. Define encephalitis and tell why its symptoms sometimes affect the buccal 
region, pages 244, 245 
4. Why may oral hygiene be an influential factor in the prevention of meningitis? 
page 245 
5. Give the cardinal symptoms of meningitis, page 246 
6. In what way may brain abscess have an important diagnostic as well as 
etiological relation to diseases of the mouth and jaws? page 248 
7. Explain why it is necessary to distinguish symptoms appearing in the 
head and face in brain tumor from those which may be indications of less 
serious affections in order that early diagnosis may be facilitated, page 250 
8. Give the general symptoms of brain tumor, page 250 
9. What are the symptoms of bulbar palsy? page 253 
10. May oral diseases be a factor in causing anosmia or loss of smell, and how? 
page 255 
11. Why should examination of the eye for choked disk be considered in diag- 
nosis of nerve disturbances in the regions of the face and jaws? page 256 
12. Paralysis of what nerve causes patheticus paralysis? page 258 
13. Through the affection of what nerve is abducens paralysis caused? page 258 
1. Describe the effect of paralysis of the motor division of the fifth nerve, page 
262 
2. How may tinnitus aurium result from this cause? pages 262, 338 
3. Describe hemiatrophy of the face, pages 263, 264 
4. Name some of the dental and oral causes of spasmodic conditions of 
the muscles of mastication, pages 264, 265 
5. Is herpes zoster sometimes associated with affections of the fifth nerve, 
and how is this evidenced? page 265 
6. How may anesthesia, hyperesthesia, and paresthesia be caused by affec- 
tions of the trigeminal nerve? pages 265-267 
7. Define pain, headache, migraine, neuralgia, and tic douloureux, pages 
268-271 
8. Give classification of the clinical types of neuralgia, page 271 
9. Give four general divisions of the causes of neuralgia, pages 271, 272 
10. Enumerate some of the important considerations in the diagnosis of tri- 
geminal neuralgia, page 275 
11. What are the distinguishing symptoms of tic douloureux? page 276 
12. Describe the non-surgical treatment of trigeminal neuralgia, pages 280-291 
13. Describe the method of deep alcoholic injection of the superior maxillary 
division of the fifth nerve at the foramen rotundum, pages 283-287 
14. Describe the method of deep alcoholic injection of the inferior maxillary 
division of the fifth nerve at the foramen ovale, pages 283-287 
15. Describe the method of the alcoholic injection of the Gasserian ganglion, 
pages 287-289 
AFFECTIONS OF THE FIFTH NERVE. 776 
SELECTED LIST OF EXAMINATION QUESTIONS 
16. What dangers are to be avoided in deep alcoholic injection of the fifth 
nerve? pages 283-287 
17. What is the danger, and what complications may follow the alcoholic 
injection of the Gasserian ganglion? pages 289-290 
18. What benefit may be expected from alcoholic injections in tic douloureux? 
pages 290-291 
19. Describe neurotomy, neurectomy, nerve extraction, and nerve stretch- 
ing in relation to neuralgia of the fifth nerve, page 291 
20. Under what conditions should the removal of the Gasserian ganglion be 
advised? page 303 
21. Describe the most important forms of dental irritation that may cause neu- 
ralgia, pages 316-322 
AFFECTIONS OF THE SEVENTH OR FACIAL NERVE. 
1. What are the symptoms of facial paralysis? pages 331, 332 
2. Name some of the causes of facial paralysis, pages 331, 332 
3. Give the diagnostic indications of central or peripheral nerve disturbances 
in facial paralysis, page 333 
AFFECTIONS OF THE EIGHTH NERVE. 
1. Describe tinnitus aurium, page 338 
2. Can tinnitus aurium be caused by mouth affections? page 338 
AFFECTIONS OF THE NINTH AND TENTH NERVES. 
1. What relation have affections of these nerves to palate and mouth conditions? 
page 340 
AFFECTIONS OF THE ELEVENTH NERVE. 
1. Describe the symptoms of paralysis of the spinal accessory nerve, page 340 
2. How may mouth infection be a casual factor in these cases? page 340 
LESIONS OF THE HYPOGLOSSAL NERVE. 
1. Name the prominent symptoms of paralysis of the hypoglossal nerve, pages 
341, 342 
SPASMODIC NEUROSES. 
1. What relation may irritation of the fifth nerve from dental and oral dis- 
orders bear to facial spasm, chorea, and epilepsy? pages 342, 343, 349, 350 
2. Define tonic and clonic spasms, page 342 
NERVOUS DISEASES. 
1. Define hysteria, neurasthenia, angioneurotic edema, and trophic changes, 
and tell how these conditions may be subject to oral influences, pages 354-358 
DISEASES OF BONE. 
1. Define osteogenesis, and describe its relation to osteoclasts, osteoblasts, 
and osseous apposition, page 359 SELECTED LIST OF EXAMINATION QUESTIONS 
777 
2. Define bone atrophy in relation to lacunar absorption, perforating canal 
absorption, osteoporosis, and halisteresis, page 359 
3. Describe local and constitutional forms of halisteresis, page 359 
4. Describe osteomalacia, page 360 
5. How may bone regeneration occur? page 360 
6. Describe pressure atrophy of bone, page 360 
7. Name the general causes of malformation of bone, page 361 
8. Define agenesis and osteogenesis imperfecta, page 361 
9. Describe rickets, acromegaly, facial hemihypertrophy, leontiasis ossea, 
osteitis deformans, pages 361, 362, 364, 365 
DISEASES OF THE PERIOSTEUM. 
1. Give the principal causes of hemorrhage under the periosteum, page 366 
2. Describe simple, purulent, and osteoperiostitis, pages 366, 367 
3. Describe the symptoms of circumscribed and diffuse purulent periostitis, 
page 367 
4. Give the treatment of periostitis in its various forms, pages 367 
INFLAMMATION OF BONE. 
1. Name two recognized forms of inflammation of bone, page 368 
2. Define and give etiology, pathology, symptoms, and treatment of necrosis 
and caries, pages 368, 369-374, 377-382 
3. Enumerate the principal causes of necrosis of the jaws, page 370 
4. What is a sequestrum? page 378 
5. Describe the treatment of necrosis with special reference to the removal of a 
sequestrum, as distinguished from the so-called carious conditions, pages 381, 382 
6. How may necrosis, resulting from the effects of mercury, arsenic, phos- 
phoris, or other mineral poisons, syphilis, tuberculosis, exanthematous diseases, 
actinomycosis, glanders, and leprosy be diagnosticated? pages 374-379 
FRACTURES OF THE JAWS. 
1. Define the term fracture, as applied to bones, page 382 
2. Name the varieties of bone fractures, pages 382, 383 
3. Which jaw is most subject to fracture? page 384 
4. Give the diagnostic indications of fracture, page 384 
5. Describe the methods of retaining fractures of the maxilice that are most 
commonly employed, pages 389, 390 
6. Tell what important principal must govern the selection of a method of 
retention in the treatment of fractures of the jaws and give these as nearly as possible 
in the order of their importance, page 389 
7. Describe the repair of fractured bones, page 403 
8. What conditions may modify the time required for complete union? page 
404 
9. What complications are most frequently found in fractures of the maxilloe? 
pages 404, 405 
AFFECTIONS OF THE TEMPOROMANDIBULAR ARTICULATION. 
1. How may alterations of form of the mandible and in the region of the glenoid 
cavity become disturbing factors? pages 406, 407 
2. Define dislocation or luxation of a joint, page 407 
3. Give classification of dislocations of the mandible, page 407 
4. Describe the diagnostic symptoms in the following mandibular disloca- 
tions: unilateral, bilateral, compound, backward, pages 409, 410 
5. Describe the reduction of a complete bilateral dislocation of the lower jaw? 
pages 410, 411 778 
SELECTED LIST OF EXAMINATION QUESTIONS 
DISEASES OF THE JOINTS. 
1. Define the terms synovitis, arthritis, and ankylosis, pages 412, 413 
2. Name the forms of ankylosis of the lower jaw, page 413 
3. Give the principal causes of ankylosis, page 414 
4. What conditions would govern the treatment to be advised in cases of tem- 
porary, fibrous, and bony ankylosis? pages 415-417 
5. Give prognosis in the foregoing cases, pages 415, 417, 423 
6. Describe the Murphy operation for ankylosis of the temporomandibular 
articulation, pages 425-428 
7. Define arthrodesis, page 432 
1. For what purposes would resection of the jaws be recommended? pages 446- 
450 
2. Give classification of the forms of resections of the jaws, page 433 
3. What principles must be borne in mind in undertaking resection of 
the jaws? pages 434-437, 441-444 
RESECTIONS OF THE JAWS 
DISEASES OF THE SALIVARY GLANDS. 
1. Tell something of the purposes and diagnostic possibilities of the study 
of saliva as undertaken by Michaels and Kirk, page 458 
2. Describe the diagnostic indications of anomalies and injuries of the 
salivary glands, and foreign bodies in the salivary glands, page 458 
3. Describe the symptoms and treatment of salivary fistula, page 460 
4. Define sialolithiasis, sialodochitis, pages 463, 464 
5. How may stones in the salivary glands or their ducts be diagnosticated? 
page 464 
6. Give etiology, symptoms, and treatment of mumps, pages 466, 467 
7. What danger is to be apprehended from metastatic extensions in mumps? 
page 466 
8. Define aptyalism, page 470 
9. Give the symptoms and most common causes of ptyalism, pages 469, 470 
10. What are the symptoms of Mikulicz's disease? pages 471, 473 
DISEASES OF THE LYMPH GLANDS. 
1. Describe the symptoms of adenoids and of enlarged tonsils, page 475 
2. Describe suprahyoid median phlegmon, page 480 
3. Define lymphadenitis, page 480 
4. Give the symptoms of Hodgkin's disease, page 484 
TUMORS. 
1. Define a neoplasm, page 486 
2. Describe the distinguishing characteristics of benign and malignant tumors, 
page 489 
3. Define a cyst, page 490 
4. Give classification of cysts, including seven varieties, page 490 
5. Define the term ranula, page 492 
6. Give the etiology, symptoms, and treatment of ranula, pages 492, 493 
7. Describe periosteal cysts of the jaws, proliferation cysts, multilocular cysts, 
dermoid cysts, parasitic cysts, odontoma, epithelial odontoma, follicular odontoma 
{or dentigerous cyst), fibrous odontoma, cementome, radicular odontoma, composite 
odontoma, compound follicular odontoma, myxoma, papilloma, adenoma, neuroma, 
glioma, lipoma, chondroma, osteoma, fibroma, myoma, angioma, lymphangioma, 
lymphoma, epulis, pages 495-527, 528 SELECTED LIST OF EXAMINATION QUESTIONS 
779 
8. Name six varieties of sarcoma, page 527 
9. Define epulis, page 528 
10. Give treatment and prognosis in cases of giant-celled sarcoma, pages 530-533 
11. Give prognosis in cases of carcinoma and sarcoma under usual conditions, 
pages 530, 543 
12. Why is it important to treat cases in the precancerous stage? pages 543, 544 
DISEASES OF THE MAXILLARY SINUS. 
1. What relation does the development of the superior maxillary bone 
bear to nasal diseases? pages 558, 620, 621 
2. Describe the nasal accessory sinuses, pages 559, 560 
3. How may irregularities of the upper dental arch be an important factor 
in causing disease of the maxillary and other nasal accessory sinuses through 
pathological nasal conditions? page 560 
4. Give classifications of the diseases of the maxillary sinus, page 561 
5. Describe some of the most important predisposing and exciting causes 
of maxillary sinus disease, page 561 
6. What oral factors may lead to empyema of the maxillary sinus? page 563 
7. Describe the symptoms of empyema of the maxillary sinus, page 569 
8. What diagnostic indications are useful in examination to determine the 
existence of diseased conditions of the maxillary sinus, and which may be relied 
upon? pages 570-575 
9. In the surgical treatment of the maxillary sinus, what five methods may 
be used? pages 575, 576 
10. Tell the differences between the Kuster, Caldwell-Luc, Canfield-Ballenger, 
and Denker maxillary sinus operations, pages 579-591 
11. Describe in detail a radical operation for the cure of chronic empyema 
of the maxillary sinus, according to the Kuster operation, pages 579-584 
1. Describe glossitis, page 599 
2. Describe the indication of disease that may be noted on the surface 
of the tongue, page 601 
3. Describe aglossia, lobulated tongue, microglossia, macroglossia, long 
tongue, tongue-tie, adherent tongue, pages 612-615 
DISEASES OF THE TONGUE. 
HARELIP AND CLEFT PALATE 
1. What important general division is made in the classification of cleft palates? 
page 650 
2. What is meant by congenital and acquired cleft palate? page 650 
3. Name some of the etiological factors that may be important in leading to 
congenital harelip and cleft palate, pages 650-655 
4. Describe the most common forms of harelip and cleft palate, pages 650, 651 
5. Describe the early preparatory treatment of an infant born with harelip, 
pages 656, 666 
6. Define cheiloplasty, staphylorrhaphy, uranorrhaphy, uranoplasty, urano- 
staphylorrhaphy, pages 666, 661, 698 
7. Describe the distinctive principles of five different types of surgical opera- 
tive methods in treatment of cleft palate, pages 699, 700, 701 
8. What are the objectionable features to each operation? pages 703, 704, 705, 706 
9. Describe the modified von Langenbeck operation for cleft palate, pages 
717-724 
10. What conditions govern the speech results after surgical closure of cleft 
palate? pages 724-729 
11. Describe in detail the ill results that follow closure of cleft palate in early 
infancy by compression to force the sides of the fissure into contact and passing 
wires through the upper maxillce to hold them in this position, pages 703, 704, 705, 
727, 728 INPEX. 
A 
Abducens paralysis, 258, 260 
Abscess of brain, 248, 249 
Abscesses, dento-alveolar, 162 
diagnosis of, 162 
etiology of, 162 
exsection of roots of teeth in, 
163 
treatment of, 163 
Acapnia, 62 
Accessory nerve, spinal, lesions of, 340 
sinuses, nasal, 558, 565 
pneumococcus infection 
of, 568 
thyroid tumors, 512 
Acinous adenoma, 510 
Acquired syphilis, 121 
Acromegaly, 362-364 
Actinic rays in treatment of carcinoma, 
545 
Actinomycosis, 142 
agglutination test for, 147 
of bone, 375 
diagnosis of, 146 
etiology of, 143 
of mucous membranes of mouth, 
181 
pain in, 144 
pathology of, 143 
prognosis of, 147 
of salivary glands, 473 
symptoms of, 143 
of tongue, 605 
treatment of, 147 
sulphate of copper in, 147 
trismus in, 146 
Acupressure in hemorrhage, 41 
Adenia, simple, 482 
Adenoid cancer, 524 
vegetations. See Adenoids. 
Adenoids, 474 
etiology of, 474 
exanthematous fever and, 474 
pharyngeal, 474 
symptoms of, 475 
treatment of, 475 
Adenoma, 510 
acinous, 510 
classification of, 510 
differential diagnosis of, 512 
Adenoma, etiology of, 511 
malignant, 534 
symptoms of, 511 
of tongue, 608 
treatment of, 513 
tubular, 510 
Adherent tongue, 615 
Adrenalin in hemorrhage, 43 
Agenesis, 361 
Agglutination test for actinomycosis, 
146 
for glanders, 150 
Aglossia, 612 
Alcohol, injection of, in trigeminal 
neuralgia, 282 
technic of, 282 
Alveolar abscess, disease of maxillary 
sinus and, 564 
fractures of jaws, 382 
operation for disease of maxillary 
sinus-, 575 
sarcoma, 527 
Amputation neuromas, 515 
Amyelinic neuromas, 514 
Amyotrophic lateral sclerosis, 226 
Analgesia, 17 
in syringomyelia, 221 
Anemia of optic nerve, 256 
Anesthesia, 17 
conductive, 20 
desirable conditions for, 33 
Gwathmey apparatus in, 34 
hyoscin-morphin and, 35 
infiltration, 20 
intravenous, 19 
morphin and atropin before, 35 
in operation for cleft palate, 708 
rectal, 19 
scopolamin-morphin and, 35 
of trigeminal nerve, 267 
Anesthetics, 17 
general, 29 
chloroform, 30 
ether, 30, 32, 34, 37, 38 
ethyl chloride, 30 
nitrous oxide gas and oxygen, 
30 
oxide - oxygen - ether 
sequence, 32 
somnoform, 33 
local, 17-24 782 
INDEX 
Anesthetics, local, apothesin, 19 
cocain, 19 
eucaine, 19 
novocain, 19 
quinine-urea hydrochloride, 19 
Schleich's infiltration, 20 
scopolamin, partial, for aged, 
20 
stovain and novocain, 19 
principal, 17 
for removal of impacted teeth, 77 
Angina, diphtheroid, 188 
Ludwig's, 187 
Vincent's, 188 
Angiomas, 521 
arterial, 522 
capillary, 521 
cavernous, 522 
diagnosis of, 522 
plexiform, 522 
prognosis of, 522 
treatment of, 522 
Angioneurotic edema, 357 
Angiosarcoma, plexiform, 527 
Angle's splint, 396 
Ankyloglossia, 613 
Ankylosis of jaws, 413 
bony, 422 
etiology of, 422 
prognosis of, 423 
symptoms of, 423 
treatment of, 425 
Esmarch's operation, 
432 
Murphy's operation 
in, 425 
postoperative, 432 
fibrous, 416 
diagnosis of, 416 
etiology of, 416 
pathology, 416 
prognosis of, 417 
symptoms of, 416 
treatment of, 417 
postoperative, 419 
temporary, 414 
etiology of, 414 
pathology of, 414 
prognosis of, 415 
symptoms of, 415 
treatment of, 415 
of roots of teeth, trigeminal neu- 
ralgia and, 317 
Anoci-association, 39 
Anosmia, 255 
Anterior poliomyelitis, 222 
chronic, 225 
Anthrax, 151 
diagnosis of, 153 
etiology of, 152 
intestinal, 152 
prognosis of, 153 
symptoms of, 152 
Anthrax, treatment of, 153 
Antiseptics, 751 
Antitoxin, tetanus, 101 
Antrum of Highmore. See Maxillary 
sinus. 
Aphthse, Bednar's, 174 
Aphthous stomatitis, 173 
Apothesin in local anesthesia, 19 
Aptyalism, 470 
Argyria, 192 
Arsenic for syphilis, 140 
Arsenical necrosis of bone, 378 
pathology of, 378 
symptoms of, 378 
treatment of, 378 
Arterial angiomas, 522 
Arthritis, 412 
Arthrodesis, 432 
Aseptic fever, 91 
wound fever, 91 
Astomia, 646 
Ataxia, Friedreich's, 238, 239 
locomotor, 238 
Atrophic paralysis, chronic. See Polio- 
myelitis, anterior, chronic. 
spinal paralysis, acute. See Polio- 
myelitis, anterior. 
Atrophy of bone, 359 
concentric, 359 
eccentric, 359 
pressure, 360 
muscular, in syringomyelia, 222 
of optic nerve, 256 
progressive muscular. See Polio- 
myelitis, anterior, chronic. 
of tongue, 604 
Auditory nerve, lesions of, 337 
"Aura" in tic douloureux, 277 
Autogenous bacterins in septic fever, 97 
B 
Bacillus of tetanus, 97 
of tuberculosis, 102 
Bacteriemia, 90 
Bacterins, autogenous, in septic fever, 
97 
Bandaging for avoidance of shock, 61 
Barlow's disease, 206 
Beck's paste, 585 
Bednar's aphthae, 174 
treatment of, 174 
Bifid tongue, 612 
Bilateral harelip, 650 
parotid tumors, 470 
Blastomycosis cutis, 212 
Blisters, fever, 200 
Blood, transfusion of, in hemorrhage, 
direct, 43 
indirect, 47 
technic of, 49 
Bone, actinomycosis of, 375 INDEX 
783 
Bone, atrophy of, 359 
caries of, 369 
diseases of, 359 
hypertrophy of, 362 
inflammation of, 368 
leprosy of, 375 
malformation of, 361 
necrosis of, 368 
arsenical, 378 
mercurial, 376 
phosphorus, 377 
regeneration of, 360 
syphilis of, 375 
tuberculosis of, 374 
periosteal, 375 
Bbnnecken's artificial jaw, 439 
Brain, abscess of, 248, 249 
diseases of, 241 
nasal disease of, facial paralysis 
and, 330 
tumor of, 250 
complete report of case of, 
250-252 
Brewer's glass cannula for transfusion, 
45 
method of transfusion of blood, 45 
Bridge-work, improper, trigeminal neu- 
ralgia and, 323 
Brophy's method of wiring in opera- 
tion for cleft palate, 699 
Brown's clamp for surgical treatment 
of harelip, 674, 675 
gag for cleft palate, 709, 710 
knife for cleft palate, 719 
method of treatment of ranula, 493 
operation for cleft palate, 706, 708- 
716 
for double harelip, 682, 685 
for harelip, 666-682 
closure of lip fissure in, 
666 
of immediate surgical separa- 
tion of superior maxillary 
bones to widen the nares 
for improvement of respi- 
ratory and other condi- 
tions, 627 
periosteal elevator for cleft palate, 
686, 687, 712 
Bubo, chancroid and, 142 
Bulbar palsy, 253 
Burns and scalds, 194 
Burrie's method of identification of 
Spirocheta pallida, 133 
C 
Calculi, salivary. See Salivary 
stones. 
Caldwell-Luc operation for disease of 
maxillary sinus, 585 
Cancer. See Carcinoma. 
Cancrum oris. See Stomatitis, gan- 
grenous. 
Canfield-Ballenger antrum operation 
for disease of maxillary sinus, 588- 
591 
Cannula, transfusion, Brewer's glass, 45 
Crile's, 44 
Capillary angiomas, 521 
Carbon dioxide content of blood, shock 
and, 62 
Carcinoma, 534 
of cheek, treatment of, 552 
colloid, 536 
diagnosis of, 540 
epithelial, 534 
etiology of, 536 
gelatiniform, 536 
glandular, 536 
of jaw, treatment of, 552 
of lips, treatment of, 547 
location of, 537 
melanotic, 536 
mucoid, 536 
of palate, treatment of, 552 
prognosis of, 543 
in region of maxillary sinus, treat- 
ment of, 552 
symptoms of, 538 
of tongue, 611 
treatment of, 550 
treatment of, 543, 544 
actinic rays in, 545 
burning in, 547 
dried thymus gland in, 544 
drugs in, 545 
enzyme, 544 
extirpation in, 547 
Finsen light in, 545 
liquid air in, 545 
operative, 547 
radium in, 544 
thyroidfextract in,[544 
ultraviolet rays in, 545 
x-rays in, 545, 546 
Caries of bone, treatment of, 380 
of jaw, 368 
Carious teeth/trigeminal neuralgia and, 
322 
Carotid, external, ligation of, in hem- 
orrhage from wounds of mouth, 86 
Carrel's sodium hypochlorite solution, 
Castor oil in treatment of trigeminal 
neuralgia, 281 
Catarrh of mucous membrane of 
mouth, 172 
Catarrhal maxillary sinuitis, acute, 560 
chronic, 560 
Cavernous angiomas, 522 
hemangioma of tongue, 610 
lymphangioma of tongue, 611 
Cellulitis,^ diffuse submaxillary. See 
Ludwig's angina. 784 
INDEX 
Cementome, 502 
Cephalic tetanus, 99 
Cephalitis, 244 
Cerebral axis, diseases of, 253 
diseases, 241 
embolism, 241 
hemorrhage, 241 
meningitis, 245 
spastic paralysis, 242 
thrombosis, 241 
Cerebrospinal meningitis, epidemic, 
245 
Chancre, 127 » 
hard, 127 
Hunterian, 127 
indurated, 127 
of lip, 128 
soft. See Chancroid. 
of tongue, 128 
Chancroid, 141 
bubo and, 142 
diagnosis of, 142 
etiology of, 141 
mixed sore and, 142 
prognosis of, 142 
symptoms of, 141 
treatment of, 142 
Cheiloplasty. See Harelip, treatment 
of, surgical. 
Chin, receding operation for, 450 
Chondroid, 516 
exostosis, 516 
Chondromas, 516 
etiology of, 516 
prognosis of, 516 
symptoms of, 516 
treatment of, 517 
Chondrosarcoma, 527 
Chloroform in general anesthesia, 30 
"Choked disk," 256 
Chorea, 343 
etiology of, 343 
prognosis of, 344 
symptoms of, 344 
treatment of, 344 
Circumscribed glossitis, 599 
Clamp, Brown's, for surgical treatment 
of harelip, 674, 675 
Cleft palate, 650. See also Harelip. 
Friedreich's ataxia and, 238 
harelip without, treatment of 
686. 
operation for, 698 
access to field of, 709 
aluminum plates in, 706 
anesthesia in, 708 
Brophy's method of 
wiring in, 699 
Brown's, 706, 708-716 
changes in form after, 721 
choice of, 706 
compression in, 699, 703 
disadvantages of, 703 
Cleft palate, operation for, Davies- 
Colley, 701 
essentials of, 707 
Ferguson's method in, 700 
flaps in, anterior ends of, 
detachment of, 701' 
inversion of, disad- 
vantages of, 704 
mucoperiosteal, 701 
turning over of, 700 
fracture of palate bones 
in, 700 
gag for, author's, 709, 
710 
incision in, for relief of 
tension, 712 
knife for, author's, 719 
Lane's method in, 700 
methods of retention in, 
705 > 
muscular alignment in, 
722 
needles for, 718, 719, 720 
periosteal elevator for, 
author's, 686, 687, 712 
position of patient for, 
707 
preservation of blood 
supply in, 710 
retention appliances in, 
702 
sutures in, 702 
rubber plates in, 706 
separation of mucoperi- 
osteum in, 717 
speech results after, 724 
. phonographic records 
of, 730-733 
sutures for, 714 
retention, 714, 715 
transplantation of tissue 
in, 705 
types of, 699 
speech defects and, conditions 
governing, 726 
correction of deformity 
of dental arch, 
and, 729 
operative, 730 
due to early operations, 
727 
to flexibility of 
tissues, 728 
to insufficient vel- 
um, 728 
to nasal maldevel- 
opment, 728 
to postoperative 
imperfection,727 
to shortening of 
hard palate, 728 
etiological factors, in- 
fluence of, 726 INDEX 
785 
Cleft palate, speech defects and, im- 
provement of, 729 
reconstruction of de- 
formed lips and, 729 
treatment of, surgical, 698 
wide, reduction of, by maxil- 
lary operation, 706 
Cocain in local anesthesia, 18 
Cold abscess, 375 
in hemorrhage, 42 
shock and, 56 
Colles' law in hereditary syphilis, 118 
Colloid carcinoma, 536 
Coloboma of face, 648 
Columnar-cell epithelioma, 534 
Complicated wounds, 82 
Compression in operation for cleft 
palate, 699, 703 
Conductive anesthesia, 20 
Congenital cystic hygroma, 523 
Connective-tissue tumors, adult, 515 
Contracted nares, treatment of, 621 
Convulsions, 342 
eruption of teeth and, 342 
etiology of, 342 
pathological dentition and, 343 
Copper, sulphate of, in treatment of 
actinomycosis, 147 
Coryza, acute, disease of maxillary 
sinus and, 561 
Coxalgia, 375 
Cranial nerve, diseases of, 254 
eighth. See Auditory nerve, 
eleventh. See Spinal acces- 
sory nerve. 
fifth. See Trigeminal nerve, 
first. See Olfactory nerve, 
fourth, lesions of, 258 
ninth. See Glossopharyngeal 
nerve. 
second. See Optic nerve, 
seventh. See Facial nerve, 
sixth, lesions of, 258 
tenth. See Vagus nerve, 
third, lesions of, 258 
twelfth. See Hypoglossal 
nerve. 
Crile's method of transfusion of blood, 
43, 44 
transfusion cannula, 44 
Cryptogenetic septic fever, 92 
Cushing's operation for removal of Gas- 
serian ganglion, 303, 304, 305 
Cutaneous horns, 508 
test, von Pirquet's, for tuber- 
culosis, 110 
Cylindric-cell epithelioma, 534 
Cystic hygroma, congenital, 523 
Cysticercus cysts of tongue, 606 
Cystocele of maxillary sinus, 597 
Cystomas, 490 
classification of, 490 
Cysts of base of tongue, 607 
Cysts, dentigerous, 502 
dermoid, 499 
echinococcus, 501 
of glands of Blandin-Nuhn, 492 
of maxillary sinus, 560, 597 
of mucous glands, 491 
multilocular, 498 
parasitic, 501 
periosteal, 495 
proliferation, 498 
retention, 491 
of salivary glands, 473 
sublingual, 492 
thyroglossal, 607 
of tongue, 605 
D 
Dactylitis, hereditary syphilis and, 
120 
Dakin's solution, 752 
Davies-Colley's operation for cleft 
palate, 701 
Denker operation for disease of maxil- 
lary sinus, 587 
Dental arch, deformed, correction of, 
improvement of defects of 
speech after, 729 
irregularity of, surgical treat- 
ment of harelip and, 664 
aspects of trigeminal neuralgia, 314 
cysts, maxillary sinus and, 597 
factors of trigeminal neuralgia, 
316-329 
origin of disease of maxillary sinus, 
563, 564 
pulp, diseases of, 317 
trigeminal neuralgia and, 
,318 
Dentigerous cysts, 502 
maxillary sinus and, 597 
symptoms of, 502 
Dentition, pathological, 63 
convulsions and, 343 
diagnosis of, 66 
in adults, 67 
differential, 71 
in infants, 66 
etiology of, 63 
extraction of teeth in, 75 
preservation of teeth in, 75 
symptoms of, 64 
general, 65, 66 | 
local, 64, 65 
treatment of, 71 
in adults, 73 
in infants, 71 
. palliative, 75 
Dento-alveolar abscesses, 162 
diagnosis of, 162 
etiology of, 162 
exsection of roots of teeth in, 
163 786 
INDEX 
Dento-alveolar abscesses, treatment of, 
163 
Dermoid cysts, 499, 500 
prognosis of, 501 
symptoms of, 499 
of tongue, 606 
Development, imperfect, defects of 
speech due to, 734 
Diffuse suppuration of floor of mouth. 
See Ludwig's angina. 
Diphtheroid angina, 188 
etiology of, 190 
treatment of, 190 
Direct transfusion of blood in hemor- 
rhage, 43 
Disarticulation of jaw, 441 
Disk, choked, 256 
Dislocations of jaws, 407 
bilateral, 408 
chronic, 411 
etiology of, 412 
treatment of, 412 
classification of, 407 
complicated, 408 
compound, 408 
diagnosis of, 410 
etiology of, 408 
forward, 408 
incomplete, 408 
pathology of, 409 
simple, 408 
symptoms of, 409 
treatment of, 409 
unilateral, 408 
Double harelip, 650 
treatment of, 680 
Dry mouth, 470 
Duchenne type of muscular dystro- 
phies, 229 
Duct, salivary, fistula of, 460 
injuries of, 459 
Steno's 459 
Wharton's, 458 
Dystrophies, muscular, 228 
analysis of cases of, 231-237 
Duchenne type, 229 
Erb type, 229 
etiology of, 228 
Landouzy-Dejerine type, 229 
prognosis of, 229 
symptoms of, 229 
"tapir mouth" in, 229 
treatment of, 229 
syphilitic, 126 
E 
Echinococcus cysts, 501 
of tongue, 606 
Eczema, 204 
labialis, 204 
Edema, angioneurotic, 357 
Edema of optic nerve, 256 
Eighth cranial nerve. See Auditory 
nerve. 
Elephantiasis congenita mollis, 523 
grecorum. See Leprosy. 
Elevator, periosteal, Brown's, for oper- 
ation for cleft palate, 717, 718, 719 
Eleventh cranial nerve. See Spinal 
accessory nerve. 
Embolism, cerebral, 241 
Empyema, chronic, of maxillary sinus, 
560 
disease of maxillary sinus and, 
566, 567 
latent, diagnosis of, from disease 
of maxillary sinus, 571 
simple, diagnosis of, from disease 
of maxillary sinus, 571 
Encapsulated lipomas, 515 
Encephalitis, 244 
Enchondroma, 516 
Enchondrosis, 516 
Encystment of teeth, 65 
Endemic meningitis, 245 
Endothelioma, 527 
of tongue, 611 
Enostosis, 517 
Epidemic cerebrospinal meningitis, 245 
Epilepsy, 346 
dental irritations and, 347-350 
etiology of, 346 
fenestration of skull for, 348 
grand mal, 347 
pathology of, 346 
petit mal, 347 
symptoms of, 346 
treatment of, 347 
Epileptiform neuralgia, 271 
Epipharyngeal tonsils. See Adenoids. 
Epithelial carcinoma, 534 
odontoma, 501 
tumors, adult, 501 
Epithelioma, 534 
cylindric-cell, 534 
squamous, 534 
syphilis and, 131 
tubulated, 534 
Epulis, 528 
diagnosis of, 529 
etiology of, 528 
prognosis of, 530 
symptoms of, 528 
Erb type of muscular dystrophies, 229 
Eruption of teeth, 63 
Erysipelas, 213 
ambulans, 214 
migrans, 214 
of mucous membrane surfaces, 214 
neonatorum, 214 
phlegmonous glossitis and, 601 
Erythema, 197 
endemicum, 198 
multiforme, 198 INDEX 
787 
Erythema pellagrosum, 198 
symptomatic, 198 
Esmarch bandage in hemorrhage, 41 
Ether in general anesthesia, 30 
Ethmoidal sinus, 565 
Ethyl chloride in general anesthesia, 30 
Eucain in local anesthesia, 19 
Excitement, shock and, 56 
Exostosis, chondroid, 516 
Exposure, facial paralysis and, 330 
Exsection of roots of teeth in dento- 
alveolar abscesses, 163 
Extracranial operations at base of skull 
in treatment of trigeminal neuralgia, 
302 
F 
Face, coloboma of, 648 
deformities of, premanent, in early 
treatment of harelip, 658 
fissure of, 647, 648 
gunshot wounds of, 761 
hemiatrophy of, 263 
hemihypertrophy of, 364 
Facial nerve, anatomical relation of, 330 
lesions of, 330 
paralysis, 330 
spasm, 345 
diagnosis of, from tic, 345 
Farcy, 150. See also Glanders. 
Fatty tumor, 515 
Female generative organs, pathological 
affections of, harelip and, 655 
Fenestration of skull for epilepsy, 348 
Ferguson's method in operation for 
cleft palate, 700, 701 
Ferment fever, 91 
Fever, 90 
aseptic, 91 
wound, 91 
blisters, 200 
ferment, 91 
resorption, 91 
septic, 91 
splenic. See Anthrax. 
traumatic, 91 
Fibromas, 518 
etiology of, 518 
prognosis of, 520 
symptoms of, 518 
of tongue, 608 
treatment of, 520 
Fibrous odontoma, 502 
Fifth cranial nerve. See Trigeminal 
nerve. 
Finsen light in treatment of carcinoma, 
545 
First cranial nerve. See Olfactory 
nerve. 
Fischer's formula for infiltration anes- 
thesia, 21 
Fissure of face, 647 
Fissure of jaw, 647 
of lower lip, 647 
Fistula, salivary, 460 
Flesh wounds, 82 
Focal infection of oral origin, 158 
Follicular odontomas, 498, 502, 505 
Foot-and-mouth disease, 179 
tongue in, 605 
Forcipressure in hemorrhage, 41 
Foreign bodies in maxillary sinus, 560, 
595 
phlegmonous glossitis and, 601 
in salivary ducts, 462 
Fournier's teeth, 119 
Fourth cranial nerve, lesions of, 258 
Fractures of jaws, 382 
alveolar, 383 
bandages in, 401, 402 
complete, 382 
comminuted, 382 
complicated, 382 
compound, 382 
impacted, 383 
multiple, 382 
simple, 382 
complications of, 404 
diagnosis of, 384 
etiology of, 383 
fixation in, 392 
gunshot, 383, 761 
incomplete, 383 
depressed, 383 
fissured, 383 
green-stick, 383 
indented, 383 
perforating, 383 
punctured, 383 
infected, operation on, 756 
intra-uterine, 383 
pathological, 383 
reduction of, 390 
repair of, 403 
subperiosteal, 383 
symptoms of, 384 
transverse, 385 
treatment of, 389 
union in, complete, 404 
delayed, 404 
faulty, 404 
varieties of, 382 
in war wounds, 754 
Friedreich's ataxia, 238, 239 
cleft palate and, 239 
harelip and, 239 
Frog tongue, 492 
Frontal sinus, 565, 566 
Furring of tongue, 599 
G 
Gag, Brown's, for operation for cleft 
palate, 709, 710 788 
INDEX 
Ganglion, Gasserian, 260, 265,267, 321 
Ganglionic neuromas, 513 
Gangrene of tongue, 603 
Gangrenous stomatitis, 176 
Gas-producing organisms, infection by, 
750 
Gasserian ganglion, 260, 265, 267, 321 
Hartel method of injecting, 287 
removal of, 303 
Cushing's operation for, 
303, 306 
Hartley-Krause opera- 
tion for, 304 
indications for, 303 
mortality in, 309-311 
transzygomatic route for, 
304 
in treatment of trigem- 
inal neuralgia, 302 
in trigeminal neuralgia, 274 
Gelatiniform carcinoma, 536 
Gelsemium in treatment of trigeminal 
neuralgia, 281 
General anesthesia, 29 
Geographical tongue, 599 
Giant-cell sarcoma, 527 
Gingivitis, interstitial, 168 
diagnosis of, from disease of 
maxillary sinus, 573 
etiology of, 168 
symptoms of, 169 
treatment of, 169, 170 
marginal, 168 
Glanders, 149, 376 
agglutination test for, 150 
diagnosis of, 150 
etiology of, 149 
mallein in, 150 
of mucous membranes of mouth, 
187 
pathology of, 149 
Strauss' test for, 150 
symptoms of, 149 
of tongue, 605 
treatment of, 151 
Glands of Blandin-Nuhn, cysts of, 492 
mucous, cysts of, 491 
salivary, diseases of, 458 
fistula of, 460 
Glandular carcinoma, 534 
Gliomas, 515 
Glossis spinalis. See Syringomyelia. 
Glossitis, 599 
chronic, 600 
leukoplakia and, 600 
syphilis and, 600 
circumscribed, 600 
diagnosis of, 601 
interstitial, 601 
phlegmonous, 601 
erysipelas and, 601 
etiology of, 601 
foreign bodies and, 602 
Glossitis, phlegmonous, symptoms of, 
602 
treatment of, 602, 603 
pseudomembranous, 604 
treatment of, 601 
Glossopharyngeal nerve, lesions of, 340 
Goiter, lingual, 608 
Gonorrheal ulceromembranous cellu- 
litis, 190 
Grand mal, 347 
Green-stick fractures of jaws, 383 
Gumma, syphilis and, 131 
of tongue in syphilis, 131 
Gums, inflammation of. See Gingi- 
vitis. 
Gunning's interdental splint, 392 
Gunshot fractures of jaws, 383, 761 
Gwathmey apparatus for general anes- 
thesia, 34 
H 
Habit spasm of trigeminal nerve, 264 
Halisteresis, 359 
Hammond's splint, 399 
Hard chancre, 127 
Harelip, 650 
acquired, 650 
age and, 650 
bilateral, 650 
character of, 650 
classification of, 650 
congenital, 650 
double, 650 
Brown's operation for, 682- 
685 
dressings for, 685 
postoperative con- 
trol strips for, 685 
technic of, 682, 685 
treatment of, 680 
etiology of, 653 
family histories of, 655 
female generative organs and, 655 
form of, 650 
Friedreich's ataxia and, 239 
hereditary tendency and, 654 
heredity and, direct, 653 
hypophysis and, 655 
incision for, author's, 676 
maternal impressions and, 654 
metabolism and, 654 
position of child in utero and, 654 
operation for, author's, 666-680 
excessive size of lip after, 
correction of, 693 
excision of excessive tissue 
after, 693 
imperfect closure of lip fissure 
after, correction of, 689 
lip defects after, correction 
of, 687 
nose defects after, correction 
of, 687 INDEX 
789 
Harelip, operation for, removal of scars 
after, 687 
situation of scar after, 697 
unequal height of lip borders 
after, correction of, 689 
unsightly cartilage of nose 
after, correction of, 696, 697 
V-shaped notch at lower 
border of lip after, correc- 
tion of, 689 
treatment of, early, in infants, 656 
deformities of face and, 
permanent, 658 
disadvantages of, 657, 658 
effect of, upon speech, 660 
failure of, 660 
mortality and, 657 
nasal stenosis and, 659 
toxemia and, 658 
surgical, 660 
asymmetry from, 661 
author's method of, 666, 
680 
clamp for, authors, 674, 
675 
closure of lip fissure, 666 
compression of vessels 
in, 675 
deformity from, 661 
difficulties of, 662 
hemorrhage in, control 
of, 675 
incisions in, author's, 676 
irregularity of dental arch 
and, 664 
maldevelopment and, 663 
nasal deformity and, 664 
operative defects and, 664 
principles of, 660 
splint and wire tension 
suture in, 668-669 
sutures in, author's, 677 
tension and, 662 
zinc oxide adhesive strip 
in, 666 
without cleft palate, treatment 
of, 686 
Hartel method of injecting Gasserian 
ganglion, 287 
Hartley-Krause operation for removal 
of Gasserian ganglion, 304 
Headache in affections of sensory por- 
tion of trigeminal nerve, 268 
Healing by adhesion of granulating 
surfaces, 83 
by first intention, 82 
by granulation, 82 
by immediate union, 82 
by second intention, 82 
by third intention, 83 
Heat in hemorrhage, 41 
Hemangioma of tongue, 609 
Hematogenous pigmentation, 192 
Hemiatrophy of face, 263 
Hemiglossitis, 604 
Hemihypertrophy of face, 364 
Hemiplegia, 242 
Hemophilia, treatment of, by trans- 
fusion, 52 
Hemorrhage, 40 
acupressure for, 41 
adrenalin in, 43 
cerebral, 241 
classification of, 40 
control of, cold for, 41 
in wounds of mouth, 83 
Esmarch bandage for, 41 
etiology of, 40 
forcipressure for, 41 
forms of, 40 
grave, 42 
internal medication for, 42 
treatment of, 42 
heat for control of, 41 
hypodermoclysis for, 41, 43, 51 
intravenous infusion for, 41, 50 
method of, 50 
of normal salt solution 
in, 50 
ligation for, 41 
under periosteum, 366 
pituitary extract in, 43 
position in, 42 
proctoclysis for, 41, 51 
shock and, 55 
styptic for, 41 
symptoms of, 40 
general, 40 
local, 40 
tourniquet for, 41 
transfusion of blood for, 41, 43 
Brewer's method of, 44 
Crile's method of, 43, 44 
direct, 43 
indirect, 47 
technic of, 49 
Ottenberg's method of, 
45-47 
Percy's method, 47 
treatment of, 41 
Hepatogenous pigmentation, 192 
Hereditary syphilis, 117 
Heredity, direct, harelip and, 653 
Herpes facialis, 200 
simplex, 200 
zoster, paralysis of trigeminal 
nerve and, 265 
Highmore, antrum of. See Maxillary 
sinus. 
Hodgkin's disease, 482, 525 
etiology of, 482 
prognosis of, 485 
treatment of, 484 
Hunterian chancre, 127 
Hutchinson's teeth, 119 
Hydatid cysts of tongue, 606 790 
INDEX 
Hyoscine morphine, anesthesia and, 35 
Hypercementosis, trigeminal neuralgia 
and, 317, 323 
Hyperemia of optic nerve, 256 
Hyperesthesia of trigeminal nerve, 265 
Hypersecretion from salivary glands, 
469 
Hyperthermia, 90 
Hypertonic and isotonic salt solutions, 
753 
Hypertrophy of bone, 362 
Hypodermoclysis in hemorrhage, 41, 51 
in septic fever, 93 
Hypoglossal nerve, lesions of, 341 
paralysis of, 341 
Hypophysis, harelip and, 655 
Hysteria, 354 
diagnosis of, 354 
etiology of, 354 
symptoms of, 354 
I 
Immunity to syphilis, 123 
Impacted teeth, 66-72 
irritation of trigeminal nerve 
and, 264 
removal of, 75 
anesthetics for, 77 
asepsis in, 78 
exposure of embedded 
tooth crown in, 79 
Indirect transfusion of blood in hemor- 
rhage, 47 
Indurated chancre, 127 
Infantile paralysis. See Poliomyelitis, 
anterior. 
scorbutus, 206 
sialoadenitis, 467 
Infants, early treatment of harelip in, 
656 
Infected fractures, operation on, 756 
Infection, 88 
by gas-producing organisms, 750 
focal, of oral origin, 158 
shock and, 57 
Infectious diseases, 88 
of maxillary sinus, 560, 596 
Inferior maxillary nerve, operation for 
exposure of, 298-302 
Infiltration anesthesia, 20 
Fischer's, 21 
Schleich's, 20 
technic of, 22 
Inflammation of bone, 368 
Inframaxillary operation for removal 
of tongue, 551 
Infra-orbital nerve, exposure of, at 
infra-orbital foramen, 296 
operation for exposure of, 294- 
299 
Infusion, intravenous, in hemorrhage, 
41, 50 
I Interdental splints, 392-394 
Interstitial gingivitis, 168 
glossitis, 601 
neuritis, pathology of, 216 
Intestinal tuberculosis, 104 
Intoxication, putrid, 89 
septic, 88 
Intracranial pressure, 242 
Intracystic villous papilloma, 508 
Intranasal examination in disease of 
maxillary sinus, 573 
operation for disease of maxillary 
sinus, 576 
Intra-uterine fractures of jaws, 383 
Intravenous anesthesia, 30 
infusion in hemorrhage, 41, 50 
Inunction test for tuberculosis, 110 
lodism, syphilis and, 140 
J 
Jaw grinding, trigeminal neuralgia and, 
316 
Jaws, ankylosis of, 413 
caries of, 369 
disarticulation of, 441 
dislocations of, 407, 411 
fissure of, 647 
fixation of, in injuries of salivary 
glands, 459 
fractures of, 382 
infected, operation on, 756 
in war wounds, American 
Ambulance method of 
treatment, 754 
frequency of, 754 
necrosis of, 368 
prognathouslower, reduction of ,449 
resection of, for cosmetic purposes, 
446 
lower, 433 
upper, 443 
Joints in hereditary syphilis, 120 
K 
Keloid, 519 
Kingsley's interdental splint, 393 
palatograms, 736 
Knife, author's, for operation for cleft 
palate, 719 
Kocher's operation for removal of 
tongue, 551 
Kopf tetanus, 99 
Krause's operation for trigeminal neu- 
ralgia, 295, 296 
Kuster operation for disease of maxil- 
lary sinus, 579 
L 
Landouzy-Dejerine type of muscular 
dystrophies, 229 791 
INDEX 
Landry's paralysis, 237 
Lane's method in operation for cleft 
palate, 700 
Lateral sclerosis, amyotrophic, 226 
Leontiasis ossea, 365 
treatment of, 365 
Lepra. See Leprosy. 
Leprosy, 155 
of bone, 375 
etiology of, 155 
of mucous membrane of mouth, 
187 
symptoms of, 156 
of tongue, 605 
Leukemic stomatitis, 181 
Leukokeratosis buccalis, 202 
Leukoma, 202 
Leukoplakia, 202 
buccalis, 202 
chronic glossitis and, 600 
etiology of, 202 
pathology of, 202 
prognosis of, 203 
symptoms of, 203 
in syphilis, 131 
treatment of, 203 
Leukoplasia, 202 
Lichen planus, 200 
symptoms of, 200 
Ligation in hemorrhage, 41 
Lingua dissecata, 613 
frenata, 613 
plicata, 613 
Lingual goiter, 608 
diagnosis of, 609 
etiology of, 608 
symptoms of, 608 
treatment of, 609 
Lip borders, unequal height of, after 
operation for harelip, correc- 
tion of, 689 
chancre of, 128 
defects after operation for harelip, 
correction of, 687 
deformed, correction of, improve- 
ment of defects of speech after, 
729 
excessive size of, after operation 
for harelip, correction of, 693 
fissure of, 647 
imperfect closure of, after opera- 
tion for harelip, correction of, 689 
lower border of, V-shaped notch 
at, after operation for harelip, 
correction of, 689 
lymphangioma of, 646, 647 
malformations of, 646 
Lipodystrophy, progressive, 358 
Lipomas, 515 
diffuse, 515 
encapsulated, 515 
etiology of, 515 
prognosis of, 516 
Lipomas, symptoms of, 515 
of tongue, 608 
treatment of, 516 
Lobulated tongue, 612 
Local anesthetics, 17 
Lockjaw. See Tetanus. 
Locomotor ataxia, 238 
Loher's splint, 398 
Ludwig's angina, 187 
etiology of, 187 
treatment of, 187 
Lumpy jaw. See Actinomycosis. 
Lupus exedens, 534 
Lymph glands, oral, diseases of, 474 
nodes, oral, diseases of, 474 
in syphilis, 128 
hereditary, 128 
tumors of, 485 
Lymphadema, 482 
Lymphadenitis, 480 
etiology of, 480 
symptoms of, 481 
treatment of, 481, 482 
x-rays and, 482 
Lymphadenoid hyperplasia, progres- 
sive, 482 
Lymphadenoma, 482, 525 
malignant, 482 
Lymphangioma, 485, 522 
cavernous, 485 
of lips, 646, 647 
symptoms of, 523 
of tongue, 610 
treatment of, 524 
Lymphangitis. See Lymphadenitis. 
Lymphatic dilatation, 485 
nevi, 485 
Lymphoma, 525 
malignant, 482 
Lymphosarcoma, 482 
M 
Macrocheilia, 485, 523, 646 
Macroglossia, 485, 523 
Macrostomia, 646 
Maldevelopment, surgical treatment of 
harelip and, 663 
Malformation of bone, 361 
of tongue, ,612 
Malignant lymphadenoma, 482 
lymphoma, 482 
pustules. See Anthrax. 
Mallein test for glanders, 150 
Malocclusion, trigeminal neuralgia and, 
327 
with molars in contact and a wide 
separation between anterior 
teeth, operation for, 450 
Malposition of teeth, 65-72 
Mandible, unilateral shortness of, cor- 
rection of, 447 792 
INDEX 
Mandibular articulation, trigeminal 
neuralgia and, 322 
deformities due to tumor growths, 
surgical correction of, 450 
Mann's experimental studies on shock 
and hemorrhage, 57 
Marginal gingivitis, 168 
Marriage, syphilis and, 123 
Martin's artificial denture for resected 
jaw, 438 
jaw, 439 
splint, 399 
Massage in treatment of trigeminal 
neuralgia, 280 
Masseters, tonic spasm of, 264 
Mastication, muscles of, spasm of, 
264 
Maternal impressions, harelip and, 654 
Maxilla, inferior, fracture of, diagnosis 
of, 385 
etiology of, 384 
treatment of, 389 
superior, fractures of, diagnosis of, 
384 
etiology of, 383 
treatment of, 389 
Maxillae, relation of, to nasal deformi- 
ties, 616 
diseases, 616 
separation of, author's appliance 
for, 625, 626 
clinical results of, 630 
improvement in breathing 
from, 635 
operation for, 627 
tuberculosis and, 635 
Maxillary bones, destruction of, in 
syphilis, 133 
operation, reduction of wide cleft 
palate by, 706 
sinuitis, 560 
sinus, anatomy of, 559 
circulatory channels of, 568 
cystocele of, 597 
cysts of, 560, 597 
dental, 597 
dentigerous, 597 
treatment of, 597 
diseases of, 558, 560, 575 
acute coryza and, 561 
alveolar abscess and, 563 
of bony walls of, 560 
bulging of walls in, 570 
causes of, 560, 561 
exciting, 561 
predisposing, 560 
chronic rhinitis and, 561 
classification of, 560 
deflection of nasal sep- 
tum and, 562 
dental origin of, 563, 564 
diagnosis of, differential, 
570 
Maxillary sinus, diseases of, diagnosis 
of, from interstitial 
gingivitis, 573 
from migraine, 572 
from simple empy- 
ema, 571 
from stomatitis, 573 
puncture in, 574 
skiagraphs in, 573 
transillumination in, 
573 
empyema and, 566, 567 
etiology of, nasal factors 
in, 560 
oral factors in, 563 
frequency of, 565 
intranasal examination in, 
571 
nasal discharge in, 570 
operations and, 562 
polypi and, 563 
operation for, alveolar, 
575 
Caldwell-Luc, 585 
Canfield - Ballenger 
antrum, 588-591 
comparative review 
of, 592-594 
Denker, 587 
intranasal, 576-579 
Kuster, 579, 585 
oral surgery and, 
594-595 
palatal, 576 
pain in, 571 
prophylaxis of, 574 
pus in, 569 
symptoms of, 568, 569 
teeth in, 572 
traumatism and, 568 
treatment of, surgical, 
575 
turgescence of "swell 
bodies" and, 561 
"vicious circle" of nose 
and, 562 
empyema of, chronic, 560 
foreign bodies in, 560, 595 
diagnosis of, 596 
removal of, 585 
symptoms of, 596 
treatment of, 596 
infection of, from nose, 563 
from teeth, 563 
infectious diseases of, 560, 596 
symptoms of, 596 
treatment of, 596 
pathological changes in, 567 
polypi of, 560, 596 
tumors of, 560, 597 
Median phlegmon, suprahyoid, 480 
Megaloglossia, 613 
Melanosarcoma, 528 INDEX 
793 
Melanotic carcinoma, 536 
Meningitis, cerebral, 245 
pathology of, 245 
primary, 245 
secondary, 245 
symptoms of, 246 
treatment of, 247 
endemic, 245 
epidemic cerebrospinal, 245 
septic, 245 
spinal, 241 
syphilitic, 245 
tubercular, 245 
Mercurial necrosis of bone, 376 
diagnosis of, 377 
pathology of, 376 
symptoms of, 376 
treatment of, 377 
stomatitis in syphilis, 130 
Mercurialism, syphilis and, 140 
Mercury, administration of, in syphilis, 
by fumigation, 139 
internal, 137 
intramuscular, 138 
intravenous, 139 
by inunction, 139 
Metabolic pigmentation, 193 
Metabolism, harelip and, 654 
Metastasis of mumps, 466 
Microglossia, 612 
Microstomia, 646 
Migraine, 268 
diagnosis of, 270 
from disease of maxillary 
sinus, 571 
etiology of, 269 
heredity and, 269 
ophthalmic, 268 
prognosis of, 270 
symptoms of, 269 
treatment of, 270 
visual defects and, 269 
Mikulicz's disease, 470 
symptoms of, 471 
Miliary tubercles, 104 
Minor trigeminal neuralgia, 271 
Mixed infection, tuberculosis and, 
105 
Moro's inunction test for tuberculosis, 
110 
Morphin and atropin before general 
anesthesia, 35 
Motor portion of trigeminal nerve, 
affections of, 262 
Mouth, floor of, diffuse suppuration 
of. See Ludwig's angina. 
mucous membrane of, catarrh of, 
172 
diseases of, 168 
relations of, to spasmodic neu- 
roses, 349 
wounds of, 81 
Mucoid carcinoma, 536 
Mucoperiosteal flaps in operation for 
cleft palate, 701 
Mucous glands, cysts of, 491 
membrane of mouth, actinomy- 
cosis of, 181 
catarrh of, 172 
diseases of, 168 
glanders of, 186 
leprosy of, 187 
pemphigus of, 191 • 
trigeminal neuralgia and, 
322 
tuberculosis of, 181 
surfaces, erysipelas of, 214 
patch in syphilis, 130 
Multilocular cysts, 498 
Multiple neuritis, 216 
sclerosis, 248 
Mumps, 466 
complication of, 466 
etiology of, 466 
fever in, 466 
metastasis of, 466 
orchitis and, 466 
pain in, 466 
prognosis of, 467 
symptoms of, 466 
treatment of, 467 
Murphy's operation in ankylosis of 
jaws, 425 
Muscles in hereditary syphilis, 120 
Muscular dystrophies, 228 
Myelinic neuromas, 513 
Myelitis, 240 
Myeloid sarcoma, 513 
Myomas, 520 
etiology of, 521 
prognosis of, 521 
symptoms of, 521 
treatment of, 521 
Myositis, 605 
Myxomas, 526 
treatment of, 527 
Myxosarcoma, 527 
N 
Nares, contracted, treatment of, 621 
Nasal, accessory sinus, 558 
deformities, correction of, by sepa- 
ration of superior maxillae, 
621 
relation of, to maxillae, 616 
surgical treatment of harelip 
and, 660 
discharge in disease of maxillary 
sinus, 570 
diseases, relation of, to maxillae, 
616 
factors in disease of maxillary 
sinus, 561, 562, 563 
polypi, disease of maxillary sinus 
and, 563 794 
INDEX 
Nasal septum, deflection of, disease of 
maxillary sinus and, 562 
deviation of, asymmetry of 
hard palate and, 624 
treatment of, 621 
double development of, 623 
splint and wire tension suture in 
surgical treatment of harelip, 
668-669 
stenosis, early treatment of hare- 
lip in infants and, 659 
Naso-antral wall, removal of, in intra- 
nasal operation for disease of maxil- 
lary sinus, 577 
Necrosis of bone, arsenical, 378 
diagnosis of, 379 
mercurial, 376 
pathology of, 378 
phosphorus, 377 
symptoms of, 378 
treatment of, 380 
of jaws, 368 
etiology of, 369 
Neoplasms, 486 
classification of, 488 
diagnosis of, 490 
pathology of, 488 
Nerve anastomosis for facial paralysis, 
336-337 
extraction in trigeminal neuralgia, 
291 
stretching in trigeminal neuralgia, 
291 
Nerve-blocking, 20 
Nerves, injuries of, 215 
regeneration of, 215 
tumors of, 219 
Nervous system, diseases of, affecting 
buccal region, 215 
Neuralgia, 270 
trigeminal, 270 
ankylosis of roots of teeth and, 
317 
arrested development and, 315 
bridge-work and, improper, 
323 
carious teeth and, 322 
causes of, classification of, 
271-272 
classification of, 271 
dental aspects of, 314 
factors of, diagnosis of, 
321 
skiagraphs in, 324 
treatment of, 326 
pulp in, destruction of, 
327 
diagnosis of, 275 
diseases of dental pulp and, 
317 
epileptiform, 271 
eruption of teeth and, 321 
etiology of, 271 
Neuralgia, trigeminal, Gasserian gan- 
glion in, 274 
hypercementosis and, 317, 323 
jaw grinding and, 316 
major, 271 
malocclusion and, correction 
of, 327 
soft-rubber bit for, 327 
mandibular articulation and, 
322 
minor, 271 
nasal defects and, 315 
nerve extraction in, 291 
stretching in, 291 
neurectomy in, 291 
neurotomy in, 291 
oral mucous membrane and, 
322 
pathology of, 273 
pericementitis and, 317 
pulpitis and, 317 
symptomatic, 271 
symptoms of, 274 
teeth and, eruption of, 321 
extraction of, 327 
number of, 322 
temporomaxillary articulation 
and, 329 
tooth grinding and, 316 
treatment of, 280 
castor oil in, 281 
exposure of first trigemi- 
nal branch in, 292 
gelsemium in, 281 
by injection of alcohol, 
282 
technic of, 283-291 
of osmic acid, 282 
massage in, 280 
medicinal, 281 
psychotherapeutic, 280 
surgical, 291 
Neurasthenia, 355 
dental factors in, 356 
Neurectomy in trigeminal neuralgia, 
291 
Neuritis, 216 
classification of, 216 
etiology of, 216 
facial paralysis and, 331 
interstitial, pathology of, 217 
multiple, 216 
optic, 256 
parenchymatous, pathology of, 217 
pathology of, 216 
peripheral, 216 
prognosis of, 217 
segmental periaxillary, pathology 
of, 217 
symptoms of, 217 
treatment of, 218 
Neurofibromatosis, 519 
Neuroma, 219, 220, 513 INDEX 
795 
Neuroma, amputation, 515 
amyelinic, 514 
etiology of, 515 
false, 513 
ganglionic, 513 
myelinic, 513 
plexiform, 513 
prognosis of, 515 
symptoms of, 515 
treatment of, 515 
Neuroses, spasmodic, 342 
Neurotomy in trigeminal neuralgia, 291 
Nevus, 521 
Nigrities linguae, 604 
Ninth cranial nerve. See Glosso- 
pharyngeal nerve. 
Nitrous oxide gas and oxygen in 
general anesthesia, 30 
oxide-oxygen-ether sequence in 
general anesthesia, 32 
Nodular lymphangioma of tongue, 610 
Noma. See Stomatitis, gangrenous. 
Normal salt solution, infusion of, in 
hemorrhage, 50 
Nose defects after operation for hare- 
lip, correction of, 687 
infection of maxillary sinus from, 
563 
Novocain in local anesthesia, 19 
O 
Odontomas, 501 
classification of, 501 
composite, 505 
diagnosis of, 505 
epithelial, 502 
etiology of, 501 
fibrous, 502 
follicular, 498, 502 
compound, 505 
prognosis of, 506 
radicular, 504 
treatment of, 506 
(Edema. See Edema. 
Oidium albicans, 179 
Olfactory nerve, lesions of, 255 
Operative field, control of, in removal 
of impacted teeth, 78 
Ophthalmic migraine, 268 
nerve, operation for exposure of, 
292 
test for tuberculosis, 110 
Ophthalmoplegia, 259 
Opsonic index test, Wright's, for tuber- 
culosis, 110 
Optic nerve, anemia of, 256 
atrophy, 256 
edema of, 256 
hyperemia of, 256 
lesions of, 256 
neuritis, 256 
Oral deformities, etiological factors of, 
619, 620 
factors in disease of maxillary 
sinus, 563 
hygiene in syphilis, 137 
region, embryonic sections of, 
617-619 
Orchitis, mumps and, 466 
Osmic acid, injection of, in trigeminal 
neuraglia, 282 
Osseous apposition, 359 
resorption, 359 
Osteitis deformans, 365 
treatment of, 366 
sicca tuberculosa, 106 
Osteochondritis, hereditary syphilis 
and, 120 
syphilitic, 375 
Osteogenesis, 359 
imperfecta, 361 
Osteomas, 517 
prognosis of, 518 
symptoms of, 518 
treatment of, 518 
Osteomalacia, 360 
Osteomyelitis, 368 
tuberculous, 106 
Osteoperiostitis, 367 
syphilis and, 133 
Osteosarcoma, 527 
Ottenberg's method of transfusion of 
blood, 45, 46 
P 
Pachymeningitis cervicalis hyper- 
trophica, 240 
Palatal operation for disease of maxil- 
lary sinus, 576 
Palate bones, fracture of, in operation 
for cleft palate, 700 
cleft, 650. See also Harelip. 
hard, asymmetry of, deviation of 
nasal septum and, 624 
shortening of, defects of 
speech due to, 728 
syphilis and, 132 
soft, syphilis and, 132 
Palatograms, Kingsley's, 736 
Palsy, bulbar, 253 
defective speech in, 253 
diagnosis of, 253 
etiology of, 253 
pathology of, 253 
symptoms of, 253 
treatment of, 254 
"Papilledema," 256 
Papilloma, 507 
etiology of, 507 
prognosis of, 510 
symptoms of, 508 
of tongue, 608 796 
INDEX 
Papilloma, treatment of, 510 
varieties of, 507 
villous, 508 
intracystic, 508 
Paralymphadenitis, 481 
Paralysis, abducens, 258, 259 
of accessory spinal nerve, 340 
acute atrophic spinal. See Polio- 
myelitis, anterior. 
progressive, 237 
cerebral spastic, 242 
chronic atrophic. See Poliomye- 
litis, anterior, chronic. 
facial, 330 
basal disease of brain and, 
331 
fractures of skull and, 331 
constitutional disease and, 331 
diagnosis of, 333 
emotional shock and, 331 
etiology of, 330 
exposure and, 330 
localization of lesion in, 332 
nerve anastomosis for, 336 
neuritis and, 331 
neuropathic tendency and, 331 
poliomyelitis and, 331 
polyneuritis and, 331 
prognosis of, 333 
spasmodic contraction in, 332 
suppurative ear disease and, 
330 
symptoms of, 331 
trauma and, 331 
treatment of, 335 
surgical, 335 
of hypoglossal nerve, 340 
infantile. See Poliomyelitis, an- 
terior. 
Landry's. See Paralysis, acute 
progressive. 
of motor portion of trigeminal 
nerve, 262 
patheticus, 258 
retrogressive. See Poliomyelitis, 
anterior. 
of sixth cranial nerve, 258 
in syringobulbia, 222 
Parasitic cysts, 501 
Parasitic-mycotic stomatitis, 178 
Parasyphilides, 126 
Parenchymatous neuritis, pathology of, 
217 
Paresthesia of trigeminal nerve, 266 
Parotid tumors, bilateral, 470 
Partsch's artificial jaw, 440 
Patheticus paralysis, 258 
Pathological dentition, 64 
fractures of jaw, 383 
Pellagra, 198 
Pemphigus, 191 
Percy's method of transfusion of blood, 
47 
Pericementitis, trigeminal neuralgia 
and, 317 
Periosteal cysts of jaws, 495 
diagnosis of, 497 
etiology of, 495 
symptoms of, 497 
treatment of, 497 
Periosteum, diseases of, 366 
Periostitis, 366 
acute simple, 366 
hereditary syphilis and, 120 
purulent, 367 
Peripheral neuritis, 216 
Perversion of smell, 255 
Petit mal, 347 
Pharyngeal adenoids, 474 
tonsil. See Adenoids. 
Phlegmon, suprahyoid median, 480 
symptoms of, 480 
treatment of, 480 
Phlegmonous glossitis, 601 
stomatitis, 180 
Phosphorus necrosis of bone, 377 
pathology of, 377 
symptoms of, 377 
treatment of, 378 
Pigmentation, hematogenous, 192 
hepatogenous, 192 
metabolic, 193 
of mucous membranes of mouth, 
191 
treatment of, 193 
Pigmented sarcoma, 536 
Pike and Coombs' studies on shock and 
hemorrhage, 58 
Pituitary body, diseases of, 252 
extract in hemorrhage, 43 
Plexiform angiomas, 522 
angiosarcoma, 527 
neuromas, 513 
Pneumococcus infection of accessory 
nasal sinuses, 568 
Pneumonokoniosis, 192 
Poisons, 88 
Poliomyelitis, acute anterior, 222 
anterior, 222 
chronic, 225 
diagnosis of, 224 
epidemic cases of, 224 
etiology of, 223 
facial paralysis and, 331 
neutralization of virus of, 225 
prognosis of, 224 
sporadic cases of, 224 
symptoms of, 224 
treatment of, 224 
Polyneuritis, facial paralysis and, 331 
Polypi of maxillary sinus, 560, 596 
Port-wine mark, 521 
Postnasal tonsils. See Adenoids. 
Potassium iodide and mercury in 
syphilis, 139 
Pott's disease, 375 INDEX 
797 
Premaxilla, reduction of, 681 
incisions for, 681 
von Langenbeck's 681 
Pressure atrophy of bone, 360 
intracranial, 242 
Primary symptoms of syphilis, 123 
Proctoclysis in hemorrhage, 41, 51 
Progressive lipodystrophy, 358 
lymphadenoid hyperplasia, 482 
muscular atrophy, 225 
diagnosis of, from amyo- 
trophic lateral sclero- 
sis, 228 
paralysis, acute, 237 
Proliferation- cysts, 498 
Proliferous cysts, 498 
Pseudoleukemia, 482, 525 
Pseudomembranous glossitis, 604 
stomatitis, 180 
Psoriasis of tongue, 604 
Ptyalism, 469 
Pulp, dental, diseases of, 317 
trigeminal neuralgia and, 
317 
sensitiveness of, to cold, 324 
to heat, 324 
temperature test of, 325 
nodules, trigeminal neuralgia and, 
319 
Pulpitis, 317 
Puncture in diagnosis of disease of 
maxillary sinus, 574 
Purpura, 204 
hemorrhagica, 205 
diagnosis of, from scorbutus, 
206 
nautica, 205 
Pus in disease of maxillary sinus, 569 
Pustule, malignant. See Anthrax. 
Putrid intoxication, 89 
Pyemia, 89 
Pyorrhea saliyalis, 463 
Pyrexia, 90 
Q 
Quinine-urea hydrochloride in local 
anesthesia, 19 
R 
Radicular odontoma, 504, 505 
Radium in treatment of carcinoma, 
544 
Ranula, 492 
diagnosis of, 493 
etiology of, 492 
prognosis of, 493 
of salivary glands, 473 
symptoms of, 492 
treatment of, 493 
Receding chin, operation for, 450 
Rectal anesthesia, 30 
Regeneration of bone, 360 
Resection of jaws, lower, 433 
complete, 435 
partial, 433 
prognosis of, 441 
retention of divided frag- 
ments, 436 
temporary, 433 
upper, 443 
complete, 444 
exposure of arteries in, 
456 
operative dangers in, 451 
osteoplastic, 446 
partial, 444 
prognosis of, 455 
removal of both superior 
maxillae, 454 
treatment of, postopera- 
tive, 454 
Resorption fever, 91 
Retention appliances in operation for 
cleft palate, 702 
cysts, 490 
of tongue, 605 
Retrogressive paralysis. See Polio- 
myelitis, anterior. 
Rhinitis, acute, disease of maxillary 
sinus and, 561 
Rickets, 361 
Riga's disease, 605 
Rodent ulcer, 534 
S 
St. Vitus' dance. See Chorea. 
Saliva, pathological indications of, 458 
Salivary calculi. See Salivary stones. 
ducts, fistula of, diagnosis of, from 
salivary gland fistula, 461 
foreign bodies in, 462 
diagnosis of, 462 
pain in, 462 
symptoms of, 462 
treatment of, 462 
inflammation of. See Sialo- 
dochitis. 
injuries of, 459 
fistula, 460 
duct, 460 
diagnosis of, from sali- 
vary gland fistula, 461 
permanent, treatment of, 
461 
treatment of, 461 
etiology of, 460 
gland, 460 
diagnosis of, from sali- 
vary duct fistula, 461 
treatment of, 461 
symptoms of, 460 798 
INDEX 
Salivary gland, actinomycosis of, 473 
congenital defects of, 458 
cysts of, 473 
diseases of, 458 
fistula, diagnosis of, from sali- 
vary duct fistula, 461 
hypersecretion from, 469 
inflammation of, 465, 469 
injuries, 459 
fixation of jaws in, 459 
treatment of, 459 
ranula of, 473 
syphilis of, 473 
tuberculosis of, 473 
tumors of, 473 
stones, 462 
diagnosis of, 464 
etiology of, 463 
occurrence of, 463 
symptoms of, 463 
treatment of, 464 
Salvarsan for syphilis, 140 
Salt solutions, hypertonic and isotonic, 
753 
Sapremia, 89 
Sarcoma, 527 
alveolar, 527 
giant-cell, 527 
myeloid, 527 
pigmented, 536 
of tongue, 611 
treatment of, 543 
"Satellite gland" in syphilis, 128 
Sauer's splint, 399 
Scars, removal of, after operation for 
harelip, 687 
Schleich's infiltration anesthesia, 20 
Sclerosis, amyotrophic lateral, 226 
diagnosis of, 228 
from progressive mus- 
cular atrophy, 228 
etiology of, 226 
symptoms of, 226 
treatment of, 228 
multiple, 248 
of tongue in syphilis, 131 
Scopolamine anesthesia, partial, for 
aged, 20 
morphin, anesthesia and, 35 
Scorbutus, 205 
diagnosis of, from purpura hemor- 
rhagica, 206 
infantile, 206 
diagnosis of, 212 
etiology of, 207 
symptoms of, 208 
Scurvy, 205 
Second cranial nerve. See Optic nerve. 
Secondary symptoms of syphilis, 124 
Segmental periaxillary neuritis, path- 
ology of, 216 
Sensory portion of trigeminal nerve, 
affections of, 265 
Separation of maxillae, operation for, 
621, 627-629 
Sepsis, prevention of, in wounds of 
mouth, 83 
Septic fever, 91 
autogenous bacterins in, 97 
combined venesection and in- 
travenous saline transfusion 
in, 93-97 
cryptogenetic, 92 
direct transfusion of blood 
in, 93 
etiology of, 91 
hypodermoclysis in, 93 
intravenous saline transfu- 
sions in, 93 
pyemic type of, 92 
septicemic type of, 92 
symptoms of, 92 
toxemic type of, 92 
treatment of, 93 
vaccine therapy in, 96 
intoxication, 88 
meningitis, 245 
Septicemia, 89 
Septum, nasal, deflection of, disease of 
maxillary sinus and, 562 
Seventh cranial nerve. See Facial 
nerve. 
Shock, 55 
after-treatment of, 60 
bandaging in, 60 
carbon dioxide content of blood 
and, 61 
causes of, operative, 56 
psychic, 56 
cold and, 56 
etiology of, 56 
excitement and, 56 
hemorrhage and, 56 
infections and, 57 
symptoms of, 59 
treatment of, 59 
prophylactic, 59 
Sialo-adenitis, 465 
infantile, 467 
Sialodochitis, 464 
diagnosis of, 465 
etiology, 464 
symptoms of, 464 
treatment of, 465 
Sialolithiasis. See Salivary stones. 
Sialorrhea, 469 
Simple adenia, 482 
hemangioma of tongue, 609 
wounds, 82 
Sinuitis, maxillary, catarrhal, acute, 560 
symptoms of, 568 
chronic, 560 
symptoms of, 569 
suppurative, acute, 560 
symptoms of, 569 
chronic, 560 INDEX 
799 
Sinuitis, maxillary, suppurative, 
chronic, symptoms of, 570 
Sinus, accessory, nasal, 558, 565 
ethmoidal, 565 
frontal, 565 
maxillary, 558 
sphenoidal, 565 
Sinuses, venous, thrombosis of, 249, 250 
Sixth cranial nerve, lesions of, 258 
paralysis of, 258 
Skiagraphs in diagnosis of disease of 
maxillary sinus, 573 
Skin warts, 507 
Skull, basal fractures of, facial par- 
alysis and, 331 
fenestration of, for epilepsy, 348 
Smell, loss of, 255 
perversion of, 255 
Soft chancre. See Chancroid. 
Somnoform in general anesthesia, 33 
Sore throat in syphilis, 130 
Spasm, facial, 345 
treatment of, 346 
habit, of trigeminal nerve, 264 
of muscles of mastication, 264 
tonic, of masseters, 264 
Spasmodic affections of trigeminal 
nerve, 264 
neuroses, 342 
delayed eruption of teeth 
and, 350 
"periods of stress" and, 349 
relations of mouth to, 349 
of teeth to, 349 
Spastic paralysis, cerebral, 242 
Speech, defective, anatomical defects 
and, correction of, 734 
in bulbar paralysis, 253 
cleft palate and, 724 
due to early operation for 
cleft palate, 727 
to flexibility of tissues, 
728 
to imperfect develop- 
ment, 733 
to insufficient velum, 728 
to nasal maldevelopment, 
728 
to shortening of hard 
palate, 728 
improvement of, 729 
by correction of deformed 
lips, 729 
dental arch, 729 
etiology of, 734 
not due to cleft palate, 734 
training for, auditory motor 
control in, 739 
coordination in, accuracy 
of, 739 
precision of, 739 
general principles of, 739 
ideomotor control in, 739 
Speech, defective, training for, move- 
ment in, accuracy 
of, 739 
force of, 739 
muscular, quickness 
of, 739 
precision of, 739 
reflex tonus in, 739 
response in, quickness of, 
739 
simple methods of, 738 
voluntary control in, 739 
treatment of, author's method, 
734 
effect of early treatment of hare- 
lip in infants upon, 660 
Sphenoidal sinus, 565 
Spinal accessory nerve, lesions of, 340 
paralysis of, 340 
cord, diseases of, 220 
meningitis, 241 
Spirocheta pallida, 117 
identification of, 133, 134 
Burrie's method of, 133 
Splenic fever. See Anthrax. 
Splints, interdental, 392 
Squamous epithelioma, 534 
Staphylorrhaphy, 698 
instruments, author's set of, 718, 
719 
"Strawberry" tongue, 599 
Stein's antrum chisel, 578 
Steno's duct, 459 
foreign bodies in, 462 
Stenosis, nasal, early treatment of hare- 
lip in infants and, 659 
Stomatitis, 168 
aphthous, 173 
etiology of, 173 
symptoms of, 173 
treatment of, 173 
catarrhalis, 172 
etiology of, 172 
symptoms of, 173 
treatment of, 173 
diagnosis of, from disease of max- 
illary sinus, 573 
gangrenous, 176 
etiology of, 176 
prognosis of, 178 
symptoms of, 177 
treatment of, 178 
gonorrheal ulceromembranous, 190 
etiology of, 190 
symptoms of, 190 
treatment of, 191 
leukemic, 181 
blood count in, 186 
mercurial, in syphilis, 130 
parasitic-mycotic, 178 
etiology of, 179 
symptoms of, 179 
treatment of, 179 800 
INDEX 
Stomatitis, phlegmonous, 180 
pseudomembranous, 180 
simplex, 172 
symptoms of, 172 
treatment of, 172 
ulcerative, 174 
etiology of, 174 
prognosis of, 175 
symptoms of, 174 
treatment of, 175 
Stomatoplasty, 647 
Stones, salivary, 463 
Stoppany's artificial jaw, 429 
Stovain and novocain in local anes- 
thesia, 19 
Strauss' test for glanders, 150 
Styptics in hemorrhage, 41 
Subcutaneous wounds, 82 
Sublingual cysts, 492 
Submaxillary cellulitis, diffuse. See 
Ludwig's angina. 
Subperiosteal fractures of jaws, 383 
Supernumerary teeth, 65 
Suppurative ear disease, facial paraly- 
sis and, 330 
maxillary sinuitis, acute, 560 
chronic, 560 
Suprahyoid median phlegmon, 480 
Surgical wounds, 82 
"Swell bodies" turgescence of, disease 
of maxillary sinus and, 561 
Symptomatic erythema, 198 
Synovitis, 412 
monarticular, 413 
polyarticular, 413 
treatment of, 413 
Syphilis, 117 
abortion of, 136 
acquired, 121 
etiology of, 121 
extragenital inoculation in,121 
immunity to, 123 
marriage and, 123 
symptoms of, 123 
primary, 123 
secondary, 124 
tertiary, 125 
arsenic for, 140 
of bone, 375 
chancre in, 127 
chronic glossitis and, 600 
diagnosis of, 126 
clinical, 127 
differential, 129 
laboratory, 133 
method of, 127 
epithelioma and, 131 
gumma and, 131 
hard palate and, 132 
hereditary, 117 
bones in, 120 
Colles' law in, 118 
dactylitis and, 120 
Syphilis, hereditary, joints in, 120 
lymph nodes in, 120 
muscles in, 120 
osteochondritis and, 120 
periostitis and, 120 
symptoms of, 118 
teeth in, 119 
Fournier's, 119 
Hutchinson's, 119 
iodism and, 140 
leukoplakia in, 131 
lymph nodes in, 128 
maxillary bones in, destruction of, 
133 
mercurial stomatitis in, 130 
mercurialism and, 140 
mercury for, administration of, 137 
by fumigation, 139 
internal, 137 
intramuscular, 138 
intralvenous, 139 
by inunction, 139 
mucous patch in, 130 
oral hygiene in, 137 
symptoms of, secondary, 130 
tertiary, 130 
osteoperiostitis and, 133 
potassium iodide and mercury in, 
139 
primary sore of, 127 
prophylaxis of, 136 
of salivary glands, 473 
salivation in, 140, 470 
salvarsan for, 140 
"satellite gland" in, 128 
"606" for, 140 • 
soft palate and, 122 
sore throat in, 130 
Spirocheta pallida in, identification 
of, 133, 134 
Burrie's method of, 
133 
symptoms of, 118, 123-126 
of third generation, 120 
tongue in, 131 
gumma of, 131 
sclerosis of, 131 
treatment of, 136 
early, 136 
Wassermann test for, 134 
Syphilitic dystrophies, 126 
meningitis, 245 
osteochondritis, 375 
"Syringobulbia," 253 
Syringomyelia, 221 
analgesia in, 221 
diagnosis of, 222 
etiology of, 221 
muscular atrophy in, 222 
paralysis in, 222 
symptoms of, 221 
treatment of, 222 
trophic disturbance in, 222 INDEX 
801 
T 
Talbot's iodoglycerol, 170 
"Tapir mouth" in muscular dystro- 
phies, 229 
Teeth, carious, trigeminal neuralgia 
and, 322 
encystment of, 65 
eruption of, 64 
convulsions and, 342 
delayed, spasmodic neuroses 
and, 350 
trigeminal neuralgia and, 315- 
328 
extraction of, serious accidents in, 
77 
Fournier's, 119 
Hutchinson's, 119 
impacted, 65-72 
infection of maxillary sinus from, 
563 
malposition of, 65-72 
relations of, to spasmodic neuroses, 
349 
roots of, exsection of, in dento- 
alveolar abscesses, 163 
supernumerary, 65 
temperature test for, 325 
Telangiectasis, 521 
Temperature test for teeth, 325 
Temporomandibular articulation, af- 
fections of, 405 
alterations in form of, 406 
ankylosis of, 413 
bony, 422 
fibrous, 416 
temporary, 414 
arthritis of, 412 
arthrodesis of, 432 
description of, 405 
dislocation of, 407 
chronic, 411 
synovitis of, 412 
Tenth cranial nerve. See Vagus 
nerve. 
Tertiary symptoms of syphilis, 125 
Tetanus, 97 
acute, 99 
antitoxin, 102 
bacillus of, 97 
cephalic, 99 
chronic, 99 
diagnosis of, 99 
etiology of, 98 
frequency of, 98 
prognosis of, 100 
prophylaxis of, 102 
treatment of, 100 
Third cranial nerve, lesions of, 258 
Thrombosis, cerebral, 241 
of venous sinuses, 249, 250 
Thrush, 178. See also Stomatitis, para- 
sitic-mycotic. 
Thymus gland, dried,' in treatment of 
carcinoma, 544 
Thyroglossal cysts, 607 
Thyroid extract in treatment of car- 
cinoma, 544 
tumors, accessory, 511 
Tic, 345 
diagnosis of, from facial spasm, 345 
douloureux, 276 
"aura" in, 277 
diagnosis of, 279 
pain in, 276 
symptoms of, 276 
motor, 278 
sensory, 276 
vasomotdr, 279 
treatment of, 280. See also 
Trigeminal neuralgia, treat- 
ment of. 
treatment of, 346 
Tinnitus aurium, 338 
diagnosis of, 338 • 
differential, 339 
etiology of, 338 
prognosis of, 339 
relation of, to oral diseases, 338 
treatment of, 339 
Tongue, absence of. See Aglossia. 
actinomycosis of, 605 
adenoma of, 608 
adherent, 615 
atrophy of, 604 
base of, cysts of, 607 
bifid, 612 
carcinoma of, 611 
chancre of, 128 
cysts of, 605 
cysticercus, 606 
dermoid, 606 
echinococcus, 606 
hydatid, 606 
retention, 605 
treatment of, 606 
diseases of, 599 
endothelioma of, 611 
fibroma of, 608 
in foot-and-mouth disease, 605 
furring of, 599 
gangrene of, 603 
geographical, 599 
glanders of, 605 
hemangioma of, 609 
cavernous, 610 
simple, 609 
treatments of, 610 
varieties of, 609 
inflammation of. See Glossitis. 
leprosy of, 605 
lipoma of, 608 
lobulated, 612 
long, 613 
lymphangioma of, 610 
cavernous, 611 802 
INDEX 
Tongue, lymphangioma of, nodular, 610 
malformations of, 612 
nervous affections of, 604 
papilloma of, 608 
psoriasis of, 604 
sarcoma of, 611 
"strawberry," 599 
in syphilis, 131 
tremor of, 604 
tumors of, 605 
Tongue-tie, 613 
symptoms of, 613 
treatment of, 614 
Tonic spasm of masseters, 264 
Tonsils, epipharyngeal. See Adenoids. 
hypertrophy of, 474 
pharyngeal. See Adenoids. 
postnasal. See Adenoids. 
Tooth grinding, trigeminal neuralgia 
and, 316 
Tourniquet in hemorrhage, 41 
Toxemia, 88, 89 
early treatment of harelip in in- 
fants and, 658 
Transfusion of blood in hemorrhage, 
41, 43-50 
cannula, Brewer's glass, 45 
Crile's, 44 
direct, 43 
of blood in septic fever, 93 
indirect, 47 
technic of, 49 
intravenous saline, in septic fever, 
93 
and venesection in septic 
fever, 93-96 
treatment of hemophilia by, 52 
Transillumination in diagnosis of dis- 
ease of maxillary sinus, 573 
Transplantation of tissue in operation 
for cleft palate, 705 
Transzygomatic route for removal of 
Gasserian ganglion, 304 
Trauma of mucous membranes of oral 
region, 193 
Traumatic fever, 91 
Tremor of tongue, 604 
Trigeminal nerve, anesthesia of, 267 
etiology of, 267 
symptoms of, 267 
degeneration of, 260 
diseases of, 260 
first branch, exposure of, 292 
general consideration of, 260 
hyperesthesia of, 265 
infra-orbital division of, ex- 
posure of, 293 
irritation of, impacted teeth 
and, 264 
motor portion of, affections 
of, 262 
habit spasm and, 264 
spasmodic, 264 
Trigeminal nerve, motor portion of, 
treatment of, 265 
paralysis of, 262 
hemiatrophy of face 
in, 263 
paralysis of, herpes zoster and, 
265 
paresthesia of, 266 
regeneration of, 260 
second branch,exposure of, 293 
sensory portions of, affections 
of, 265 
headache in, 268 
pain in, 268 
third branch of, exposure of, 
299-302 
neuralgia, 270 
Krause's operation for, 295 
pulp nodules and, 319 
treatment of, exposure of third 
trigeminal branch in, 
299 
by extracranial operations 
at base of skull, 302 
by removal of Gasserian 
ganglion, 302 
Trismus in actinomycosis, 146 
Trophic changes, 358 
Tubercular meningitis, 245 
Tuberculin test for tuberculosis, 109 
Tuberculosis, 102 
bacillus of, 102 
of bone, 105, 374 
eburnated infarct in, 106 
periosteal, 375 
diagnosis of, 106 
general, 108 
etiology of, 102 
frequency of, 114 
heredity and, 104 
inoculation of, direct, 103 
intestinal, 104 
of joints, 106 
miliary tubercles in, 104 
mixed infection and, 105 
of mucous membrane of mouth, 
181 
organs affected in, 105 
pathology of, 104 
portals of entrance of, 103 
prophylaxis, 111 
of salivary glands, 473 
separation of maxillae and, 635 
special forms of, 105 
summary of, 114 
symptoms of, 106 
general, 108 
tests for, 109 
cutaneous, yon Pirquet's, 110 
inunction, Moro's, 110 
ophthalmic, 110 
tuberculin, 109 
Wright's opsonic index, 110 INDEX 
803 
Tuberculosis, treatment of, 113 
Tubular adenoma, 510 
Tubulated epithelioma, 534 
Tumor growths, mandibular deformi- 
ties due to, surgical correction of, 450 
Tumors, 486 
bilateral parotid, 474 
of brain, 250 
connective-tissue, 515 
epithelial, adult, 501 
fatty, 515 
malignant, 527 
of maxillary sinus, 560, 597 
of nerves, 219 
of salivary glands, 473 
of tongue, 605 
wart, 507 
Twelfth cranial nerve. See Hypo- 
glossal nerve. 
U 
Ulcer, rodent, 534 
Ulcerative stomatitis, 174 
Ulceromembranous cellulitis, gonor- 
rheal, 190 
Ultraviolet rays in treatment of car- 
cinoma, 545 
Uranoplasty, 698 
Uranorrhaphy, 698 
Uranostaphylorrhaphy, 698 
Urticaria, 199 
V 
Vaccine therapy in septic fever, 96 
Vagus nerve, lesions of, 340 
Vegetations, adenoid. See Adenoids. 
Velum, insufficient, defects of speech 
due to, 728 
Venesection and intravenous saline 
transfusion in septic fever, 93-96 
Venous sinuses, thrombosis of, 249, 250 
"Vicious circle" of nose, disease of 
maxillary sinus and, 562 
Villous papilloma, 508 
intracystic, 508 
Vincent's angina, 188 
etiology of, 190 
treatment of, 190 
Virus of anterior poliomyelitis, neutral- 
ization of, 225 
Von Langenbeck's incisions for reduc- 
tion of premaxilla, 681 
Von Pirquet's cutaneous test for 
tuberculosis, 110 
w 
Wart tumors, 507 
skin, 507 
soft, 508 
Wassermann test, 134 
technic of, 134, 135 
Wharton's duct, 458 
foreign bodies in, 462 
inflammation of, 464 
"White swelling," 106, 375 
Whitehead's operation for removal of 
tongue, 550 
Woolsorters' disease. See Anthrax. 
Wound fever, aseptic, 91 
Wounds, 81 
definition of, 81 
gunshot, of face and jaws, 761 
healing of, by adhesion by granu- 
lating surface, 82 
by first intention, 82 
by granulation, 82 
by immediate union, 82 
by second intention, 82 
by third intention, 83 
of mouth, 81 
coaptation of wound surfaces 
in, to promote healing, 83 
control of hemorrhage in, 83 
drainage in, 83 
dressings for, 83, 84 
hemorrhage from ligation of 
external carotid in, 86 
treatment of, 85, 86, 87 
prevention of physiological 
action in, 83 
sepsis in, 83 
treatment of, 83 
repair of, 82 
varieties of, 82 
Wright's opsonic index test for tuber- 
culosis, 110 
X 
Xerostoma, 470 
X-rays in treatment of carcinoma, 545 
results of use of, 554 
Z 
Zinc oxide adhesive strip in surgical 
treatment of harelip, 666