results of the latter have been already mentioned; and I believe
that, if the former be allowed to proceed unchecked, the tumour may
ultimately extend to the bone, and osteosarcoma of the jaw, more or
less extensive, be established. The disease must be attacked at an
early period of its existence, and teeth, sockets, and soft parts taken
freely away, by means of a strong knife and saw, or cutting forceps.
After excision, the actual or potential cautery should be applied,
otherwise the disease is apt to recur. Portions of involved bone, which
may have escaped the knife, are by the caustic made to exfoliate. When
the potassa fusa is used for the purpose of destroying what cannot be
readily reached by the knife, and when it is pushed into the alveoli
and applied to the altered gum, its action must be limited by the
immediate use of vinegar, diluted or not.
_Inflammation of the gums_ and neighbouring parts is attended with
violent pain, swelling, and throbbing, difficulty in opening the mouth,
headache, and fever. Inflammation of the soft parts runs its course
speedily, and, as the cause is seldom removed during the existence
of the inflammatory action, generally terminates in suppuration, so
giving rise to what is termed _parulis_ or gumboil. Frequently the
inflammation extends to the sockets of the teeth, which seldom resist
the action long, but from their low degree of vitality soon become
necrosed; and by the presence of the dead portions of bone, a fresh
accession is given to the disease. Severe pain is experienced on
touching the teeth whose alveoli are affected; they project and become
loose; purulent matter is secreted, and oozes out between the loosened
teeth and diseased gums. Abscesses form, and point in different
situations; the gums are tumid and spongy; through the openings in them
the bone can be felt bare, and the purulent matter is situated within
or around the alveoli, and under the mucous membrane and cellular
tissue which invest them.
When the inflammation has been either intense from the first, or of
long duration, it not unfrequently happens that abscesses form within
the substance of the jawbone, and occasionally to a considerable
extent—a portion of the bone having become inflamed, and the action
terminating in suppuration and partial caries. This is more apt to
occur in the inferior than in the superior maxillary bone; and,
if allowed to proceed, the osseous cyst containing the purulent
matter gradually enlarges, the plates of the bone are separated and
expanded, the parietes become attenuated, and the affection is termed
spina ventosa. Purulent collections in this situation also seem, in
many instances, to arise from, or at least to be preceded by, the
formation of a cyst around the decayed root of a tooth. Such cysts
are generally of small size, and pyriform shape; externally they are
smooth, membranous, and of rather a delicate texture; internally,
they are lined by lymph of soft consistence, and contain purulent
matter. In fact, they are purulent depôts, which form in consequence of
inflammation around the fangs of the teeth, and from which the matter
is occasionally discharged through a small aperture at the upper part
of the cyst, and by the side of the affected tooth. They sometimes
attain a very considerable size.
[Illustration]
Mercury is perhaps the most common cause of this disease; but it is
also produced by certain operations on the teeth, and by the presence
of carious teeth or of stumps.
_Caries of the teeth_ is an extremely common affection, and in some
instances seems to arise from an unhealthy state of the constitution;
but it is most frequently produced by the teeth having suffered from
chemical agents, as when the mineral acids have been taken for a
considerable time as medicines, or when the individual is in the habit
of consuming sweetmeats, and confections. Sometimes the disease remains
almost stationary, and may give little or no annoyance for a number of
years; in other instances, its progress is very rapid. A portion of the
tooth gradually decays, and this is at first unattended with any uneasy
sensation; but when, from continuance of the destructive process, the
central cavity has been exposed, the pain is excruciating, attended
with headache, and swelling of the surrounding soft parts. In general,
the progress of the disease may be arrested by removing the diseased
portion, and stuffing the cavity, before any pain has been felt.
But after the central cavity of the tooth has been exposed, filled
with fungous mass, as here seen, or from their growing in a faulty
direction, and pain consequently experienced, the most effectual
remedy is extraction. The patient from whom the specimen below was
obtained, perished in consequence of the extensive abscesses of the
mouth and neck, consequent upon the awkward position of the wisdom
tooth.
[Illustration]
From the presence of carious teeth, or decayed portions of teeth, many
evils both local and general ensue, besides inflammation and abscess.
They are frequently the cause—and the sole cause—of violent and
continued headaches; of glandular swellings in the neck, terminating
in, or combined with abscess; of inflammation and enlargement of the
tonsils, either chronic or acute; of ulcerations of the tongue or lips,
often assuming a malignant action from continued irritation; of painful
feelings in the face, tic doloureux, pains in the tongue, jaws, &c.;
of disordered stomach, from affection of the nerves, or from imperfect
mastication; and of continued constitutional irritation, which may give
rise to serious diseases.
Along with abscess of the gums, purulent matter often collects in the
cellular tissue of the cheek or of the chin. In the latter situation,
the inflammation and suppuration are often caused by the teeth in
the front or side of the lower jaw being too much crowded together.
When the teeth are crowded together, the patient, of course, cannot
be effectually benefited till one or more of them are extracted, and
sufficient space allowed for development of the others. The abscess
gives way, and discharges its contents often both externally and
internally, and a fistula remains, which cannot be got rid of, unless,
as in most other affections, the cause be removed. The cavity of the
abscess must be opened into either from without or within, and after
the subsequent irritation has subsided, the cause must be removed;
carious teeth or stumps are not to be taken away during the inflamed
state of the parts, but after the pain and inflammation has subsided in
consequence of free evacuation of the purulent matter. After these have
abated, and not till then, the offending bodies are to be extracted,
both in order to procure a more speedy and effectual cure, and with
a view to prevent recurrence of the disease. If a portion of the jaw
has become necrosed, the sequestra are to be extracted as they become
loose, and openings and counter-openings must be made, according to
circumstances, so as to afford a free outlet to the matter.
The extraction of teeth, the crowns of which have not been destroyed,
is accomplished most readily by the dexterous use of variously shaped
forceps. Stumps may be occasionally extracted also by forceps, but
the lever is generally required to loosen them from their sockets.
The old key instrument and pelicans are now superseded by those above
mentioned.[37]
[Illustration]
_Spina Ventosa of the Jaw_ often originates, as before mentioned, in
a small cyst at the root of a decayed or dead tooth. An enormously
large one extracted along with the stump attached is here shown: it is
sketched from a specimen in the collection of Mr. Nasmyth, of Edinburgh.
The disease is usually situated on one side of the lower jaw; but
sometimes occurs in the upper, and is at first unconnected with the
cavity of the antrum. Inflammation has taken place in the internal
structure of the bone; matter is secreted by the medullary vessels, and
collects in the cancellated texture. Purulent formation advances, the
cancelli are broken down, the external laminæ of the jaw are extended,
protruded, and attenuated; and then the internal cavity enlarges,
containing pus, perhaps mixed with other fluids, and with disorganised
particles of bone. Sometimes the collection proceeds slowly, and the
expansion of the bone is gradual and uniform; in other instances, the
swelling rapidly attains a large size. As the disease advances, the
bony parietes become remarkably thin and delicate, particularly at
the more prominent parts of the tumour; and at many points bone is
deficient, and its place supplied by membranous expansion. Occasionally
alteration of structure takes place in the cyst; solid matter is added,
either bony or fibro-cartilaginous, and morbid action proceeds in the
new deposit. In acute cases, in which the secretion and distension
are rapid, severe pain is felt in the part at the first, and usually
continues but little unabated; when the swelling is slow and gradual,
considerable pain is experienced during the inflammatory stage, but
soon diminishes, or ceases entirely. In every instance, the features
are deformed, and the functions of the mouth more or less impeded.
Osteosarcoma may supervene on spina ventosa—morbid action occurring
in the parietes, and morbid deposit ensuing, as in the following
instance:—The patient was a male, aged twenty-one. Swelling had
existed for a considerable time at the posterior part of the lower
jaw on the left side. The wisdom tooth and last large grinder, their
pulps probably having been blighted, never appeared, and the swelling
occupied their situation. The bone was expanded on each side; the upper
surface of the tumour was soft, its growth had been gradual, and no
great pain or uneasiness was experienced. I cut out an oval portion of
the cyst where it projected into the mouth, and well-digested matter
was evacuated; a seton was then passed out near the angle of the jaw,
and worn for some weeks. The plates of the bone approximated, the
cavity contracted, and the discharge ceased. Two years afterwards rapid
swelling took place in the same situation, suppuration occurred, and
the matter was again discharged by incision; the tumour then subsided.
Again inflammatory swelling occurred twelve months afterwards; the
same course was followed and the patient relieved. A hard swelling
now occupies the jaw from its angle to the canine tooth, it is
increasing in size; the necessity for its removal is apparent, and has
been decided upon. Very shortly after writing the above, the patient
submitted to the disarticulation and removal of fully half of the jaw,
represented here. He made a rapid recovery, and showed himself to me
and the pupils at the hospital a short time since, and fully five years
from the time of the operation, in remarkably good health, and very
little deformed by his loss. His whisker effectually conceals the mark
of the incisions.
[Illustration]
But in general, after free evacuation of the purulent matter from a
bony cavity, even of very large size, the space between the parietes
diminishes rapidly, the distended and attenuated bone contracts and is
condensed, the new deposition is absorbed, and the parts regain their
natural and healthy appearance.
In the slighter cases of spina ventosa, removal of the offending teeth
or portions of teeth, is generally sufficient; the matter escapes
freely enough from the sockets, and the discharge soon ceases. When the
cavity is considerable and its parietes thin, a counter-opening at the
base of the jaw is required; and it is often of advantage to introduce
a small cord from the opening in the mouth through the counter-opening,
and to continue its use for a short time, drawing it backwards and
forwards in the cavity occasionally. For making the counter-opening
and placing the seton at the same time, a strong needle in a fixed
handle is most convenient. This practice I have employed in a good many
instances, and can confidently recommend as successful. In a large
spina ventosa, not complicated with solid growth, the parietes may be
removed freely and with safety; the cavity is dressed to the bottom,
and gradually fills up by granulation. The division of the integuments
to expose the tumour must vary according to the circumstances of the
case; the incision of the bone will generally be accomplished by a
strong bistoury. Such procedure will seldom fail in procuring a cure,
and is less severe, less dangerous, and productive of less deformity,
than division of the jaw and entire removal of the diseased portions,
an operation which can very seldom be warranted for spina ventosa. In
the following case, the tumour was the largest of this kind which I
have met with in the jaw, and yielded to the treatment just noticed.
The patient was a male, æt. 48; he applied to me in 1821. The tumour
had been of three or four years’ duration, equalled a large fist in
size, and involved the left side of the lower jaw at the junction
of the ramus with the body of the bone. The sac extended behind the
coronoid process, and downwards, through the substance of the jaw,
amongst the hyoid muscles. Several carious teeth and stumps were
imbedded in the swelling; the projection was chiefly lateral, the
parietes were yielding, and the line of the jaw could be traced from
below. There was occasional slight discharge of purulent matter from
the neighbourhood of the involved teeth. The cheek was laid open, and
the bony and cartilaginous parietes of the cavity completely removed;
the bleeding from the bony surface was arrested by cautery and pressure.
The soft parts united kindly, and the patient obtained a rapid,
perfect, and permanent cure, returning home with the cheek united in
ten days after the operation.
_Solid Tumour_ of the Lower Jaw—_Osteosarcoma_—commences in the
internal structure of the bone, frequently in the neighbourhood of
stumps. The origin may be traced to external injury of the part; or the
disease may take place in the jaw, either along with osteosarcomatous
tumours of other bones, or subsequently to their development; in such
circumstances a peculiar disposition of the system is the only cause
that can be assigned. The tumour generally occupies the lateral parts
of the bone. Its growth may be either slow or rapid, and is attended
with dull uneasiness, rather than acute pain. At first the morbid
deposit is confined to the cancellated texture, but as it increases
the external laminæ are distended, and at last give way at one or
more points, and the tumour protrudes fungous into the mouth. The
consistence of the mass is various, it may be soft and brain-like,
or cartilaginous, mixed with bone and fibrous matter in various
proportions; but the anatomical characters of these tumours have been
already detailed, and need not be here repeated. The features are much
deformed, the swelling seriously incommodes the neighbouring parts;
the teeth loosen and drop away, and fungi arise from the sockets; a
fetid, thin, sometimes bloody discharge is secreted copiously, and the
health declines. The part protruding around the gums is deeply indented
by the teeth of the upper jaw; it separates the jaws to a greater or
less extent, prevents closure of the lips, induces salivation, and
impedes the taking of nourishment. The tumour is one of those which
are apt to be reproduced, and if unmolested, gradually undermines the
system, and ultimately the patient perishes very miserably. At one time
every instance of it was regarded as hopeless; but of late a great
many tumours, in various stages of advancement, have been removed
successfully by British and foreign surgeons. In some instances,
the portion of the jaw containing the morbid growth has been sawn
out; in others, one half of the bone, or more, has been removed by
disarticulation, after being divided beyond the diseased part. A very
few weeks ago, I had occasion to remove fully three-fourths of this
bone, from the site of the first large molar on the left side to the
condyle of the right. The patient, an elderly female, is convalescent.
The operation is severe, and to a spectator shocking enough; but it can
be undertaken with safety, and in most cases with almost a certainty of
favourable termination. In no other way, assuredly, can the disease be
eradicated. Partial excisions, applications of the cautery, &c., only
hasten the malignant process.
To expose the tumour and admit of the bone being readily divided,
incision of the soft parts requires to be extensive. And previously to
determining on the plan of operation, the extent of the disease must
be ascertained accurately. If, for example, the tumour is included
between the lateral incisor tooth and last molar on the same side—these
teeth must be extracted to permit division at these points. A semilunar
incision may then be made along the base of the jaw, the horns of the
incision pointing upwards and passing over the space which was occupied
by the extracted teeth. The flap is dissected up, and the membrane of
the cheek divided along the line of incision. The bistoury is then
carried along the inside of the bone so as to divide the membrane of
the mouth and separate the attachments of the muscles. The tongue is
pushed aside, and a copper spitula placed under the jaw at the part to
be divided, in order that the soft parts may not be injured during the
sawing. A small narrow saw, or one commonly known by the name of Hey’s,
is applied to the bone at the points where the teeth were extracted,
and by a few motions of this instrument a notch is made of no great
depth; a pair of strong cutting pliers are placed in the track, and by
them division of the bone is accomplished with equal neatness, and
much more rapidly than if the use of the saw had been continued. The
pliers should be strong in every point, and the handles long, to afford
the advantage of a powerful lever. In edentulous subjects, as the one
alluded to above, there is no necessity for using the saw at all: the
bone is at once and easily cut by the forceps. The chain saw has been
recommended for performing the section of the bone, but I have not yet
seen one to be depended on; it is not only slow, but uncertain, in its
operation.
The incisions may be made otherwise. The cheek may be divided by
passing through it a long narrow bistoury, close to the anterior edge
of the masseter muscle, and carrying the instrument forwards and
through at the angle of the mouth. From each extremity of this incision
another is made downwards, the anterior one inclining forwards, the
other backwards. By reflection of the flap thus formed, the bone is
exposed more easily, rapidly, and perfectly, than by the former mode
of incision. The objection to this mode of procedure is the deformity
occasioned by the scars, though, if care is taken in putting the edges
together, this is very slight indeed, and not remarkable.
In either method, no artery, except the facial, requires to be secured
by ligature. After division of the bone, the attachments of the
tumour, which may not have been separated previously, are cut with the
bistoury, the cavity is filled lightly with charpie, and the incisions
are carefully and neatly put together, and retained by points of
interrupted and twisted suture; the latter form of suture being adopted
at those points where accurate coaptation is most important.
The _symphysis_ of the lower jaw has been removed, and its extirpation
may again be rendered necessary, either on account of tumour commencing
in its internal structure, or from disease of the sockets extending
deeply and approaching the base. I removed it in a case of malignant
disease, by which, and by the applications used as remedies, great
ravages had been made on the under lip; the gums and alveoli were
involved, as also the bone, to a considerable extent, without any
apparent affection of the lymphatics. Nothing untoward occurred in the
operation, and the case was proceeding favourably; but after some weeks
the patient was seized with violent erysipelas of the face and head,
and perished. One objection to the operation is, that the muscular
attachments of the tongue to the symphysis cannot be divided without
some risk; the antagonist muscles are unrestrained; the os hyoides
and root of the tongue may be drawn backwards upon the forepart of
the vertebræ, so as to close the air-passage, and cause suffocation.
This is guarded against by the introduction of a thick ligature. The
disposition to retraction soon ceases.