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THE MONTHLY REVIEW
OF
DENTAL SURGERY:
_THE JOURNAL OF THE BRITISH DENTAL ASSOCIATION_
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NO. VIII. OCTOBER, 1880. VOL. I.
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The subjects rightly embraced in a Medical education, and the degree and
manner in which those subjects should be respectively studied, have been
freely discussed in many places during the last few weeks. Dr. Michael
Foster in an “Address in Physiology,”[1] of unsurpassed interest,
contends without contradiction that no medical subject—now that the
entrance upon medical studies is preceded by a tested preliminary
education—need be studied as heretofore as a mere mental training, and
proposes that topographical anatomy, which has hitherto been so studied,
should, to a certain extent, give way in favour of a more complete
knowledge of physiology. The address must, and no doubt will, be read by
all interested in medical education, whether general or special. The
following quotation will answer our present purpose:—
Footnote 1:
Address in Physiology, delivered at the Annual Meeting of the British
Medical Association, 1880.—Published in _British Medical Journal_,
August 21st, 1880.
“I think I am not overstating the case when I say that, in the two
years (or less than two years) which the medical student devotes to
studies other than clinical, 60 or 70 per cent. of his time—in some
cases even more—is spent on the study of topographical anatomy. That
study may be regarded in two lights—as a discipline, and as
practical useful knowledge. The late Dr. Parkes, in a remarkable
introductory address which he delivered at University College,
London, many years ago, insisted most strongly that its value as a
discipline was far higher and more precious than its direct utility;
and I imagine that the more one reflects on the matter, the more
clearly this will appear. The details of topographical anatomy have
this peculiar feature, that, though they can only be learnt with
infinite pains and labour, unlike other things hard to learn, they
vanish and flee away with the greatest ease. I would confidently
appeal to my audience of practical men, how much of the huge mass of
minute facts, which in their youth they gathered with so much toil,
remained fresh in their minds two years after they passed the
portals of the College; and how much now remains to them beyond a
general view of the parts of the human frame, and a somewhat more
special knowledge of particular regions, their acquaintance with
which has been maintained by more or less frequent operations. I
would confidently ask them what is the ratio, in terms of money or
any other value, which the time spent in those early anatomical
struggles—say over the details of the forearm—bears to the amount of
that knowledge remaining after twenty, or ten, or even five years of
active practice, or to the actual use to which that knowledge has
been put.
“No, it is as a discipline, and not for its practical utility, that
anatomy has been so useful; and this, indeed, may frequently be
recognised in the questions set at examinations. When the candidate
is expected to describe, within the error of a few _millimètres_,
the structures traversed by a bayonet thrust obliquely through the
neck, or is invited to reproduce written photographs no less exact
of the parts which, from skin to skin, underlie a triangle or
quadrangle drawn in ink on the front or back of the thigh, it is
clear that the examiner has in view, not the needs of practical
life, but an easy means of testing the proficiency of the student in
mnemonic gymnastics. Of the value of anatomy as a discipline, there
can be no doubt. In past years, it has served as the chief culture
of the medical student—as the chief means by which the rough
material coming up to our great medical schools were trained to
habits of accuracy, of exactness, of patient careful observation;
and their memories strengthened by exercise for the subsequent
strain which would have to be put upon them by more strictly
professional learning. In this aspect, the very sterility of the
subject was a virtue. The mere fact that the separate details seemed
to hang loosely, isolated in mental space, held together by no
theory, by no ideas, inasmuch as it made the learning a harder task,
increased its disciplinary value. Most wisely did the leaders of our
profession insist that no trouble or expense should be spared to
afford the neophyte this preparatory scientific training; and that,
as far as examinations and the like can go, no pains should be
spared to compel him to avail himself of the opportunities offered.
Indeed, viewed as a branch of education, the machinery of anatomical
instruction has for many years past not been equalled by any.”
Professor Burdon-Sanderson in his introductory lecture, says,—
“The precious years which immediately precede a man’s entry on
professional duty, are far too valuable to be wasted in learning
anything he does not intend to retain.”—_British Medical Journal_,
October 9th, 1880.
The observations of these most distinguishing physiologists and
teachers, support the view which has been taken respecting the education
of the Dental Surgeon, from the time the College of Surgeons was in 1857
asked to establish a Dental department, up to the determination of the
Dental curriculum by the Medical Council in 1879.
An education equal in degree, but different in kind to that of the
General Surgeon—an education which embraces a knowledge of the general
principles of Medicine and Surgery, and a special, precise, and
practical knowledge of Dental Surgery, was asked and given, the degree
of education progressing as the attendant circumstances allowed, up to
its present advanced condition.
The place assigned by Dr. Michael Foster to topographical Anatomy in
Medical education, will certainly hold good in the education of the
Dental Surgeon. Physiology and Chemistry, subjects now inseparable and
of surpassing interest, are equally necessary to the Special and General
Surgeon.
The position of Medicine and Surgery is not quite parallel. The general
principles of each must be thoroughly known, but it is not necessary
that the Dental Surgeon should be practically acquainted with all the
details that pertain to any other branch of either than that which he
selects to practice. It is not needful that he should become a skilful
midwife or oculist, or that he should be skilled in the treatment in any
other class of diseases than those to the treatment of which he proposes
to devote his life. For if he does acquire such detailed knowledge, it
will, when no longer used, “fade like a raindrop upon a porous stone,”
and the time devoted to the acquisition will have been wasted, and,
perhaps, worse even than wasted, for the subject may have been studied
at the cost of neglect of the practical study of his speciality. It does
not admit of doubt that the high degree of manual skill, without which
the professed dentist is but a shameless pretender, can be acquired
best, perhaps can be fully acquired only during youth; that if the
acquisition be put off till a medical education is completed, the golden
opportunity will have been lost. Mr. Fawcett tells us that the blind may
acquire manual skill sufficient to secure independence, but that it can
be gained only during youth. The adult blind, he says, have a greatly
diminished power of learning.
The time may come when the principles of Medicine and Surgery will be
taught before their special application to any particular class of
disease, and their modification resulting therefrom is entered upon.
Till that time arrive, it will be in the interest of the Dental Surgeon
to study with the utmost care the general principles and their
application to his own speciality, and to acquire, while he can, a very
full and perfect knowledge, practical, as well as scientific, of Dental
Surgery, before he enters upon a detailed study of their application to
any other branch or subject of Medicine or Surgery, the practice of
which he does not propose to follow, and a trustworthy knowledge of
which can not be retained or extended in the absence of continuous
general practice.
The qualified surgeon who has devoted himself to the practice of
dentistry, may be legally qualified to treat any and every kind of case,
but would he be morally right in undertaking the treatment of a case,
say of fever or of stone? all his knowledge of which diseases lies in a
misty memory of facts brought before his notice, and studied for a pass
examination in long past student days. As a matter of fact, the dental
surgeon of necessity limits his practice to his speciality, and the
general surgeon as a further fact, where selection is possible, declines
to take Dental cases, though legally entitled so to do. In the absence
of special training, he cannot be expected to possess the special
knowledge requisite to successful treatment, and to add the Dental to
the over loaded Medical curriculum, would be to greatly increase the
rejections which, in the case of the College of Surgeons, have already
risen to the formidable amount of upwards of thirty per cent. of the
candidates for diplomas. Hence it is that Dr. Michael Foster, in asking
for more physiology, asks for less topographical anatomy.
The Dental curriculum requires for its honest fulfilment, the whole of
the assigned four years, and more must not be attempted in the same four
years, for to repeat the words of Professor Burdon-Sanderson,—“The
precious years which immediately precede a man’s entry on professional
duty, are far too valuable to be wasted in learning anything he does not
intend to retain,” to which may be added, or which his subsequent
occupation will not allow him to retain. If then more medical knowledge
is required of the student than is embraced in the dental curriculum,
more time must be given for its acquisition.
Transplantation and Replantation.
(_Continued from page 425._)
At the period when transplantation was systematically performed, the
operators kept themselves supplied with an assortment of dried teeth,
_i.e._, sound teeth, obtained generally from the dead subject, to make
use of in case the tooth to be transplanted should not prove adaptable
to its new abode. The process is not spoken favourably of, as the
results were mostly unsatisfactory, but at times such teeth became
perfectly firm, and even resisted the greatest efforts at their removal.
We can hardly for one moment suppose that teeth in the condition these
were could have ever become attached to a living alveolo-dental
membrane, and the difficulty of accounting for this firmness would have
been great indeed, had it not been already solved for us. In
Langenbeck’s Archiv. für Chirurgie, vol. iv., is a paper on “The
Replantation and Transplantation of Teeth,” by Dr. A. Mitscherlich,
which deserves to be better known, and which, apparently, cannot have
come under the observation of those who recently contributed to the
_Lancet_ on the subject, the excuse for which is less, since it has been
translated into English.[2] The author, in addition to much interesting
and original matter, records the following experiment. In the upper jaw
of a dog of a year old, Dr. Mitscherlich inserted into the socket of an
incisor he had removed, a similar tooth taken from a dog’s skull, and
which he retained in _situ_ by means of a silver wire passed through a
hole in the tooth, and a hole bored through the alveolar process of the
jaw. “After six weeks the dog was killed, having been given during the
last few days three grains of picronitrate of potash three times a day;
the carotids were immediately injected. The muscles, like the gums, were
coloured yellow: neither, however, in the implanted tooth nor in the
sound ones was any alteration of colour perceptible. The silver wire was
porous, and no longer held the tooth; it was removed. The tooth was
quite firmly seated, and could not be moved in the least by the fingers.
The gums, as in the remaining teeth, were accurately applied both to the
alveolar process and also to the tooth itself, and nowhere could any
alteration be found in it. The tooth was sawn through lengthways,
together with the upper jaw, with a fine saw, so that the pulp cavity
was laid bare in its whole extent. The latter was only filled with a
little detritus, and no trace of the pulp was discoverable; none of the
injection, too, had been forced into the cavity. The tooth was
everywhere most intimately connected with the surrounding parts, and
suppuration showed itself nowhere. Of the periosteum, on the other hand,
there were only in a few places some small remains discoverable. On the
posterior surface of the tooth two small cavities were visible; the
larger of which lay more towards the point of the fang, and extended to
the pulp cavity; they were filled with a soft substance, and their walls
appeared roundish. These appearances were entirely confirmed by
microscopical examination, inasmuch as only in a few places, especially
on the anterior surface of the tooth, were traces of the periosteum to
be demonstrated; where this was absent the tooth was eaten away, and its
absorption had proceeded in such a manner, that a multitude of globular
elements appeared on the section, resembling the fragments which we find
in ivory pegs which have been bored into bones, and retained in them a
considerable time; in the two above-mentioned cavities the absorption
had proceeded farther and farther, and had at last attained its
above-mentioned great extent. The cementum could still be demonstrated
in certain places, it was, however, absorbed in the greatest part of its
extent. In the cavities of the tooth substance, masses of bone were
embedded, they were applied to the walls of the cavities without any
kind of intermediate substance, and so held the tooth with such
extraordinary firmness. This osseous deposit, which was directly
connected with the alveolar processes, was freely traversed with blood
vessels, which sometimes extended themselves close up to the tooth
substance. It was also so fully developed, that the process had to be
looked upon as fully accomplished, and therefore, a later exfoliation of
the tooth was not to be expected. The dentine itself showed nothing
abnormal.”
Footnote 2:
“Archives of Dentistry,” Edited by Edwin Truman, vol. i., p. 169.
We have quoted the author of the foregoing at some length, as some of
his conclusions upon this interesting experiment might seem antagonistic
to our own. Thus, whilst we agree with him in concluding that a dead
tooth becomes united to a living jaw by a certain amount of absorption
of its fangs by osteoblasts, and a subsequent calcification of such
tissue, we do not believe such process as fully accomplished or
permanent. The valuable researches of Tomes and De Morgan show that
during life a continual process of formation and absorption is taking
place in bone, whilst the former has also pointed out that the process
of absorption in the fangs of temporary teeth is one alternating between
absorption and deposition, though in the end in favour of the former,
_i.e._, that the osteoblasts which effect the absorption of the dentine
often become calcified, but are again eventually decalcified and become
active osteoclasts. What determines these bodies to act, so to speak, in
a positive or a negative capacity would be most interesting to discover,
and, in considering the subject, we can hardly overlook the views of Mr.
Bridgman, who compares the process of bone formation and decalcification
to what occurs in an electrolytic cell, where, by changing the direction
of the current, the electrodes assume precisely opposite functions.
If, then, we could discover the conditions that would preserve the bone
tissue, in connection with the dentine, from undergoing decalcification,
we might, with every prospect of success, transplant dead teeth, but
which, as at present carried out, invariably, we believe, eventually,
suffer the fate of ivory pegs introduced into the extremities of bones
in disunited fractures. Indeed, this result, although more slowly
effected, appears nearly always to follow in those cases where the
transplanted or replanted tooth has lost much of its alveolo-dental
membrane; whether the excising of a portion of the fang, as advocated by
Magitôt, will prove beneficial or otherwise, remains to be seen.
Porcelain teeth having indentations in their fangs have been suggested,
first, we believe, by Mitscherlich,[3] and again by a recent writer in
the _Lancet_. The former actually attempted two cases, and with the
success we should have anticipated, for when after four or five weeks
the caoutchouc splint which retained them in _situ_ was removed they
immediately followed the splint and fell out. “Ossification had not
taken place; the entirely heterogeneous mass of stone had acted as a
foreign body, produced granulation and suppuration, and so prevented
union.”
Footnote 3:
_Op. Cit._
In conclusion, we think enough has been stated to show that
transplantation or replantation of living teeth, or at all events, of
teeth having living alveolo-dental membrane may be exceptionally carried
out with benefit to the patient; if the chances of permanent success be
not very great the chances of injury are, we believe, small, and have
been greatly exaggerated. No such case has come under our observation,
but then in all we have witnessed, the transplanted or replanted tooth
has never been ligatured or otherwise forcibly retained in its alveolus.
We believe many of the cases of failure, as probably those also of bone
exfoliation, arose from this procedure. A tooth, after either operation,
although at the time perfectly adjusted to its proper position, becomes,
after a day or two, elongated from its socket and less firm; the result
of effusion into the alveolo-dental membrane and about the tooth; as
this material becomes organized it forms, no doubt, the medium of union
between the dental and alveolar portions of that membrane. At all
events, after a week or so the tooth again recedes into its socket, and
as it does so becomes firmer and less sensitive to pressure; if our view
be correct, the employment of a ligature or forcible retention of the
tooth can only be objectionable. A very different matter, however, will
be the adjustment of a plate contrived so as to protect the transplanted
or replanted tooth from violence or pressure until its attachment is
ensured.
Mercurial Amalgams.