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up is from the first bicuspid to the second molar, and the patient strongly objected to gold showing. There was a further complication of a close bite, with its attendant risk of breaking porcelain facings. I decided in this case to make the bridge in two sections. I fitted a gold crown over the molar and a "Richmond" cap on the bicuspid root. I then took a plaster impression of these in position and fitted a piece of No. 9 gold on the gum between the two teeth and soldered it to the band and crown (fig. 8). I then prepared three bosses on this base, one to form a socket for the pin (C, fig. 7) to slip into, and two others for the reception of screws (A and B, fig. 9), and over the base-plate I fitted another plate to which were soldered the porcelain facings (fig. 7). The plate carrying the porcelain facings is fixed to the bridge by screws, and in case of breakage the screws are very easily removed. (See diagrams 7, 8 and 9.)
This brings to a conclusion my short paper. There are many points I have not mentioned, but I have no doubt that you will be able to fill up the gaps yourselves. I have endeavoured to make my remarks as practical as possible and yet to keep within the time allowed me. I may say that in designing the bridge described my sole consideration has been how to supply the deficiencies of my patients with the minimum amount of pain and the maximum amount of usefulness, two things not always easy to accomplish; but if by a few extra hours' work in the laboratory we can save our patients any pain or discomfort I think it is our duty to do so..
Abstracts and Translations.
Some Morbid Conditions of the Mouth.
THE first of a course of three lectures by Mr. Edmund R. Roughton, B.S.Lond., F.R.C.S.Eng., delivered at the Medical Graduates' College and Polyclinic, on February 10, upon "Some Morbid Conditions of the Mouth," we select the following extracts from, as reported in the Lancet :
During the ten years that I have been attached to the National Dental Hospital I have gained the impression that diseases of the mouth, and more especially of the teeth, are not so familiar to medical practitioners as they ought to be. I think that it is unfortunate that there are no facilities for the newly qualified man who is preparing for general practice to attend a short dental course, not indeed with the object of becoming proficient in dentistry, but to furnish him with a knowledge which I am sure would prove of great use in after life, more especially to those who are about to practise in country districts, where expert dentistry is not obtainable. This remark applies with even greater force to Army and Navy surgeons. Another reason why dental disease does not receive the attention it deserves at the hands of the general
practitioner is that there is a tendency amongst many medical men to regard dental disorders as the exclusive province of the dentist, and as having nothing to do with medicine or surgery proper.
The mouth is a very perfect bacteriological incubator, and as a natural consequence is at all times teeming with myriads of micro-organisms. For our knowledge of the mouth bacteria we are indebted chiefly to Professor Miller, of Berlin, who has shown that very many varieties of organism, both pathogenic and non-pathogenic, may be found in the mouth; he has isolated and cultivated more than one hundred different species and has established the fact that the mouth is the receptacle and often the breeding ground of many specific organisms and is the source through which many serious, and even fatal, diseases may take place.
The conditions which obtain within the mouth are extremely favourable for bacterial growth. The temperature-viz., 37° C.—is that at which we keep our warm incubators in the laboratory; sufficient access of air is afforded for those germs which require oxygen or are indifferent to its presence. Food materials (culture media) are present in abundance; fragments of food remaining after a meal, cast off epithelial cells, saliva, buccal mucus, inflammatory exudations from the gums, exposed pulps of teeth, and even dentine itself when decalcified, all serve as culture media for bacterial growth.
With such favourable conditions and the frequent entry of germs into the mouth with air, food and drink, it is little to be wondered at that so many organisms are constantly found; indeed, one might expect to find every germ in the bacteriologists' catalogue were it not for the fact that the struggle for existence is in operation here, as elsewhere, causing the stronger to prevail and the weaker to perish. Thus it happens that although many species of bacteria may be at times found in the mouth, the regular tenants are but few in number. There are about six species of organisms which seem to find the conditions of the mouth exactly to their liking; they flourish and crowd out all others. Do they do any good? Do they do any harm? The first question has not been as yet fully answered, but it is probable that they take some share in the process of digestion. That these bacteria may do harm is well known. I propose in these lectures to deal with some of the morbid conditions which they produce.
It is well known that extensive dental caries may be present without toothache or pain of any kind, especially so long as the person is in good health; but it not uncommonly happens that diseased teeth, previously the seat of little or no pain, are prone to ache when the patient has become lowered by disease or exhaustion or when the buccal secretions become vitiated by dyspeptic derangement or in pregnancy.
In acute inflammation of the antrum severe toothache and facial neuralgia are common, especially when temporary blockage of the ostium maxillare leads to retention of discharge under pressure. In such cases even teeth which have long since been extracted may appear to ache. This is doubtless due to involvement of the superior dental nerves. In chronic empyema of the antrum pain is not common and when present is often in the supra-orbital region, and may lead to a false suggestion of disease of the frontal sinus. Syphilitic nodes, foreign bodies, exostoses, necrosis, or other lesions involving some part of the fifth nerves might be added to the list of diseases causing healthy teeth to ache or to seem to do so. Lastly, there are cases of toothache and pain in other parts of the distribution of the fifth nerve not due to any discoverable organic lesion of teeth, nerves, or other parts.
I now come to a branch of my subject which is of a more speculative character, the so-called dental reflexes. Unfortunately, a knowledge of these undoubted reflex neuroses has led many writers to attempt to explain away many obscure symptoms and conditions, most of which probably have nothing to do with the nervous system. The sympathetic system is their sheet anchor, and they seem to think that the chief function of these imperfectly understood nerves is to produce pain in the wrong place and to lead the practitioner away from the true scent in his hunt for the seat of disease. The specialist is usually the worst offender in this respect, and it may be remarked that he does not usually try to refer symptoms in his own little sphere to disease in distant parts that he is not accustomed to operate on. As far as my experience and reading go, the dentist is not prone to over-estimate the remote effects of dental disease, the records of so-called dental reflex neurosis being from the pens of practitioners in other branches of the healing art. It is, however, an undoubted fact that reflex spasm may be due to dental disease. I have frequently seen cases in which trismus or inability to open the mouth was dependent upon spasm of the muscle of mastication due to an impacted lower wisdom tooth. Owing to want of room between the second molar and the ramus of the jaw, or owing to some malposition of the tooth itself, the wisdom tooth is unable to assume its normal position, and by the pressure it exerts on neighbouring structures sets up irritation which induces a state of tonic spasm of the masseter, pterygoid, and temporal muscles.
Although muscular spasm may certainly be of dental origin it appears very doubtful whether paresis or paralysis is ever due to the same cause. There are, however, many cases on record in which so-called reflex paralysis is attributed to dental disease. Thus Gillman, Evarts, and Coale each record a case of facial paralysis due to carious teeth; Whitney relates a case of paralysis of the arm from dental irritation, and Salter gives a case of paralysis of the arm from an impacted and carious wisdom tooth, and others might also be cited. But although the paralytic conditions are usually said to have disappeared after dental treatment it seems to me very difficult, if not impossible, to prove that they were due to the teeth and not really of the nature usually designated "hysterical "-whatever that may be.
Many cases of ophthalmic disease supposed to be due to diseased teeth are on record. Pain in the eye and excessive secretion of tears may certainly be due to dental irritation, but so far as I can discover there is no authentic case which definitely proves that any actual eye disease is really a reflex dental neurosis.
Mr. Henry Power believes that carious teeth are a common cause of phlyctenular ophthalmia; the two conditions, however, are so common that it would be strange were they not often associated. Sir W. J. Collins, who has devoted much attention to oculo-dental affections, asserts that he knows of no case of ophthalmoplegia of any kind due to dental disease.
It must be admitted, however, that there are some cases on record in which the association between dental disease and amaurosis is, to say the least, remarkable.
Many diseases of the ear have been attributed to dental disease, but I think without sufficient evidence. Epilepsy, mania, delusions, and other nervous disorders, including neuroses of the alimentary canal, larynx, heart, and uterus, as a sequel of dental irritation have from time to time been described by
writers. When I say that amongst the list may be found cases of vicarious menstruation and urethral catarrh, you will probably agree with me that I have pursued the subject far enough.
On a Simplification adapted to the Mode of Fixation of Immediate Prosthetic Apparatus in Resections of the Mandible.
BY DR. CLAUDE MARTIN (LYONS).
(Abstracted from a Communication read before the Munich Congress,
August 4, 1902.)
ABOUT twenty-four years ago I proposed the method of immediate insertion of a prosthetic apparatus after resection of the maxillæ. I desire now to indicate an important simplification in the fixing method in one of the more complex cases, and you will be able to judge of its advantages and application.
My practice, since 1877, has remained fundamentally the same in the 130 to 150 cases where I have had occasion to apply immediately a prosthetic apparatus. Numerous publications have appeared on this subject, and I must acknowledge that in Germany the most attention has been given to it quite recently, in June, 1901, Dr. Fritzsche, of Leipsic, having devoted to it much consideration. Others, such as Boennecken, Röse and Stoppany, have but partially adopted my method. I remain, nevertheless, persuaded that this is due to an exaggeration of its difficulties. From the extreme variety of the cases I have encountered I am convinced that my method is adapted to all exigencies. And for this reason I have made no essential change in my practice, which, in my view, is simpler, more rapid, and offers greater security.
I will not cite all the cases in which application of this prosthesis has been made, but will describe one which, to me, presented at the outset the greatest difficulties in the construction of the apparatus and its maintenance. When the resection affected the body of the mandible comprising a portion or the whole of the ascending ramus, the means of fixation had to be modified, and was more complicated. In fact, the apparatus could only be fixed to the bone by that extremity adjoining the remaining fragment. The other extremity was liable to be raised, and impinge upon the posterior wall of the upper maxilla of the same side, forming an obstacle to the closing of the mouth, and to deglutition. It was necessary, therefore, to firmly attach the apparatus to the fragment remaining. This was done as follows: The teeth implanted in this fragment were encased in a grooved splint of tinned steel plate, or even of vulcanised rubber. This was fixed to the apparatus by means of a metal plate, which was screwed or soldered to the encasing piece, and fixed by means of screws to the artificial mandible. To give greater fixity, I have often been obliged to employ a spring attached to an upper plate in order to keep down the mandible. This supplementary fixture must in no case replace the external plates, which, fixed by screws, unite the remaining fragment with the artificial mandible and insure the maintenance of the apparatus.
To obtain a firm attachment in cases of this sort it is needful to have recourse to rather complicated apparatus; consequently there will be occasional failures, especially by beginners. Hence I have felt great satisfaction
in modifying, or simplifying, the procedure. To-day their attachment is much simplified; two screws suffice, in fact, to give them all the necessary solidity. To the apparatus which is to be joined to the remaining fragment I fix first, as usual, on the internal side a plate to be applied simply to the internal surface of the osseous fraginent; then, to the external portion I fix two plates (as in all apparatus of this kind) which on the one hand are screwed to the remaining artificial piece, and on the other to the remaining fragment; but instead of being horizontal they must be crossed in X-fashion. This simple arrangement renders the encasing piece unnecessary, and gives even greater solidity.
Where the immediate prosthetic apparatus is not between two osseous fragments, it is necessary to retain the fragment in its normal position by wings which prevent it from being drawn inwards.
As I have frequently described these wings, I will only recall the fact that one of the plates which compose them is fixed to an upper plate, the other to a little piece supported by the remaining fragment; the lower plate ought to pass outside the upper in such a manner that the latter prevents the deviation of the fragment inwards. These plates should have a sufficient length to slide upon each other and remain in contact.
This wing-system can also be employed for ante-operative cases where for some reason immediate prosthesis is undesirable. For it is well to avoid as far as possible the deformity resulting from the resection, and particularly the luxation inwards of the remaining fragment. The winged apparatus, put in place before the operation, retains it in relation to the superior maxilla. Moreover, they facilitate the subsequent adaptation of appliances to depress the tissue of the resected part, and thus restore the outline of the face.
It must be noted, nevertheless, that this ante-operative prosthesis is only possible when there is a certainty of leaving sufficient of the mandible to afford support. It is necessary to fit the apparatus at least the day before the operation, so that the patient may be accustomed to it; withdraw it at the moment of operation and replace immediately after.-Translated abstract from L'Odontologie, September 30, 1902.
On the Use of Alkalies in Relieving Pain.
THE presence of acid in a carious tooth is a most potent cause of toothache, and my friend and colleague, Sir Dyce Duckworth, has shown how toothache may be stopped almost magically by putting into the decayed spot a little cotton wool dipped in sodium bicarbonate and thus neutralising the acidity. The sodium bicarbonate may be mixed with laudanum, or cocaine, or both, in order to lessen the irritability of the nerves of the tooth, but very often this is quite unnecessary, and the sodium bicarbonate is quite efficacious by itself. When pain is felt, not in one tooth only, but in all, it frequently depends on irritation of the roots of the teeth just at the edge of the gums by acid fluid in the mouth, the gums themselves being sometimes a little retracted. This pain may be generally removed by rubbing a little sodium bicarbonate along the edge of the gums with the fingers, or by thoroughly washing the mouth out with some sodium bicarbonate in water. The strength of the solution is no great importance, but