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order to obtain its effects. Moisture is necessary to its absorption, for the fluids containing the cocaine must be taken up by osmotic action by the contents of the tubuli. For this reason it is better to apply it and give it the time requisite before the rubber-dam is applied. We read of experiments where the dam was adjusted, the cavity carefully dried with hot air, and the solution applied with no effect. Of course it failed, because the fluid soon dried and the drug became inert. The dry dentine absorbed a proportion, but not sufficient to obtain the toxic, benumbing effect necessary to insensibility. Therefore, it is necessary to apply it moist, and the best time is before the application of the dam. Ee-application being necessary every few minutes, nothing is lost by solution in the saliva, but considerable advantage is gained by the cotton being kept moist. By thus applying it other operations can be proceeded with in the same mouth.
It seems that the procedure most successful and satisfactory is about as follows: Apply the four per cent, or five per cent, for twenty minutes. If not quiet, re-apply for the same time, and repeat, if not conquered. If not insensible then, or nearly so, re-apply for the same time, and repeat as often as may be necessary. If, after repeated applications, the pain cannot be controlled, you will, of course, acknowledge defeat. But there are very few cases which four or five applications of twenty minutes each will not conquer; usually two or three will suffice. The time required to wait must be utilized upon other operations in the same denture or for other patients. This time necessary to secure its effects is the great drawback to the employment of the cocaine, and will require us to re-arrange our method of appointments. It is, under our present system, the great impediment in the way of its universal use, and an objection which as yet we cannot overcome. At present, if we cannot employ the time on other operations in the same denture, or . upon other patients, it is a dead loss, and costs more than the effect of the cocaine is worth. Our minutes are literally golden, and our time in hours the greatest expense we have, and we can ill afford to wait half an hour or more for an obtundent to take effect. Besides, every hour in the day has its appointed work, which cannot be deferred because a cavity happens to be unexpectedly sensitive. This is a matter that yet remains to be provided for, and until the methods are improved to shorten the time required, or our system re-organized, the new anesthetic is impracticable in every-day workIt is better for our time to continue the practice of inserting temporary fillings for sensitiveness, and dismissing the patient until another sitting.
Except for the time required to secure its effects, cocaine will be
come to us a very useful remedy, and it will retain its place in our cabinets for the occasional employment where the favorable disposition of our time will allow us to use it in sensitive cavities.
In extracting it does not, as yet, seem to be of much value. By copious application to the gum, as well as injecting it around the tooth beneath the gum to reach the pericementum, and over the roots, inside and out, in the hope of its being carried by the circulation to the parts beneath, some reduction of sensibility can be attained, but not sufficient to render its use any way reliable. The superficial parts can usually be made insensible, which is often desirable, but the agony of the dislocation cannot be reached by it. Hence its use in extraction is limited.
The operation of injecting at the foramina of the dental nerves was not experimented with by the writer. It seems to be a perilous operation, and is necessarily impracticable and uncertain. The effects being uncertain, the risks encountered do not warrant its constant use. The great danger from this operation is that injury may be inflicted upon the nerve-trunk, either by the needle or the injection, and permanent paralysis ensue. With this possibility staring us in the face, we may well consider the propriety of attempting that operation at all, and of giving preference to the general anesthetics for extensive operations of extracting. For simple sensitiveness of cavities, it is an unmitigated folly to run the risk of paralysis for the alleviation of pain which can be overcome in other ways. Being impracticable and dangerous in skillful hands, it should not be attempted by the ordinary practitioner.
In conclusion, we may safely say that we have, in the hydrochlorate of cocaine, a very useful addition to our pharmacopoeia. Its use is limited, at present, by the imperfection of the methods we employ, and by our insufficient knowledge of its properties and powers. When these have been improved, as they should and must be, we can accomplish much in alleviating the pain incident to dental operations, and, perhaps, dispel some of the terror with which our ministrations are viewed.
THE OLINIOAL SIGNIFICANCE OP SECESSION OF THE GUM.
BY HABRISON ALLEN, M. D., PHILADELPHIA, PA.
The recession of the gum from the necks of the teeth has been studied, so far as I know, as a phenomenon entirely distinct from those changes of a morbid character which occur on other portions of the mucous membrane lining the mouth, the nose, and the throat. I will attempt, in this communication, to trace the connections which may be assumed to exist between the gums and the membranes with which they are continuous.
The first instance of recession of the gum which came under my notice was in 1879, when a gentleman, aged thirty-six, who was suffering from a serpiginous ulcer in the roof of the mouth, and who had also had an abscess in the right maxillary sinus, requested an opinion as to the nature of the palatal lesion. I believed the ulcer to be of syphilitic origin, since he gave a history of synovitis, with recurrences for three years succeeding the first attack, in the shoulders, the knees, and the toes. He denied, however, the specific nature of his complaint, and declared the arthritic complications to be gouty. Evidences of chronic pharyngitis were conspicuous; the pharynx was of small calibre, exhibited infiltrated walls, and the uvula was large and edematous. The recession of the gums from all the teeth was strikingly shown. The patient was the brother of a well-known dental practitioner, who pronounced this condition pyorrhea alveolaris. The disease was thus found associated with chronic pharyngitis, ulceration of the hard palate, and a constitutional sta.te which was certainly either syphilitic or gouty.
The next case came under my care in December, 1883. A gentleman, aged thirty, reported for the relief of so-called chronic pharyngitis. He acknowledged^having been a masturbator for many years. He had suffered from spermatorrhea, and for the last ten years from a constant disposition to hack. He referred a peculiar sense of dryness and thirst to the region of the pharynx. Moderate epistaxis existed, yet the patient did not complain of the ordinary symptoms of catarrh. The gums were everywhere of a peculiar white, macerated appearance, and were markedly retracted from the necks of the teeth, so that the cementum of each root was exposed fully a line in height from the enamel to the beginning of the gum. There was no purulent discharge noticed, yet, when the patient was referred to Dr. E. C. Kirk, the diagnosis was made of pyorrhea alveolaris. In this case the roof of the mouth exhibited in the interval between the teeth and the region occupied by the rugae a broad, uniformly flat surface, the crescentic marks, which in the normal hard palate correspond to the palatal aspects of the several teeth, being entirely absent. The rugsB were crowded together, and presented a peculiar lumpish appearance. Associated with the dental condition were the ordinary evidences of chronic nasal catarrh, notwithstanding the curious fact that all the symptoms were referred by the patient to the pharynx.
In a third instance, a gentleman aged forty, who had contracted the habit of masturbation in youth, but had long since abandoned it; who had been married about ten years and was the father of a healthy child, was referred to me by Dr. S. Weir Mitchell for an opinion respecting the nature of a pharyngeal distress, which consisted in constant hacking and a sense of fullness referred to the region above the palate and associated in the mind of the patient with a constant disposition of mucus to collect at that point and to fall to the lower part of the throat. The appearances described in the preceding case of the hard palate and the necks of the teeth were very conspicuous. Pyorrhea alveolaris was undoubtedly present.
The fourth case, a gentleman thirty years of age, exhibited the characteristic features of lupus of the throat. This condition was of fourteen years' duration, and was associated with marked atrophy of the turbinated bones and with all the characteristic signs of pyorrhea.
The fifth instance was a gentleman twenty-nine years of age, who for ten years had complained of hoarseness and a disposition to hack, excited heart, and impaired circulation. There was an acknowledgment of the habit of masturbation, which lasted for three years during early manhood. The prepuce was tight, the glands macerated, and the bladder irritable. He had undoubtedly recession of the gums from the upper and lower incisors an.d the upper bicuspids. There was an unusually large amount of tartar collected on the lingual surface of the lower incisors.
Remarks.—In the five cases described, it is noted that all were males, and, with the exception of the case last mentioned, they were all in middle life. The local lesion of the gums corresponded to those referred to pyorrhea alveolaris. In two of the instances named, at least, this diagnosis was confirmed by dental practitioners. It would appear to be more than a coincidence that in all the ^lvq cases, which includes the entire number of examples of recession of the gum which have come under my notice, some constitutional depressing condition existed. The list embraces one case of syphilis or gout; three of spermatorrhea, and one of lupus. So far as I know the association of pyorrhea with any of these affections has never been noted. That all these patients should have had catarrh or troubles referable to the pharynx may be a coincidence, yet this is by no means probable. Prof. E. T. Darby has informed the writer that he has in several instances detected the evidences of catarrh in patients reporting to him for treatment of pyorrhea.
The association of catarrhal states with recession of the gums would point to the conclusion that such catarrhal disposition would be atrophic in character rather than hypertrophic, and would lead the observer further to the conclusion that a disposition to atrophy of the gum need not be a local dyscrasia, but may be simply the most superficial lesion of a group of lesions which may be spread over the mucous membrane of both nasal chambers and even of the throat.
Many observations of interest might be made upon the palatal rug© and the gums. In hypertrophy of the gums the rugae are apt to be unusually pronounced. In the person exhibited as Krao, who is an example of hypertrichosis, the anterior group of-rugae are of enormous size. I was interested in making this observation from the fact that excesses of hair-growth are apt to be correlated with aberrations of nutrition in the gums. So far as I know no studies on the atrophy of the gums have been made. May not systematic researches of these important topics be looked for from those who have opportunities for study in our dental dispensaries?
In conclusion, the evidence supports the belief that a careful study of the gums will assist the observer in framing diagnoses of pharyngeal and nasal diseases; and in addition, that the care of pyorrhea alveolaris should embrace the condition of the entire system of mucous membranes of the mouth, the throat, and the nose.
Philadelphia, No. 117 S. Twentieth St., April 21, 1885.
EEDUGTION OF FEAOTUEE OF LOWEE MAXILLA-APPLIANCES.
BY JOHN H. MEYER, D.D.S., NEW YORK, N. Y.
(Bead before the Brooklyn Dental Society, February 9, 1885.) Joe Haff, a driver by occupation, thirty-three years of age, was admitted to Bellevue Hospital, August 18, 1884. Upon examination he was found to suffer from a compound fracture of the lower maxilla and from several scalp wounds, in one of which the bone was exposed. There existed also a few lacerations and contusions of the face and neck. The point of fracture was between the lateral incisor and cuspid of the right side. The left lateral incisor was missing. There existed also an external abscess. The displacement was five-sixteenths of an inch inwards and one-half of an inch downward. On September 16 a scale of bone half an inch square came away from the end of the outer fragment. At Prof. Bryant's surgical clinic, on September 27, forty days after the accident, I took impressions of the upper and lower jaws in plaster of Paris, for the purpose of making an interdental splint, and models were made as shown in Fig. 1. No effort up to this time had been made to reduce the fracture. The displaced portions were then separated in the model and articulated to the upper teeth, and in that position cemented together before forming the splint. The splint was then made upon the reconstructed plaster cast shown in Fig. 2. In this case a splint was made, as shown in Fig. 2 in position, for the purpose of widening the arch. This was done, at the suggestion of Dr. Kasson 0. Gibson, on account of the long standing of the fracture