PROFESSOR ERICHSEN'S LECTURES ON THE

SURGERY OF THE MOUTH AND JAWS.

ON Tuesday, November 29th, Mr Erichsen delivered his third lecture on the "Surgery of the Mouth and Jaws," at the College of Dentists. Having expressed regret at the unavoidable postponement of the lecture from the previous Tuesday, Mr Erichsen said that he had hitherto confined himself to the subject of malformations of the mouth and jaws. He now proposed to proceed to the consideration of injuries of the soft parts-the cheeks, lips, and structures within them; also to observations on dislocations of the lower jaw.

Injuries of the cheeks, lips, &c., resulted from cuts, blows, and accidents of all kinds; it was always the object of surgery to effect union, in such cases, by the first intention, in the same manner as in hare lip, namely, by bringing the parts into apposition and securing them with stitches or pins, until complete re-union results, particular care being necessary in treating injuries about the lips.

The inconveniences attending wounds about the cheeks were then described. If the parotid gland be cut there is danger of salivary fistula; these fistula are very difficult to heal. When the stenonian duct is wounded the best plan of procedure is that adopted by the French surgeon who used a seton to form an aperture-an oblique seton aperture, which allows the saliva to flow away, so as not to prevent satisfactory union. Mr Erichsen then remarked, he wished it to be distinctly understood that the fact of his addressing an assembly of dentists did not imply that dentists were the practitioners who should treat the injuries &c. he was engaged in describing, but he considered it essential that the educated dentist should well understand their nature.

The lecturer proceeded to explain the various characters of wounds of the cheeks, palate, &c., caused by gunpowder, and he dwelt at some length at suicidal attempts on life by means of firearms, detailing the particulars of a case under his care, in which the suicide had adapted fan "italian iron" to the purpose

of self-destruction, by drilling a hole near the back part, and loading the interior with gunpowder; the iron being then placed in the mouth and fired from the touch-hole, inflicting frightful injury. Generally speaking, in such lamentable cases as these, little or nothing can be done beyond extempore treatment according to the nature of the injury.

Fractures and dislocations of the lower jaw were now described, some prefatory remarks on the construction of the skull and bones thereof being given, in which the employment of the arch in every direction was pointed out, as designed to impart strength and power of resistance, the arch being of all mechanical forms the best adapted to repel pressure of external force. The superior

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maxilla was rarely fractured, except from gun-shot injuries which were, of course, as likely to be inflicted on one part of the body as another. Le Druin, Wiseman (an old surgeon of the time of Charles I.) and others had, it was true, recorded cases of fracture of the superior maxilla; but such cases were nevertheless very rare, except in military practice. In treating these fractures, very little could be done beyond placing the fractured portions of bone in apposition, and bringing together the soft parts, there keeping them in situ by means of silver thread. A rule to be observed in practice is never to remove a tooth, however loosened, as experience had proved that in apparently hopeless cases, teeth loosened by violence, may acquire adhesion, and become firm and useful again. Fractures of the lower jaw are infinitely more common than fractures of the upper jaw, and would be still more frequent were it not for its arched shape, and the thickness of bone at the lower part. The construction of the lower jaw is of a nature combining strength with lightness. But this, notwithstanding, fracture of the lower jaw is frequent, and more so with men than with women, by reason of the former being more exposed to the action of violence in their avocations. The lower jaw may be broken at any part; but the fracture generally occurs at the side of the symphisis. A fracture of the symphisis itself is very rare, although it does sometimes occur. In some instances a fracture occurs on each side of the symphisis, constituting a double fracture; thus the centre of the jaw becomes detached and drawn down by muscular force, so as to render it difficult to replace the fractured parts in normal position. Sometimes again fractures occur near the ramus; but this is very rare, except from gun-shot injuries. Cases are on record, where the condyles of the lower jaw have been broken off. These accidents have been occasioned by kicks, as from a horse, by blows from the fist, by falls from a height, or by other acts of violence. Fractures of the lower jaw may be always recognised. The signs are-the loss, to a certain extent, of the contour of the mouth, an irregular outline of the teeth, the teeth on one side appearing higher than the other. On examining the interior of the mouth, bleeding will be observed at the seat of fracture. On telling the patient to bite or antagonize the teeth, a crepitous or grating sensation is perceptible. Another and sufficient proof of fracture may be obtained by the surgeon taking hold of the lower jaw, and ascertaining its seat with the fingers. In fractures of the lower jaw, there is much pain, and dribbling of saliva.

Surgeons divide fractures into simple and compound-simple where the skin remains unbroken; compound where the fractured lines are exposed to the air. In fractures of the lower jaw the gum is generally lacerated, and the injury compound, so that the process of healing is naturally retarded. The teeth in such fractures are frequently loosened.

The treatment of fractures of the body of the lower jaw was then explained, by the lecturer, as consisting of two or three methods, namely, the use of a four tailed bandage, adjusted to the chin, and fixed round the neck and head; but this plan is not very efficient. A good method is to tie the teeth on each side of the fracture together (two or three teeth away from seat of fracture), but silk thread should not be used for the purpose, as the strain upon the ligature, together with the action of the fluids of the mouth, would soon destroy the agent. Metallic ligatures, gold or silver thread, will keep the fracture in correct apposition. The thread should be applied, if possible, without touching the gum, as it was likely to cause irritation there. Loose teeth should never be removed if it is possible to retain them. In some cases they should be retained in situ by tying, rather than remove them. A simple means of keeping a fracture together is to mould a piece of gutta-percha, so as completely to grasp the lower jaw.

Mr Erichsen here clearly showed the manner of applying the gutta-percha, by means of bandages. When a very perfect union is required, an instrument, of a somewhat complicated, though most efficient nature, must be employed. This instrument was designed by the late Mr Lonsdale, of the Orthopaedic Hospital, who died suddenly two years ago. It consists of a rest for the lower jaw, and attached appliances for keeping fractured parts of the jaw in complete apposition. The instrument was exhibited and the manner of its use demonstrated by Mr Erichsen.

The lecturer then went on to explain that compound fractures are tedious to unite in consequence of contact with the air. The manner of the cure of fractures was next considered This consists of an effusion of lymph, which, in simple fractures, becomes callus in six weeks; but in compound fractures the process is different and longer-granulations appear and ossify, three months being often occupied in the process. If the jaw is moved, callus or new bone does not form, but fibrous (gristly) tissue; the latter unites the parts, but not by the proper bone substance. Thus the jaw cannot be said to be properly cured, nor can it be used for any purposes requiring solidity. To obviate these defects the teeth may be capped, or inflammation may be induced by means of a seton to excite the effusion of lymph, so that new bone may be formed, using Lonsdale's apparatus during the process. Where the jaw is very severely fractured, there is danger from portions of bone becoming so mixed with the saliva as to render the latter horribly offensive, insomuch that typhoid affection may ensue. To avoid this, Dupuyten recommends an incision down the cheek to the seat of fracture, and a removal of loose particles of bone. In these severe fractures the lower jaw cannot be perfectly restored, but still a useful bone may be formed.

Mr Erichsen, after entering into some further details as to the modus operandi in fractures, then alluded to " disclocations" of the lower jaw. He pointed out the striking fact, apparent on examin

ing the articulation of the jaws, of the seeming ease with which the lower jaw may become dislocated by reason of the shallowness of the support at the point of articulation, the zygmoid cavity having but little depth. Nor is the lower jaw connected to the upper by strong ligaments (one excepted). So it would appear at first sight wonderful that it is not more often dislocated; but the want of depth in articulation, and the slightness of attachment by ligaments, is amply compensated for by strength of the muscles, which in reality bind together all the bones of the body, but especially is this the case with the lower jaw. Dislocations of the lower jaw occur more frequently in women than in men, there being less strength of muscle. The age at which it is most liable to occur is from twenty to thirty. It is said not to take place in old persons and children, although no doubt it had occured to such in rare instances. It occurs from various causes, as from violence, opening the mouth too wide, &c., and sometimes when the dentist is operating for the removal of a tooth..

The three distinct kinds of dislocation of the lower jaw were then described of both condyles or bilatoral dislocation; of one condyle uni-lateral dislocation; and sub-luxation, in which the dislocation is partial. The modes of reducing each of these kinds of dislocations was clearly explained-and, with some valuable observations on their after-treatment, the lecture was brought to a close.

On Tuesday evening, December 6th, Mr Erichsen delivered his fourth lecture on the surgery of the mouth and jaws at the College of Dentists.

Mr. Erichsen commenced by observing that, in his previous leeture, he had treated of the injuries of the jaws and of dislocation of the lower jaw; the several forms of the latter having been explained with one exception, namely, congenital dislocation of the lower jaw. This form of dislocation was shown to arise from a want of development of the temporal bone. The glenoid cavities of the temporal bone, not being existent at birth, it is supposed by some that their formation is owing to the working of the lower jaw; but this explanation appears too mechanical, their origin being more probably owing to a normal growth of the parts; and what is termed (perhaps incorrectly) congenital dislocation of the lower jaw, is owing to an abnormal development. The lecturer, having given some interesting details in illustration of this opinion, proceeded to advert to a peculiar class of injuries connected with dental surgery, and one of considerable interest to the dental practitioner, i. e., injuries which have occurred, and which do occur from the accidents of swallowing artificial teeth. The false teeth so swallowed, by lodging in the air passages or in the esophagus, are the cause of serious inconvenience and danger, life itself having been sacrificed in such cases. The term "swallowing" cannot properly be applied to this accident, as

we can only swallow into the stomach, and we do not "swallow" into the air passages; but foreign substances may be "sucked" into the air passages, especielly during the prevalance of a fit of laughter. Surgeons are conversant with such accidents. The case of the late eminent engineer, Mr Brunel, was quoted as an example. Mr Brunel, some sixteen years ago, accidentally had a half sovereign slip into the larynx, and it there remained until an opening had been made in the trachea for its removal.

Several cases are on record, in which false teeth have been drawn into the lungs. Such cases are always attended with considerable danger, when the foreign body cannot be expelled by natural efforts. The manner in which these foreign bodies are sucked in, may be understood by the familiar expression of "going the wrong way." Such accidents cause violent suffering, and have resulted in inflammation, afterwards ulceration and suppuration, terminating in death. The remedy alone available in these serious cases, is to perform the operation termed tracheaotomy, so as to form an aperture to allow the foreign body to be expelled through the larynx. Sometimes a considerable time elapses after the operation before expulsion.

In Mr Brunel's case six weeks intervened; and, in the meantime, he exercised himself violently by a turn-table, which turned him completely and suddenly over. In one of these exercises the half sovereign was happily expelled. For substances lodged in the larynx, bronchi or lungs, tracheotomy is the only remedy.

The danger from swallowing false teeth is enhanced by the sharp edges, &c., of the plate on which the teeth are mounted. The accident occurs sometimes during sleep, and sometimes whilst eating the teeth drop towards the back of the mouth, and are driven down into the esophagus. The shape of the piece is of a nature to render it impossible to push it either up or down, and the use of the probang is impracticable from the danger of wounding the walls of the pharynx and of the carotid artery, with the sharp edges of the gold plate. When the piece becomes fixed in the æesophagus it becomes necessary to perform what is termed the æsophagean operation; this consists in laying open the lower part of the pharynx-a delicate and dangerous operation but one, nevertheless, which has been performed successfully in several cases. Gutta-percha pieces are sometimes swallowed; these are removed with more facility in many instances, but not always. Mr Erichsen here recorded a case in which he had been consulted where the patient had three years previously swallowed some teeth mounted on a gutta-percha plate, and which could not be detected in the esophagus by the surgeons who had attended him, nor was Mr Erichsen more successful, for he could by no means detect the presence of the teeth. Nothing, therefore, could be done, and the patient went about his usual work as best he could. Two months after Mr Erichsen's examination, the patient, whilst at dinner, vomited a quantity of blood, and death immediately