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in the hard palate a half-inch in length. Front teeth quite loose from necrosis of the maxillary bone. These were at once removed. Rhinoscopic examination very difficult to make, as the uvula and soft palate were much swollen. Large ulcers on the pharynx. To combat the specific poison the patient was put upon iodide of potassium, two grammes, and increased to four grammes a day, with tonics and nourishing food.
April 29, 1875, operated for the extirpation of the necrosed bones. There were present Drs. A. C. Post, J. T. Darby, Leonard Weber, L. B. Bangs. All the necrosed bones were removed by the revolving multiple knives through the opening in the palate and through the nostrils. The necrosed palatal vault, both inferior turbinated bones, and a small portion of the vomer, were removed through the opening in the palate ; through the nostrils, all the necrosed portion of the maxillary bone, and the anterior portion of the vomer and ethmoid.
The posterior portion of the vomer was now seized with the forceps, and removed. By this means the soft parts covering the vomer were left intact, so that by a rhinoscopic examination the posterior part of the septum was seen as before the operation. In this case there appeared to be a reproduction of bone in this part of the vomer, and, to some extent, of the hard palate.
A few days after removed by the knives some small necrosed portions of the intermaxillary, after which the parts healed rapidly. The voice somewhat nasal in tone until the opening in the palate was closed.
In October, 1875, about six months after the extirpation of the necrosed bones, uranoplasty was performed for the closure of the opening in the hard palate, which was now three-fourths of an inch in length. After removing the mucous membrane from edges, an incision is made on each side of the fissure through the soft parts and newly formed bone of the hard palate.
The soft parts were cut through by means of a galvanocautery knife, and so had no bleeding. The bone is now pierced by the drill, and the bone separated by a chisel after the method of Sir William Ferguson; or it may be sawed through, and then they are sprung together and the fissure thus closed. In this case four horse-hair sutures were used to hold the flaps together.
These side-incisions must be kept open by packing them, or removing the granulations each day, to prevent healing until the edges of the fissure are united. A gutta-percha splint is now fitted and worn over the palate. This prevents the food, fluids, and air from causing disturbance to the healing process.
I present wax models of this case, taken from casts of it before, during, and after completion of the operation.
It will be seen that the external appearance of the nose has not altered in shape, notwithstanding the nasal .septum and bony palate upon which it rests, are gone. Have never seen the nose fall in, except when the cartilage or nasal or maxillary bones were involved, -in other words, the bridge of the nose.
CASE II.—Mrs. F. C., aged 21; born in New York State, was sent to me by Dr. J. Marion Sims. She was married in 1865; then quite healthy; has had three still-born children, and one now living.
In January, 1872, had inflammation of the brain, which was afterwards followed by inflammation of the bowels. In 1873 had severe neuralgic pains on the bridge of the nose, centre of the hard palate, and left side of the face. This was followed by a swelling of the centre of the hard palate, and all the upper teeth were extracted. In December, 1873, when she came under my care, her condition was as follows: Her physical powers were very much reduced; constant pains in her head; a hole in the left canine fossa; great discharge from the nose and mouth. By rhinoscopic examination, and by a probe through the hole in the canine fossa, I discovered necrosis of the nasal septum and turbinated bones of both sides.
The specific origin of disease being recognized, she was put upon iodide of potassium, tonics, cod-liver oil with phosphates. December 26, as there was a good deal of pain and swelling of the nasal septum, it was lanced, and bled freely, and gave her great relief. January 4, 1876, lanced the nasal septum again. February 3, periostitis of the left nasal bone externally appeared; applied a leech. February 4, swelling and pain gone. February 9, patient having improved in strength, but still suffering intense pain, removed all the necrosed bone by the revolving knives. In this operation removed the vomer, lower portion of the ethmoid, inferior and middle turbinated, maxillary walls of both right and left antrum, and a good portion of the hard palate. Present, Drs. George A. Peters, E. L. Keyes, F. R. Sturgis, and G. H. Fox. February 10, found the patient going about the house attending to some of her household duties; no pain since the operation., February 13, removed small pieces of the intermaxillary bone. March 6, had some swelling of the left side of the nose, extending under the eye.
Feeling herself so much better after the operation, she had neglected to take the potassium as ordered, and this is the penalty of such disobedience. Ordered a leech, and increased the dose of the iodide of potassium to four grammes per day. March 8, swelling very much reduced and pain nearly gone. March 10, pain and swelling gone. There was a small amount of pus on the left side of the nose, which was drawn away with the aspirator. April 10, patient expresses herself as being nearly well. Iodide of potassium reduced to two grammes every other day. Cod-liver oil to be continued. June 23, 1876, patient now quite well, and by a rhinoscopic examination no discharge was discovered. There now only remains the opening of the canine fossa to be closed.
NECROSIS OF VOMER AND VAULT OF THE HARD PALATE, ETC.
CASE III.-Dr. F. N. Otis, of New York, referred to me William H. G., aged 27 years, of London, England, who, before leaving home, had been under the care of Dr. R. Living and Dr. W. J. Coulson.
Two and one-half years ago had the specific initial lesion, and is now in the third stage.
He now has necrosis of the vomer and vault of the palate, with a small hole in it. Fetid discharge from the nose occasionally stained with blood from excessive granulations. Administered iodide of potassium and cod-liver oil. Local treatment consisted in blowing into the nasal cavities iodoform and camphor triturated to an impalpable powder, with subnitrate of bismuth and sulphate of potash to reduce the superabundant granulations, and so have less bleeding during the operation. By invitation of the late Professor James R. Wood, M.D., to deliver a clinical lecture on extirpation of bones of the mouth and nose, I operated on this patient at his clinic at Bellevue Hospital, January 15, 1880. Administered four ounces of whiskey before the operation, and kept him under the influence of nitrous oxide during the operation, which lasted about fifteen minutes. No external incision was made, and the necrosed vomer, lower portion of the ethmoid, both inferior turbinated bones and vault of the hard palate, were removed by the revolying knives through the nostrils.
No portion of the soft tissue on the hard palate was removed. On the completion of the operation, he was directed to blow his nose to free his nasal cavity of the cut-up necrosed bones and blood, and then he was positively forbidden to again blow his nose for the next twenty-four hours. After that time the clotted blood is carefully removed by the dressing nasal forceps, and the nasal cavity completely covered by blowing in the iodoform and camphor powder.
On the second day a nasal douche is given before the application of powder.
On the next day after the operation he was able to attend to his daily duties.
The wax model illustrating his case shows the opening in the palate one-fourth inch in length before the operation. Atrophy of the nose before the operation, from the non-respiration and constant blowing of the nose, as seen in the right alie, and the development of the alie, as seen in the left side of the nose, after the operation.
The other model shows the opening in the palate closed and a new deposit of bone over the palate.
IIe is in perfect health at the present time.
My time or your patience will not allow me to extend the subject farther, or to show that tooth disease may lead to necrosis, caries, abscesses in jaws, antrum, salivary glands, tonsils, cheeks, throat, and nose, producing naso-pharyngeal catarrh, amarosis otalgia, and disturbing the whole system in many ways.
When we consider these many diseases, how important it is that they should receive proper attention. But it cannot be denied that there is a vast amount of ignorance in the profession in regard to them. And it is also to be deplored that a great number of oral, nasal, eye, and ear troubles are often the result of unskilled dental operations.
Out of such necessity comes a desire for instruction and improvement, hence the formation of this section.
I sincerely trust that the day is not far distant when we shall have endowed universities where every branch of the healing art and allied sciences will be theoretically and practically taught.
BY WILLIAM D. KEMPTON, M.D., D.D.S.,
From the beginning of the school of medicine up to a comparatively recent period the sole aim of practitioners was to discover remedies that would cure disease. Consequently, patients were often dosed with substances that were, if not harmful, at least disgusting. If they recovered, even though it were in spite of medication, the drugs received all the credit.
There came a time, however, when investigators began to inquire into the causes of diseases, with the hope of discovering some means of preventing them, and their efforts were gradually crowned with success.
The profession is, however, indebted to specialists for many, if not most, of these discoveries. To the ophthalmologist is due the discovery that the virus of purulent conjunctivitis is carried from patient to patient by means of towels, wash-basins, sponges, etc. I might enumerate many other bequests made by the specialists to the profession.
Although Jenner, who discovered the virtues of vaccination, was a general practitioner, still the specialist, by devoting his energies to a comparatively small territory, is more apt to arrive at definite results than he whose attention is occupied by the whole field of medicine. Yet, unless his efforts are seconded by the profession at large, they avail but little, as those who consult the specialist are already suffering from maladies that might have been prevented, in many cases, had the medical attendant pointed out to them the necessity of such prophylaxis, and only when more attention is paid by medical schools to “oral pathology” can much real good be expected from the efforts of dental surgeons in this direction.
So much for preliminaries.