Page 67 - An essay on the diseasesof the jaws, and their treatment

— DISEASES OF THE JAWS. 45 Tlie second indication is, to procure the most favourable dis- charge of the matter, and promote the healthy action of the parts lions rather than to the removal of the excitmg cause of the disease. Yet by his own reports it is evident that no progress was made in the case till after the exciting causes were removed. The tedious and ineffectual treatment detailed by Mr. Bell at pp. 234—7 of his " Anat. Phys. and Diseases of the Teeth," exhibits a strange neglect of one of the first principles of surgery, namely, the paramount importance of removing exciting causes. The efforts of the surgeon in this disease, especially when it affects the antrum, are generally too exclusively directed to evacuating the matter confined in the maxillary cavity and acting upon its lining membrane by stimulants. Confinement of matter in the antrum is, undoubtedly, the immediate cause of the enlargement of the parts, but it is no more the real origin of the disease than is confined matter in any other position, when occasioned by the presence of a foreign body, the cause of the attendant suppurative inflammation. This is dwelt on by most writers as affording the first and principal indication, whereas it is clearly secondary. In respect to injections, as an auxiliary to the operation of perforating the sinus, no great reliance is to be placed on them, as is very evident from the progress of Dr. Harris's case, as well as from Sir Benjamin Brodie's observations on the subject. The latter of these gentlemen relates two cases in which a dis- charge from the antrum continued during life, notwithstanding the persevering use of injections, and he states that " in some cases the patient recovers perfectly after the operation and in others not."— (" Medical Gazette," vol. xv., 1S34,) The whole treatment of the elder surgeons may be comprised in this one sen- tence from Mr. Benjamin Bell's " Syshem of Surgery," vol. iv. p. 521 :— " In the treatment of abscesses of the antrum maxillare, nothing will accomplish a cure but our giving a free discharge to the matter." Modern surgeons, however, pay more attention to the true nature of the disease, and consequently do not neglect the re- moving of the local exciting causes of irritation ; but it must be confessed that few of them have any knowledge of the effects of a thorough dental treatment, and that they are generally but too ready to press upon nature the services of the knife. Mr. Lawrence, in speaking of the morbid irritation resulting from affections of — the teeth, says: " In cases where pain or uneasiness may be experienced about the jaw, it is expedient to pay close attention to the state of the teeth and gums —to examine them carefully, to see that they are in a sound state ; or, if not, to take care that any decayed or rotten stump should be removed, so as to take away the irritation; or if the gums are found in the condition that I have men- tioned [spongy, detached from the teeth, and discharging purulent matter], to take care that suitable means be put in practice by the dentist to put a stop to the disease."— ("Medical Gazette," 1830, p. 456.) Mr. Liston's precepts in — regard to the treatment are: "You take out whichever tooth is decayed perhaps one large or two small grinders—and all the stumps that are present, with the view of relieving the irritation, getting more readily at the antrum, and making a sufliciently large opening." " There can be no doubt as to the propriety and absolute necessity of taking away all sources of irritation as a pre- liminary step to operations of any kind on tliis cavity."— (Lectures in " Lancet," 1840—1.)—Mr. Fergusson takes much the same view of the treatment, but he speaks less decidedly of th6 removing of the sources of dental irritation. Before perforating the antrum, " it will be best," he says, " to extract any stumps or diseased teeth immediately below, as possibly the inflammation and suppuration may be at the root of a fang. With stumps removal should be immediately resorted to ; but if a tooth be sound, or tolerably so, it may be a question as to whether it should be removed or not. K there is great tenderness on pressing upwards, it should be extracted."— (" Practical Surgery," p. 4S0.)