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invasion of the deep structures, liquefaction of dences of destruction very similar to those en the bone and membrane is instituted, producing countered in the virulent form. Taken as a the pockets, filled with necrotic and purulent whole, the two types do not differ markedly matter surrounding the necks of the teeth. These except in the light of a few striking differentia pockets, as a result of their rapid production, features. In the latter, or non-virulent variety show an almost equal tendency to a lateral and the glands of the gums may entirely escape vertical extension. Their boundaries have sharp being involved, and when so affected it is nearly limitations as though cut away by an instrument, always secondary to long-standing foci of infec and immediately outside of, and bounding the tion located elsewhere in the tissues. Hence we pocket, is found the defensive wall of leuccocytes. have in this sub-division of the disease a more That portion of the pocket in close apposition nearly normal appearance of the gum tissue with the tooth involved has a greater vertical than is found at any time in the virulent variety range than any other part, so that the pocket In the latter stages, the gums appear flat and de formed resembles a funnel-shaped depression, pressed over the areas of subjacent alveolar the mouth of which is directed toward the roots necrosis, but aside from the presence of a flat of the tooth first attacked.

and collapsed appearance, nothing distinctive or The pericementum that normally encases the characteristic is noticeable on the gums. roots of the tooth and furnishes the attachment The production of the pockets by Done disser to the firm process is covered with fine granu- lution is started, etiologically, by factors nearly lar deposits of lime salts that in common par- identical with those engaged in the virulent form lance are termed “the serumal deposits." These --the chief distinguishing features consisting in deposits are very hard, and being firmly attached the nature of the resulting pathology. The de to the underlying membrane, are removed only velopment of this form of the disease is mor with great difficulty. The membrane, by the insiduous and the pockets formed, though deep time the disease has clearly asserted itself, has in the vertical direction, are more shallow hori suffered greatly from liquefactive and necrotic zontally. The margins of the pocket are ill-ce changes to so great an extent that only the ele- fined and irregular, so that the whole bony pro ments of Sharpey's fibres, embedded within the cess seems to be more or less completely an protective cementum, still retain their healthy progressively involved. condition. This they do, apparently, for quite à The peridental membrane, while sharing long time after the other elements have been the effects of the disease quite as extensively a destroyed. Studying the tooth itself, we find in the virulent form, seldom becomes the se on those root areas from which the peridental of lime salt deposits, and hence we are not calle membrane has been lost, deposits similar to those upon to deal with that obstinate feature in ou previously formed on the membrane. The at treatment of this form of pyorrhea. In substi tachment of the tooth to the process. has. tution for the calcareous deposits of the viru through the effects of the disease, been largely lent form, we often find soft, and apparently re destroyed, and as it is then very yielding, the cently formed, organic adhesions, which fre tooth easily goes into mal-position.

quently may be dealt with summarily in the firs Examining the neck of the tooth carefully.

sitting. we find striking evidence of extensive erosion

On studying the necks of the teeth carefully on the surface from which the gum has now

we find erosions similar to those met with i retracted, and over which the pus, coming from

the virulent form, though never so extensiv the chief seat of the disease, is seen to flow in

In addition to the erosions which serve to dis zbrindance.

tinguish this type of disease, a more strikin

feature is observable. The large quantities The Non-Virulent Variety

pus seen coming from beneath the gums in th In this type of the disease, no such surface virulent cases, are.

virulent cases, are wholly absent in the non-virt manifestations are seen, as are met with in the

lent, and are obtainable only by pressing on th virulent form, and hence the deep undermining gums, producing pressure on the underlying destructive elements often pass unchallenged struct into the very last stages, when the afflicted sub

The Catarrhal Type ject, alarmed by his loose and falling teeth, first As regards the third or catarrhal variety, w calls attention to his condition. Even then its find evidences of generalized tropic disturbi real nature frequently escapes detection and ances and long standing infection. The epight the patient is dismissed with the explanation that lial constituents of the gum suffer from atropiii nothing can be done for his relief. Of course degeneration and this is followed by a fibrou not-little or nothing can ever be done for an tissue overgrowth, giving to the gums a toug individual whose condition is unknown, but the leathery consistency and imparting the pal disturbance is really present, and if we but look grayish appearance characteristic of scar tissu deeply and examine carefully, we will find evi- The glands are involved in the disease proces


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with signs of a catarrhal-like disturbance. The for this disease, it is convenient to divide the secretion manifests itself as a profuse discharge treatment into prophylactic and surgical fields, of a thick, slimy, ropy consistency that adheres respectively. closely to all structures with which it comes in

Prevention contact.

This disease is absolutely preventable, and The alveolar process suffers more generalized when found existing, we may feel sure that an destruction in this type of the disease than in ill-kept mouth was the early or remote anteeither of the other two varieties. When the case cedent of the trouble. Poor or faulty prophylacis well advanced the bone is extensively riddled tic considerations in caring for the teeth may by liquefactive and necrotic processes, so that work their ill effect in two ways—either the the pockets formed are ill-defined and very ir- teeth are not kept free from organic matter, or if regularly marginated. Pus is present, though so kept, by faulty methods, injury may be only in small quantities, and is only very rarely wrought to structures, hard or soft, that will seen to exude from the pockets at the gingival predispose to the pyorrheal infection, margin.

In the first instance, the bulky accumulations In the catarrhal variety, the peridental mem

of organic matter, or the less noticeable placques brane enjoys no greater freedom from attack

and adhesions variously spread over the teeth,

furnish an ideal culture-bed for bacterial growth. than does the bony process. Liquefactive necrosis early obtains. Broadly speaking, so far as

The fermentation products from those accumudeposits on the teeth are concerned, we find that

lations, being kept in continual contact with the they are generally free from such, but the necks

gum tissue, lower their vitality, and thus make of the teeth, early present signs of distinct

possible the pyorrheal infection that is to follow erosions.

later. The gums and the ducts leading therefrom

become inflamed by the chemical and mechanical Causes of Pyorrhea

irritation produced by the presence of these In any localized disease, so diverse in nature,

foreign substances, so that the bacterial invasion so disastrous in results, and so notoriously ob

is readily made possible. The removal of these stinate in its treatment as in pyorrhea, it is very

substances is therefore clearly imperative, and natural to attribute its existence to a multiplicity

it is equally necessary to care for one part of of causative agents and so has it been with the the tooth as much as for the other. The interdisease. We should not be at all amazed at this proximal spaces, like the free surface, must be fact when we realize the frequent failures and kept free from all accumulations of foreign difficulties experienced by some in making their matter. diagnosis of the condition. A large majority of

Process of Treatment the cases completely escape detection until the In the treatment of the disease itself, after advanced stage is reached, and then, because of it is once established in any one of the previously the absence of purulent matter appearing at the mentioned varieties, we are ever to bear in mind gingival border, the diagnosis is often incor- its infectious nature, and like any other local inrectly made. Then, too, unchallenged by ra- fection, that it is to be treated surgically: tional treatment, the disease advances spelling surgical principles and indications involved in widespread disaster to the mouth, making it still the treatment of the disease are in no respect more difficult of recognition, and unfortunately different from those governing a similar infecthose few cases recognized early, have to extend tion of the arm or leg. The indications to be higher on the root than that point to which the met with here as well as elsewhere may be dealt peridental membrane extends intact and health with under three distinct heads, viz., first, reful. For this reason all the structures appear lieve the infection; second, pr greatly shrunken and the involved teeth much tion; third, stimulate a healthy, vigorous blood elongated and less firmly rooted in their osseous supply to the parts. The accomplishment of attachments. In this condition the gums will be these ends is indeed all-sufficient, so far as the seen to have fallen back and turned away from cure of the disease is concerned, but the diffithe neck of the tooth, causing eversion of the culty with which they are realized has constimouths of the ducts coming from the glands tuted our most baffling problem in the treatment higher up. This, together with loss of the gum of pyorrhea. ilap deprives the new attachment of its natural Preparations designed to assist in the realizprotection by the gum against food accumula- ation of each of the surgical indications sepations. In this way, sooner or later, loss of the rately have frequently been presented and their teeth or recurrence of the disease is made a efficiency tried, but to a remarkable degree the conspicuous end-result in the great majority of difficulties still prevail. cases dealt with by this form of surgical treat

Antisepsis ment.

In overcoming the infection in pyorrhea, we In outlining the principles involved in caring find difficulties of the most obstinate nature. In the great majority of the cases of drainage a preparation known as the pocket packer. the pus and other infectious matter is fairly well The pocket packer is a preparation of medicarried out by means of the openings leading cated paraffin that at body temperature is firm, from the pockets. However, some of the septic maintaining the form and position into which material always remains, and that element hav- moulded when heated for application. It is antiing the greatest responsibility in perpetuating septic, stimulating, and impermeable to moisture, the trouble takes its form in the deposits so often so that when applied over any portion of the found on the roots of the teeth involved. So gums and in openings leading from pockets, it long as they are present, resolution of the disease reduces the infection of the parts, together with process is an impossibility, their removal by exerting a stimulating effect on the tissue cells. harsh methods occasioned such damage that the In its chief capacity, owing to its antiseptic results have never been desirable. Efforts have qualities and the close contact which it assumes been made everywhere to secure some kind of with the disease-structures, it prevents the enchemical compound that would effect a dissolu- trance into these areas of any infective agents in tion of these deposits, but with what results you the form of food, moisture, or liquids from the all know.

mouth. We have thus reduced our difficulties The paste which is used in conjunction with to a parallel with those confronting a surgeon in the pocket packer and wet spray from the gas caring for an infected wound on any part of the machine, in a manner to be more fully ex- body. plained in the description of the treatment from

Nature Helps its clinical aspects, has for its field of useful ap- In the third surgical indication to be met, an plication the treating of pyorrhea pockets with effort is made to induce nature to render her astheir contents, as well as any recesses formed be- sistance in overcoming and effecting a cure of neath the gingiva and around the necks of the the local disease. By securing a hyperemia of teeth.

the affected part it is believed that nearly every Being highly antiseptic in nature, the paste morbid condition involving the tissues will be inhabits all bacterial growth in places where it greatly benefited, if not entirely conquered. The finds lodgment. By virtue of its dehydrating principle of hyperemia is one of the most ancient properties, it performs the double office of de- and yet most modern of surgical procedures. hydrating the toxins, besides inducing the for- Its beneficial influences seem manifold, and mation of a serous exudate into the pocket from possibly the greatest benefits we realize from the adjoining healthy structures. The toxins

our treatment are due to the hyperemia procontained within the pocket, because of the de- duced. All of the disease conditions seem rapidly hydrating influence of the paste, yield up one to improve upon its establishment, and that you molecule of water from each molecule of toxin.

may realize its possibilities. Professor Bier says Their nature is thus altered, and though still

regarding its effects: “I have not the least doubt harmful in action, they seem far less capable of that arterial and venous hyperemia relieves pain, exerting their former disastrous influences. As

that both are solvents, that arterial hyperemia a result of the serous exudate which is caused absorbs, and that passive hyperemia cures into flow from all of the tissues surrounding the fectious diseases, for I have seen these with my pocket, its passage through those structures own eyes innumerable times." supporting the fixed sanguinary deposits causes

Granting the fullness and accuracy of Profesa loosening of the elements, because of the fluid

sor Bier's findings, I am sure you will agree with formation which gathers beneath their bases.

me in saying that so potent a therapeutic agent This aids greatly in their detachment and be

is one of the greatest importance in the cure cause of its combined activities its application

of so obstinate a disease as pyorrhea; and with leads to an early resolution of the disease pro

it, we are in the possession of an invaluable cess.

means for not only arresting the disease, but also Reinfection

for curing it. The rebuilding of structures lost The second surgical indication which has for by the disease has been our most difficult probits object the prevention of reinfection of the lem, because in most cases the vitality of the parts under treatment, while less difficult of ac- cells seemed greatly impaired, but, owing to the complishment than the foregoing, is no less vital nutritive and invigorating effects of the hyperto the cure we are seeking. Located within the emia, reproduction of the lost elements is exmouth, and impossible of elimination, is the same tensively and often quite fully realized. On this group of organisms that caused the original in- Professor Bier has said: “The assertion that fection, and to prevent their admission into the hyperemia as such has a nutritive effect is very affected area is equally important with the elim- old, and it even seems that by means of hyperination of those engaged in the destructive pro- emia the deficient stimulus to formation of bony cess. Their entrance into the field of infection tissue in absent formation of callous can be is prevented by sealing the parts involved with fanned into life.”

From this we see how all important hyper- erties. We must not rest satisfied by the fulemia is, both in causing the elimination of the filment of any one indication alone. Having infection, and in promoting the activity of the done this, we may feel secure in believing that regenerative forces, and I am sure that to one our treatment will be effective, and a cure be who partially appreciates the defensive and life our reward. giving forces of the blood, a preparation, that, Rialto Building. when introduced within the soft tissues surrounding the teeth, is capable of producing a OBSTETRIC CLINIC. KANSAS CITY GENmarked and lasting hyperemia of the parts.

ERAL HOSPITAL This preparation, which is known as the ethyl

Under the auspices of the Medical and Surgical Club, held borate gas, is especially prepared, at the time

March 12, 1918. of its administration, in a machine particularly By Geo. C. Mosher, Senior Attending Obstetrician, and adapted to its making.

Buford G. Hamilton, Junior Attending Obstetrician.

Gentlemen :
Necessary Aids

It gives us a great deal of pleasure to see so

many of you interested in the work which everyThe gas is an unstable oxygen compound,

one of you who is engaged in general practice formed by the uniting of the Dunlop compound

must himself, encounter in his own experience. oxygen with the Dunlop ethyl borate solution.

Surgery of a major type is of value to you, In the free state it is a transparent, semi-volatile

mainly from the point of diagnosis, and you liquid of a slightly acrid taste, but pleasant odor.

send the patient to an expert operator in whom In the gas machine, and under pressure of about

you have confidence. Obstetrics you will yourone-half an atmosphere, or seven pounds, the self manage in a great majority of instances. liquid becomes surcharged with oxygen from

I see a number of my old students here and the specially prepared gas in the tank, and is

to them the clinic must be of peculiar advantage discharged through the needle as a highly diffus

as a contrast to methods which we taught and Pible oxyethl-borate gas with the oxygen in loose

practiced several years ago. It is hoped that combination. Upon its release into the soft tis

these ward walks and clinical demonstrations : sues of the mouth, the oxygen is separated from

may attract each month those of you who care the compound and passes into the blood, while

to follow out the demonstration of modern obthe ethyl borate is precipitated into the inter

stetric practice. You are always welcome. stices of the soft tissues. Though still active,

The greatest interest which is being manithe oxygen thus liberated is so modified as to

fested in the domain of obstetrics and gynecolhave lost considerable of its oxidizing powers,

ogy today is on the question of diagnosis and and is taken up by the blood without producing

those points which pertain to lessening shock any untoward symptoms. The oxygen joins

and minimizing dangers of sepsis. We shall with the hemaglobin, producing oxy-hemaglobin

have in the series of cases shown today an opand liberating the carbon dioxide locally from its

portunity to see how these are manifested. union. This, according to Professor Bier, in

The first patient, Mrs. C., is a primip, aet 32. creases either the resistance or phagocytic pow Her blood pressure ranges from 140 mm. to 160 ers of the blood. The carbon dioxide thus pre

mm. Her urine shows albumin and casts. She cipitated when taken up by the red corpuscles,

has some headache but no other symptoms. She causes an increase in their size, and through this

has been in ineffectual labor for 36 hours with they cause a dehydration of the blood serum that

an R. O. P., cervix somewhat softened but no results in a concentration of the opsonins con

engagement. We find by the tape that her Mctained therein. By this concentration of the

Donald measurement is 37 and by the pelvimeter opsonins, and possibly to some extent from the

that the Ahefeld is 26, these being interpreted alkalinizing effects of the carbon monoxide, as

that the Ahlfeld is 26, these being interpreted suggested by Bier, the phagocytic powers of

should indicate a foetus of 52 c.m. Now you will 'the leuccocytes are greatly increased, and the understand the calculation of the length of the infection is correspondingly diminished.

foetus by external measurements is not exactly a In general, this seems to be the effect pro- mathematical one but it is wierd and sometimes duced by the oxygen liberated from the gas. The astonishing how near we come to the total length ethyl borate precipitate, which falls deep into of the foetus by the estimate which is, of course, the tissues, produces its effects by causing a always verified post partum by measuring and stimulation of the vasodilator nervous mechan- weighing the baby. The reason for delay in this ism locally, in such a way as to cause almost case which has pelvic measurements 29-25 and immediately a most distinct hyperemia to be 191/2 c.m., is that the head has not rotated and established. It is this hyperemia which means therefore there is no adjustment possible of the so much as our foremost therapeutic agent, but head and the pelvic canal. We do not avail which alone, and unaided by our other efforts ourselves of the other pelvic measurements if would be quite ineffective in its curative prop- these three are reasonably harmonious, but if

either is abnormally short the interval or true perhaps a matter of being more familiar with conjugate and the inter trochanteric by Whit- the retractors. Also the dorsal position is used ridge Williams pelvimeter is also taken.

rather than the lateral for the same reason. The Having concluded that the patient is at term

cervix is held down firmly by two vulselli, one

cervix is held down firmly by tw and the labor being ineffectual the cervix should

in either lip of the cervix. This is also a reby rectal examination to be undilated and the finement over some operators' technique and presenting part free above the inlet, we are to really is an aid in accurate placing of the dilators decide as to whether we advise an immediate and the bag with the least delay. caeserian section agreeing with our friend Ru- The bag being placed is held by a long uterdolph Holmes that obstetrics is a lost art or else ine dressing forceps within the uterus while the we set about to assist nature in her attempt to water is slowly forced into the cone of the rubber bring the labor to a close by means more in har- bulb. We secure the rubber pipe of the bag by mony with the plan of voluntary emptying the folding it on itself and slipping on two of Petuterus by trying to supply the elements to the tit's funis clamps; a bit of adhesive adhering to problem which nature has aparently failed to the lower abdomen keeps the bag in position bring into play. That is dilatation, better flex- while it is doing its work. The patient is re ion and more forceful efforts on the part of the turned to bed and in a variable period from 20 pains which are stimulated by the Vorhees bag minutes to six hours labor is on. It is usually according to the plan worked out by Charles B. some what shorter than a similar labor in which Reed of Wesley Hospital, Chicago, and reported no artificial stimulus is employed. by him in S. G. and O., a series of 1000 cases. Let us repeat: we have never yet ruptured

Please note that stress is to be put on first, the membrane nor has any patient developed accurate diagnosis ; second, failure of powers of after labor is inaugurated, an infection. nature; and third, supplying the artificial help You will observe that McDonald and Ahlfeld in a manner least likely to cause shock, interfer- have been several times mentioned, and in order ence with mechanism, loss of liquor amnii or to make it clear it may be well to explain just infection. All these we believe we find in the what is meant by these names used in an obVorhees bag properly placed and carefully stetric sense. watched. Barnes fiddle bag we have not found as Several years ago Ahlfeld said it was not a efficacious although some of our confreres still matter of pride to be able to boast of having employ this veteran agent. You will observe we delivered a patient of a 12 pound baby but a disuse slight anesthesia in the introduction of the grace that the average mother should be unbag. This is our own variation as Dr. Reed necessarily mutilated and subjected to shock beintroduces the bag without an anesthetic. We cause of the terrific stress of a long labor and have found that the average patient is very apt to the overgrown baby so often born asphyxiated be apprehensive of any operative interference in or suffering from brain lesion due to difficult labor and in her shrinking from being hurt she forceps operation. He devised a method of measbecomes panicky, delaying the process and work- uring the child in utero, placing one end of the ing herself into an emotional stew which is not pelvimeter, thus, at the upper border of the conducive to the best efforts to help herself be- synphysis and the other at the fundal pole of cause she has become exhausted. Dr. Geo. F. the uterus. He then read the index, subtracted Pendleton, who has usually given the anesthetic 2 c.m. for thickness of the skin and multiplied for me, has acquired a facility of keeping the by two which he declared gave the length of the patient at just about the proper degree of anal- foetus from vertex to sole, and was able to prove gesia, not a definite anesthesia and she usually it post partum. McDonald reached the same end rouses as soon as we are through with the plac- by using a tape measure thus, over the parabola ing and filling the bag. Dr. Buford Hamilton, described by the contour of the maternal abmy junior attending, has in the meantime filled domen and taking 35 c.m. as indicating a foetus the bag into a roll occupying the least possible of 50 c.m. total length maintained that such a space and firmly grasped it by a Paen forceps, measurement meant a foetus at full term. Ahlfeld having first satisfied himself the bag is perfect, took the diameter between the points of the that is, that no leaks exist. We use a metal pelvimeter and if it measured 27, he subtracted piston syringe for filling, although Reed prefers 2 for the skin and doubled the 25 which also gave an ordinary Davidson syringe. Our dilatation 50 as the length. Now, we are not always willing is done with a set of the old reliable Hegar's to induce labor on account of the measurements dilators graduated up to 20. The latter admits alone, but in case of indication of interference the large size bag. The dilators are passed rap- we agree with Dr. Chas. B. Reed that in the cases idly as you see to avoid unnecessary delay and as where labor has been induced for cause, our post soon as No. 20 passes readily the bag is intro- partum results have agreed with the antepartum duced. It will be observed that we use long re- calculations with at most 2 c.m. variation. tractors instead of bivalve speculum. This is A paper which is now under preparation

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