James Edmund Garretson.

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no bones are so constantly found in irritative conditions. The term bone is
used, the reader being reminded that the portion of a tooth which takes on
this morbid action, the cementum, is, in a surgical sense, that structure.

Non-specific exostosis, occurring on any portion of the maxillas removed
from the alveolar borders, is an exceedingly infrequent disease. With every
opportunity for observation, the author is surprbed at the small number of
cases met with by him ; and these, with a very few exceptions, have been of
little consequence. *

Around the base of the alveolar processes, however, and particularly on the
lingual aspect of the lower jaw, the affection, in a minor form, is exceedingly

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commoD ; the eDlargemeDts vary from the size of a small shot to that of a
lifle-ball. As pathological relations are coDcerDed, the growths seem of little
ooDseqaeDce; the treatment is, commonly, the very simple one of letting
them alone.

It is not improbable, though, that cases may occur upon which operations
will be demanded. The mode of procedure is simply to lay off from the tumor
the soil parts, and, with a chisel or bur, cut away the mass ; there is no
hemorrhage or other trouble attendant on the operation. (See Hyperostosis,)

Exostosis of the fangs of the teeth — exostosis dentium — finds location in
the cemental structure of the organs ; for while the writer has seen two or
three cases where the crowns of the teeth were enlarged, as if from a species
of hypertrophy, yet these were so anomalous that the growth is to be de-
scribed as associated exclusively with the fangs ; and even here it is found in
the majority of instances confined mostly to the apex, growing, bulb-like, as
it were, about the end of the root.

The diagnosis of exostosis in these situations is not always without con-
fusion. The most frequent pathognomonic feature is a sense of continued
uneasiness about the parts, this not amounting to pain, but serving as a con-
stant reminder of the presence of the tooth. The organ itself may or may
not be carious. Pressure, or the stroke of an instrument, does not, in ordi-
nary cases, either increase or diminish the soreness; the sense of fulness
about the parts is particularly observed where the absorption of the alveolus
is not proportionably active with the exostosis. In these latter cases, the ex-
tremest symptoms of neuralgia are not infrequently produced, and, if not
comprehended, are of course treated without avail.

One of the most remarkable cases of dental exostosis on record is related
by Mr. Pox. The subject was a young lady, who, at the time she sought
the professional aid and advice of this practitioner, had suffered so severely
and so long that the palpebrae of one eye had been closed for nearly two months,
and the secretion of saliva had for some time been so copious as to flow from
the mouth whenever opened. The patient had tried every medicine recom-
mended by the ablest professional advisers, without deriving any permanent
benefit, and was only relieved by the extraction of every one of her teeth.

The surgeon may infer from the mention of this case that he is likely to
meet with many gradations of the trouble. Such inference is right. Cure
is found in the removal of the affected member. This is easily accomplished
with the aid of a pair of cutting- forceps, or by means of an engine drill.

Warty Teeth. — In this association reference is to be made to an anoma-
lous confusion and development of teeth-germs to which the term warty has
been applied. On another page has been discussed the aspect of dentigerous
cysts. The rarity of these warty teeth permits few the opportunity of seeing
them. Among recorded examples familiar to the writer are four by S. J. A.
Salter, one by Mr. John Tomes, two by Wedl, two by M. Oudet, two by M.
Forget, and one by Mr. Harrison.


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To teeth of snch anomalous development M. Broces has applied a name
that has now come into somewhat general use, namely, odontomata. These
F ^e^i ^^' ^'^^ ^^^ propriety and clinical justice, has classi-

fied into oircumscrihed and diffused, — the first includ-
ing all masses in which recognition of the tooth exists ;
the second, where it is lost in an anatomical confusion
of the structures. The odontoma described from the
practice of M. Forget, on a succeeding page, constitutes
the most marked example of the latter on record.
Fig. 562 is an example of the former.
Odontoma. ^ ^^'"^ ^^ dental exostosis termed by Mr. Salter

the enamel nodule exhibits a pearl-like protuberanoe
growing from a tooth. Excrescences of this kind are considered to be essen-
tially submerged cusps, being composed of a cone of dentine enveloped by a
cap of enamel.

As an illustration of extreme dental hypertrophy, combined with the ex-
istence of an enamel nodule, attention may be directed to a specimen belong-
ing to the Philadelphia Dental College, exhibited in Fig. 563. This mass is
two and a half inches in length by two and five-eighths inches in circum-
ference ; it was associated with the roots of a lefl superior molar, and was
extracted from the mouth of a laborer by Dr. S. H. Whitman, of Newport,
Perry County, Pennsylvania.

In examining this specimen, it is observed that to the right of the palatine
root, and connected with it, is a portion of enamel ; being an outgrowth, as

Fio. 563. Fio. 564.

has been inferred, either of a wisdom or of a supernumerary tooth, — most
likely, however, a production of the tunica propria of the tooth itself Mr.
Salter describes such cusps as being clothed with a pulp, — the enamel pulp,

A microscopical section of this growth is figured (Fig. 564) and described
by Dr. J. H. McQuillen, through whom the specimen was received as a
donation to the museum :

A first or outer section presents only the lacunae and canaliculi charac-

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teristic of cementam. A second cat differs somewhat from this, id havings
in addition, certain spaces of no definite shape, and apparently being the-
blenditog of a number of the lacunse. In a third section the lakes are quit&
numerous, and the canaliculi starting from them are of considerable lengthy
and pursue a tortuous or curved direction, resembling very much the appear-
ance and course taken by the dentinal tubuli in secondary dentine. Fig. 564
is fit)m a drawing of one of the preparations as seen under the microscope.
A few canals (cut transversely), evidently existing for the passage of blood-
vessels, are observed, but no Haversian canals, as in bone, with the lacunae
and canaliculi arranged in concentric layers around them.

In the venereal, scorbutic, and tubercular hypertrophies or exostoses of the
maxillary bones, the features of the common disease become quickly evident
in the local trouble : so remarkably so, indeed, that no one would be likely to
misunderstand the condition ; presupposing the general disease to be recog-
nized. The growths are rapid, painful, and almost always more or less amen-
able to constitutional treatment.

Scrofulous and scorbutic tumors differ from the venereal in being more
loose and spongy in structure, and, in consequence, more apt to run into
abscess, being possessed, as it were, of elements for their own destruction.

In these forms of maxillary disease, the lesion is commonly heralded by
deep-seated, dull pains, which precede by some time the visible enlargement
of the part. Afler the tumefactive process sets in, it goes on, if uncombated,
until the parietes of the bone are completely disparted. Associated with this
enlargement is an unhealthy condition of the soil parts.

As the disease advances, the centre of the tumor soflens, while the char-
acter of pain changes, becoming sharp and throbbing ; as pus forms, sinuses
are created, and thus ulcerations occur on the face of the tumor. Enlarge-
ment of the maxillss from these causes is, however, very uncommon, and
might only escape being confounded with cancer by observation of the asso-
ciation with the disease at large.

The treatment of inflammatory tumors of these and similar types is to be
conducted in consideration of their twofold requirements. The systemic
influences are to be corrected, while, locally, as a rule, they will be found to
succumb to the treatment commonly directed against similar lesions of the
soil parts. Great confidence is to be entertained in the use of tents and
stimulating injections.

There is a simple inflammatory tumefaction of the maxilla sometimes met
with, which might be mistaken for specific exostosis. It is to be distin-
guished, however, by the rapidity of the formation and by the greater soreness
attendant on it ; it comes as a cold in the head, or on the chest, comes, — with-
out, in the majority of cases, the patient being able to assign any cause, —
and it is found soon to give way to antiphlogistics. This tumefaction is
extra- rather than in tram axillary ; it is simply a periosteal exudate, and has
no constitutional association.

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In this connectioD, attention is to be directed to a form of tumor frequently
found in the mouth, which, clinically, is classible with the exostoses. Allu-
sion is made to an apparent expansion of bone frequently found in association
with a strumous diathesis, and invariably in connection with periodonteally
diseased teeth or roots of teeth.

These tumors have a common history. The nerve of a tooth dies, and the
periodonteum takes on a chronic irritative condition, or perhaps a tooth has
been fractured in attempts at extraction, and the root, or some portion of it,
has been left in the socket. After a time, sooner or later, a slight swelling,
apparently of the gum, is observed. This may readily be taken for a chronic
alveolar abscess ; there is no pain, however, associated with the enlargement,
which is soon seen to differ from abscess in the slowness of its evolution ;
it is also hard, being perfectly unyielding under pressure. As we watch such
a case, month after month, we find that it gradually grows, giving the im-
pression of an expansion of the bono under the gum, although, as we un-
derstand, there are no special or marked signs of such cystiform condition.
If we pass an exploring-needle into the tumor, it feels as if it were cutting
its way through spongy bone ; and so indeed it is, as dis.section reveals that
the cancellated structure has taken on hypertrophic action. It is such spongy
enlargement that bulges out the overlying parts and makes the tumor. The
author has treated quite a number of these growths, invariably in connection
with the inferior jaw. He does not think they are often to be found in the
superior, such chronic conditions being in the latter relation more apt to
induce caries, which disease is known to be as uncommon to the lower as it
is common to the upper jaw. These tumors either remain fixed in character,
after growing to the size of half a walnut, or, in very bad subjects, they
degenerate into abscess, and discharging thus the offending body, correct
themselves. Such spontaneous cure is, however, not common.

The surgical treatment of the growths is both simple and effectual. It is
enough, not infrequently, to remove the tooth or root, particularly if, in con-
nection with such removal, the socket is kept open for a few weeks with a
tent of cotton or sponge. A certain method of cure consists in cutting
away, with a bur or gouge, the enlarged mass : this is easily accomplished by
using the opening made in the extraction of the tooth as a means of ingress
to the mass ; the disease can, in this way, be taken out, particle by particle,
without external incision, and with a wound not larger than that made by the
preliminary extraction. After such operation the parts are to be well syringed,
and a tent kept in the tooth-socket, to insure granulations from the circum-
ference of the wound. In two or three weeks cure will be found com-

In this connection attention is to be directed to an obscurity which some-
times exists in the diagnostic relationship of diseased teeth, — that is, no teeth
or roots of teeth seem to be present. A sufficiently close observation, how-
ever, will always detect in the neighborhood a fistulous opening ; it may be

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yery minute, but it is seldom, if ever, absent. If a probe be passed into the
orifice, it will lead to the pffending agent.


In connection with the simple tumors, reference is now to be made to gen-
eral faciul hyperostosis sometimes existing. In a work published by Mr.
Heath, being a Jacksonian prize essay of the Royal College of Surgeons,
England, the following illustrative diagram and description of a case are given :

The patient, when about forty-five years of age, and apparently in perfect
health, was exposed to a cold wind ; immediately after which he perceived an
itching and heat in the eyes, a swelling of the face rapidly supervening. A
small tumor formed just below the inner angle of each eye, which burst, and
after twelve weeks he was able to resume

his employment. He suflfered from in- ^^«- 565.-Hyperosto8I8.

flammatory attacks in the growth, with
much pain in the head on more than one
occasion. He consulted many medical
men ; but no treatment relieved the dis-
ease nor retarded the growth of the en-
largements, which increased slowly and
were of stony hardness. The eyes were
projected from the orbits by the tumors.
The right inflamed and burst. The left
was accidentally ruptured by a blow. The
patient lived to be over sixty years of
age, and died of apoplexy, having been
occasionally maniacal during the last two

years of life. The portrait is taken from the work of Mr. Howship (" Practi-
cal Observations on Surgery"). The skull of the patient is preserved in the
College of Surgeons, and shows, as might be anticipated from the portrait,
two large masses of almost exactly symmetrical form and arrangement, which
have partially coalesced in the median line. The tumors are as hard as ivory,
and consist of very close, cancellous structure. They project more than three
inches from the face, and an inch beyond the malar bones on each side. The
man attributed the growths to repeated blows received on the face in fighting.

The skull of a Peruvian (3093, College of Surgeons, London) is also
alluded to by the same author. In this case the lesion is of a more diffused
character, all the bones of the face, as well as the frontal and the adjacent
parts of the sphenoid and parietal, being enlarged and thickened in a remark-
able manner. The nasal fossae and orbits are nearly closed, the superior max-
illary bones having grown into great knobbed and tubercular masses, in which
their original form can hardly be di.scovered. The hard palate is similarly
diseased. The lower jaw is enormously enlarged at its right angle, and in

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the <;reater part of its right half it measures upwards of five inches in cir-
cumference ; all hut three of its alveoli are closed up. A section of the
lower jaw shows that its interior is composed of an almost uniformly hard
and compact, but finely porous, bone. There is no history attached to the

Hyperostosis is simply exostosis or enostosis. It is analogous to hyper-
trophy of the sofl parts, and has a similar meaning.

As can be very well understood, varieties in form and character present
themselves. These growths are sometimes associated exclusively with the
face of a bone, as in the ordinary exostosis. In these cases the periosteum may
separate the two bodies. In other instances there is hypertrophy of the bone
proper. The condition is one of disease only as there is a lack of correspond-
ence in other parts. Any section of a hyperostosed bone exhibits the pecu-
liar features of bone-substance ; it may be, as is often seen^ that the cellular
substance is compressed and much altered, but there is the distinction to be
observed between it and a cortical boundary, and the analysis remains the
same, — that is, as the constituent parts are concerned. When these hyper-
trophies associate exclusively with the medullary canal, as in long bones, they
obliterate or diminish the cavity, and, if of sufficient size, expand the external
parts into a tumor, greater or less in size.

The history of any form of hyperostosis is the history of certain of the
phenomena of inflammation ; there is, from some cause or other, irritation
attended with vascular changes, the effusion of plastic matter being associated
with osseous transformation. What this source of irritation is, and how to
control it, are matters which necessarily invite the attention of the surgeon.

Reference has been made on a preceding page to the hypertrophies of the
specific conditions ; such enlargements are easy enough to understand, even
if not so easy to remove. But the hyperostoses here considered are not of
such character, but are entirely of local signification ; hence a local source of
offence is not to be sought for in vain, as, for example, in Mr. Howship's case,
where the ostitis was justly attributed to blows received. The inflamma-
tory thickening of bone, alluded to a few pages back in connection with
diseased teeth-roots, is but another illustration of the results of local irri-

That the hyperostoses are to be viewed, and in every way treated, as simple
overgrowths, is certainly well exhibited by Mr. Quekett, who, submitting to
microscopic examination portions of all the osseous tumors in the Royal
College of Surgeons, confirms the position in all particulars. The rates of
the growths of such tumors are influenced by individual susceptibilities or
peculiarities. There is certainly in this respect the greatest possible difference.
In the Osteographia of Mr. Cheselden is an engraving of an osseous tumor
surrounding the head of a tibia, which measures exactly one yard in cir-
cumference. An imposing growth is also figured in Mr. Paget's Surgical

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Id this latter cftse, as Professor Clark describes the tumor, the hardest parts
have neither Hayersian canals nor laounse. In the less hard parts the canab
are very large, and the lacnnse are not arranged in circles around them ;
everywhere the lakes are of irregular or distorted form.

A remarkable specimen of an osseous tumor of the left upper maxilla
(Fig. 566), from the Traits de Pathologic Exteme, found in the Mus^
Dupuytren, is described in Mr. Heath^s essay

as being limited behind by the pterygoid process, ^ig. 566.-088kouk Tcmor.
internally by the intermaxillary suture, above
and externally by the malar bone. The tumor
encroaches considerably upon the cavity of the
mouth, and reaches back as far as the front of the
spine. Its form is bilobed, and in the deep sulcus
between is to be seen a molar tooth. All the
other teeth of the jaw have disappeared, and
there is no trace of alveoli. The lefl orbit and
the nasal fossa are not sensibly diminished in
size, but the cavity of the mouth is almost en-
tirely occupied by the posterior lobe of the
tumor. The lower jaw has, in this case, un-
dergone several remarkable alterations. It must at first have combated the
growth and prodijfced the deep sulcus between the lobes ; but in its turn the
tumor has reacted on the jaw with the following effect : it has caused a double
luxation, the left condyle resting against the root of the zygoma, and the
glenoid cavity being filled with sofl material. The teeth of the lefl side have
disappeared, and absorption of part of the coronoid and the whole of the al-
veolar process has taken place, so that only the base of this part of the bone
is left. The outer surface of the growth is smooth, and presents numerous
vascular grooves of good size ; at many points it is perforated with holes.
The vascularity of the other bones of the face does not appear to be aug-

In Guy's Hospital Reports a case is described by Mr. Hilton in which a
tumor similar in signification to the one just referred to spontaneously sepa-
rated from the face. The patient was a man aged thirty-six, who, twenty-
three years before Mr. Hilton saw him, noticed a pimple below the left eye,
dose to the nose, which he irritated, and from that spot the tumor appears
to have origioated. The disease, in its growth, displaced the eyeball, giving
rise to excruciating pain, which subsided on the bursting of the ball. It
began to loosen by a process of ulceration around its margin six years
before it fell out, which event was unattended by bleeding or pain. The
tumor weighed fourteen and three-quarter ounces. It was tuberculated ex-
ternally, and an irregular cavity existed at the posterior part. A section
presented a very hard, polished surface, resembling ivory, and exhibited lines
in concentric curves, enlarging as they were traced from the posterior part.

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The huge cavity lefl by the separatioD was bounded below by the floor of the
nose and antrum, above by the frontal and ethmoid bones, internally by the
septum nasi, and externally by the orbit, which last had been considerably
encroached upon by the growth.

Among several rare and interesting cases in this direction described by
Mr. Hilton, particular mention is to be made of that of a lad, William
Mars, born with a general enlargement of the whole left side of the face, —
cheek, jaw, teeth, tongue. As the boy grew, so in a relative proportion
enlarged the lefl side. The exact mcsinn line of distinction was curious to
observe : the left side of the tongue was quite one-third larger than the right,
the papillae likewise showing the distinction. Commencing with the led
central, the teeth were also one-third larger than their fellows of the opposite
side. The ears, also, differed in size. No sense of discomfort was experi-
enced by the patient. This congenital peculiarity was confined strictly to the
head, all other parts being in correspondence.

The cut of a case of osseous hypertrophy — being the exact duplicate of an
impression in plaster in the cabinet of the Hospital of Oral Surgery, taken by a

Fig. 567 — Hypkrostosis of Tuberosity of Maxilla.

practitioner of a distant county, in whose own mouth also the tumor exists —
is kindly sent the writer by D. H. Goodwillie, M.D., of New York, the
following description accompanying :

Osseous Tumor of the Right Superior Hazilla.— Mrs. B., aged
forty-four years, has always enjoyed good health. About six years ago
she noticed that the alveolus of the right superior jaw began to enlarge,

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and has gradually increased to the present time. In size and shape it very
much resembles a hen's egg, the large end presenting posteriorly. It extends
antero-posteriorly from the right superior canine to the internal pterygoid pro-
cess, laterally from near the centre of the palate to the maxillo-malar fossa,
forward to the canine fossa, and to a slight degree into the antrum of High-

The mucous membrane over the surface of the tumor appeared a little lighter
in color than normal ; this, no doubt, was due to the tension on it by the
parts below. On the face of the enlargement could be seen the fangs of the
first and second molars. The canine and bicuspidati were not decayed. First
bicuspis and canine retained their normal position in the jaw, but their crowns
were somewhat buried in the tumor. The crown of the second bicuspis
could all be seen above the surface of the tumor, but the whole tooth was
raised out of its natural position, and thrown inward about one-half an inch.
One of the roots of a molar was lying longitudinally in the soil parts on the

Patient has experienced no pain, nor discharge from the mouth or nose,
during the long period of growth ; from its apparent firm texture, together
with the excellent health the lady has always enjoyed, there appears no doubt
of its benignant character.

Pathological Appearances. — On making a section of the tumor

Fir.. r)f;«.

through the longitudinal direction of the teeth, the following was to be
seen : At the apex of the second molar tooth there was a small, sofl cyst.

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coDtainiDg some pus, and for a short distance surroundiDg this the bone ap-

Online LibraryJames Edmund GarretsonA system of oral surgery: being a treatise on the diseases and surgery of ... → online text (page 98 of 113)