Part 45

_Ranula_ is a swelling produced by accumulation in, and distention of, the extremity of the combined ducts of the sublingual and submaxillary glands. The extremity of the duct contracts, or is completely closed, and in consequence of the saliva and mucus (the one the secretion of the gland, the other of the duct) collect, distend the canal, and cause thickening of the parietes. Thereby a tumour is formed, which, in some instances, attains a very large size, displacing in some measure the neighbouring parts, and incommoding the tongue in particular. Indistinct utterance and impeded deglutition result.

The orifice of the duct, if discovered, is to be dilated gradually by occasional introduction of variously sized probes. Often it is necessary to make a small incision in the situation of the orifice, and introduce a bit of gum-elastic bougie, by continuing the use of which for some time, permanency of the opening may be obtained.

_Deposition of Earthy Matter_—principally phosphate of lime—not unfrequently takes place in the extremity of the submaxillary and sublingual ducts, and the concretion so formed is often of considerable size; some are larger than an almond. The colour is either white or yellowish, and the surface either smooth or roughened by nodules; in all the calcareous matter is friable, and disposed in concentric layers. They are of the same nature as the earthy deposits, called tartar, which form on those teeth opposite to the extremities of the salivary ducts. The foreign body produces uneasiness in the mouth, swelling, and indistinctness of speech; occasionally painful swelling of the salivary gland and surrounding parts takes place. Concretions also form, though very rarely, in the extremity of the parotid duct, and are attended with like inconvenience; of this I have seen only two cases.

The foreign body is easily removed; an incision is made through the membrane of the mouth, and the concretion dislodged by forceps, a scoop, or the fingers. The saliva regains its course, and irritation subsides. Sometimes the foreign body is exposed by ulceration, and might ultimately escape from its bed spontaneously.

A figure of a salivary calculus of considerable size is here given. When the concretion is small, its extraction is not so easily accomplished as might be supposed. It is apt to slip back out of reach, so that it cannot be seized, brought forward and extracted either by scoops or forceps. The flow of saliva must be promoted by giving the patient something to masticate; the probability is, that the foreign body will then be presented, and perhaps expelled, if the opening of the duct has been previously dilated. A young lady was brought to me lately suffering great uneasiness from the presence of a concretion, not larger than a millet-seed. She complained of great pain under the jaw on seeing anything savoury, that, as the vulgar phrase is, made her mouth water. Various unsuccessful attempts had been made to remove it. A small incision of the surface of the duct was made, but the foreign body eluded the grasp of the forceps, and completely disappeared. The patient was given a bit of bread to chew, and almost immediately the concretion was expelled.

_Tumours_, unconnected with the salivary ducts, occasionally form in the loose cellular tissue under the tongue. They may be either sarcomatous or encysted; the former are rare. I have removed several solid tumours, principally adipose, from this situation. They were loosely connected, and taken away without almost any dissection; indeed they were lifted out with the fingers, after division of the membrane of the mouth and of the cellular cyst which surrounded them. One was as large as an orange, and of a flattened form. The tongue had been displaced by the swelling, and articulation, deglutition, and breathing impeded. The patient, an old lady, had a good recovery. The case had been by some mistaken for ranula; and I mention this circumstance, lest others may reckon more on the situation of a swelling, than on its feel and other external characters. A sketch of the tumour is given at page 137.

Encysted tumours below the tongue are common. The cysts are generally thin and adherent, the contents albuminous and glairy. They attain a large size, and prove very inconvenient. Occasionally the cysts are thick and more loosely attached; such usually contain atheromatous matter. I removed one uncommonly large, from the inner surface of which numerous hairs were growing.

Encysted tumours here can seldom be removed by dissection; the depth of their situation, their firm connexion, the awkward situation in which the patient is necessarily placed, and the risk of hemorrhage, forbid the surgeon from attempting regular extirpation. A more simple and equally effectual procedure is as follows:—The membrane of the mouth and the cyst are divided by the point of a bistoury; and if the tumour be large, and the distention great, an oval portion of the parietes may be cut out. The contents are thus evacuated. The bleeding is allowed to cease, and the cavity having been wiped out clean, a stick of caustic potass is applied to the surface, so as to annihilate the cyst effectually. This I believe to be the only radical and safe mode of removal; after any other, the tumour is certain to be reproduced. It has been recommended to pass a seton, so as to excite inflammatory action, and lead to obliteration of the cyst. I have made trial of this practice, but most dangerous swelling ensued, the mouth was rapidly filled, and the system alarmingly shaken; after all the disease was not eradicated.

Tumours beneath the tongue, however originating, occasionally inflame, and become the seat of unhealthy abscess. A large and painful swelling forms, and projects under the chin. The matter gradually approaches the surface, and perhaps evacuates itself imperfectly into the mouth, or the integuments give way, and afford an external issue. In such cases, an early incision from the mouth may prevent the internal mischief, and the disfiguration of the countenance which would otherwise ensue may, in short, limit the suppuration; at a later period a free opening requires to be made below the chin, in the mesial line, and in the direction of the muscular fibres. A ready drain is thus obtained for the matter, and the cavity of the abscess gradually contracts.

_Tumours of the Gums_ are usually hard, and not inclined to increase rapidly. They are of the same consistence as the parts to which they are attached, and grow either inwardly, outwardly, or both. They surround one or more teeth, which at last become loose, the alveolar processes then soften, and form part of the swelling.

These may degenerate, and grow rapidly, or the tumour may be soft (tumor mali moris) from the first. The attention of the patient is directed to the part by the occurrence of discharge from about the teeth, which loosen one after another. A soft tumour arises from the sockets after either extrusion or extraction of the teeth, it grows rapidly, and involves more and more of the gums and alveolar processes. Angry ulceration attacks the prominent parts of the swelling; the bone is softened to a considerable extent around; the discharge is thin, bloody, and profuse. Ultimately the lymphatics become affected, neighbouring parts are contaminated, malignant action acquires a firm footing, and extends, the patient becomes hectic, and dies.

Each kind of tumour should be removed freely and early; the untoward results of the latter have been already mentioned; and I believe that, if the former be allowed to proceed unchecked, the tumour may ultimately extend to the bone, and osteosarcoma of the jaw, more or less extensive, be established. The disease must be attacked at an early period of its existence, and teeth, sockets, and soft parts taken freely away, by means of a strong knife and saw, or cutting forceps. After excision, the actual or potential cautery should be applied, otherwise the disease is apt to recur. Portions of involved bone, which may have escaped the knife, are by the caustic made to exfoliate. When the potassa fusa is used for the purpose of destroying what cannot be readily reached by the knife, and when it is pushed into the alveoli and applied to the altered gum, its action must be limited by the immediate use of vinegar, diluted or not.

_Inflammation of the gums_ and neighbouring parts is attended with violent pain, swelling, and throbbing, difficulty in opening the mouth, headache, and fever. Inflammation of the soft parts runs its course speedily, and, as the cause is seldom removed during the existence of the inflammatory action, generally terminates in suppuration, so giving rise to what is termed _parulis_ or gumboil. Frequently the inflammation extends to the sockets of the teeth, which seldom resist the action long, but from their low degree of vitality soon become necrosed; and by the presence of the dead portions of bone, a fresh accession is given to the disease. Severe pain is experienced on touching the teeth whose alveoli are affected; they project and become loose; purulent matter is secreted, and oozes out between the loosened teeth and diseased gums. Abscesses form, and point in different situations; the gums are tumid and spongy; through the openings in them the bone can be felt bare, and the purulent matter is situated within or around the alveoli, and under the mucous membrane and cellular tissue which invest them.

When the inflammation has been either intense from the first, or of long duration, it not unfrequently happens that abscesses form within the substance of the jawbone, and occasionally to a considerable extent—a portion of the bone having become inflamed, and the action terminating in suppuration and partial caries. This is more apt to occur in the inferior than in the superior maxillary bone; and, if allowed to proceed, the osseous cyst containing the purulent matter gradually enlarges, the plates of the bone are separated and expanded, the parietes become attenuated, and the affection is termed spina ventosa. Purulent collections in this situation also seem, in many instances, to arise from, or at least to be preceded by, the formation of a cyst around the decayed root of a tooth. Such cysts are generally of small size, and pyriform shape; externally they are smooth, membranous, and of rather a delicate texture; internally, they are lined by lymph of soft consistence, and contain purulent matter. In fact, they are purulent depôts, which form in consequence of inflammation around the fangs of the teeth, and from which the matter is occasionally discharged through a small aperture at the upper part of the cyst, and by the side of the affected tooth. They sometimes attain a very considerable size.

Mercury is perhaps the most common cause of this disease; but it is also produced by certain operations on the teeth, and by the presence of carious teeth or of stumps.

_Caries of the teeth_ is an extremely common affection, and in some instances seems to arise from an unhealthy state of the constitution; but it is most frequently produced by the teeth having suffered from chemical agents, as when the mineral acids have been taken for a considerable time as medicines, or when the individual is in the habit of consuming sweetmeats, and confections. Sometimes the disease remains almost stationary, and may give little or no annoyance for a number of years; in other instances, its progress is very rapid. A portion of the tooth gradually decays, and this is at first unattended with any uneasy sensation; but when, from continuance of the destructive process, the central cavity has been exposed, the pain is excruciating, attended with headache, and swelling of the surrounding soft parts. In general, the progress of the disease may be arrested by removing the diseased portion, and stuffing the cavity, before any pain has been felt. But after the central cavity of the tooth has been exposed, filled with fungous mass, as here seen, or from their growing in a faulty direction, and pain consequently experienced, the most effectual remedy is extraction. The patient from whom the specimen below was obtained, perished in consequence of the extensive abscesses of the mouth and neck, consequent upon the awkward position of the wisdom tooth.

From the presence of carious teeth, or decayed portions of teeth, many evils both local and general ensue, besides inflammation and abscess. They are frequently the cause—and the sole cause—of violent and continued headaches; of glandular swellings in the neck, terminating in, or combined with abscess; of inflammation and enlargement of the tonsils, either chronic or acute; of ulcerations of the tongue or lips, often assuming a malignant action from continued irritation; of painful feelings in the face, tic doloureux, pains in the tongue, jaws, &c.; of disordered stomach, from affection of the nerves, or from imperfect mastication; and of continued constitutional irritation, which may give rise to serious diseases.

Along with abscess of the gums, purulent matter often collects in the cellular tissue of the cheek or of the chin. In the latter situation, the inflammation and suppuration are often caused by the teeth in the front or side of the lower jaw being too much crowded together. When the teeth are crowded together, the patient, of course, cannot be effectually benefited till one or more of them are extracted, and sufficient space allowed for development of the others. The abscess gives way, and discharges its contents often both externally and internally, and a fistula remains, which cannot be got rid of, unless, as in most other affections, the cause be removed. The cavity of the abscess must be opened into either from without or within, and after the subsequent irritation has subsided, the cause must be removed; carious teeth or stumps are not to be taken away during the inflamed state of the parts, but after the pain and inflammation has subsided in consequence of free evacuation of the purulent matter. After these have abated, and not till then, the offending bodies are to be extracted, both in order to procure a more speedy and effectual cure, and with a view to prevent recurrence of the disease. If a portion of the jaw has become necrosed, the sequestra are to be extracted as they become loose, and openings and counter-openings must be made, according to circumstances, so as to afford a free outlet to the matter.

The extraction of teeth, the crowns of which have not been destroyed, is accomplished most readily by the dexterous use of variously shaped forceps. Stumps may be occasionally extracted also by forceps, but the lever is generally required to loosen them from their sockets. The old key instrument and pelicans are now superseded by those above mentioned.[37]

_Spina Ventosa of the Jaw_ often originates, as before mentioned, in a small cyst at the root of a decayed or dead tooth. An enormously large one extracted along with the stump attached is here shown: it is sketched from a specimen in the collection of Mr. Nasmyth, of Edinburgh.

The disease is usually situated on one side of the lower jaw; but sometimes occurs in the upper, and is at first unconnected with the cavity of the antrum. Inflammation has taken place in the internal structure of the bone; matter is secreted by the medullary vessels, and collects in the cancellated texture. Purulent formation advances, the cancelli are broken down, the external laminæ of the jaw are extended, protruded, and attenuated; and then the internal cavity enlarges, containing pus, perhaps mixed with other fluids, and with disorganised particles of bone. Sometimes the collection proceeds slowly, and the expansion of the bone is gradual and uniform; in other instances, the swelling rapidly attains a large size. As the disease advances, the bony parietes become remarkably thin and delicate, particularly at the more prominent parts of the tumour; and at many points bone is deficient, and its place supplied by membranous expansion. Occasionally alteration of structure takes place in the cyst; solid matter is added, either bony or fibro-cartilaginous, and morbid action proceeds in the new deposit. In acute cases, in which the secretion and distension are rapid, severe pain is felt in the part at the first, and usually continues but little unabated; when the swelling is slow and gradual, considerable pain is experienced during the inflammatory stage, but soon diminishes, or ceases entirely. In every instance, the features are deformed, and the functions of the mouth more or less impeded.

Osteosarcoma may supervene on spina ventosa—morbid action occurring in the parietes, and morbid deposit ensuing, as in the following instance:—The patient was a male, aged twenty-one. Swelling had existed for a considerable time at the posterior part of the lower jaw on the left side. The wisdom tooth and last large grinder, their pulps probably having been blighted, never appeared, and the swelling occupied their situation. The bone was expanded on each side; the upper surface of the tumour was soft, its growth had been gradual, and no great pain or uneasiness was experienced. I cut out an oval portion of the cyst where it projected into the mouth, and well-digested matter was evacuated; a seton was then passed out near the angle of the jaw, and worn for some weeks. The plates of the bone approximated, the cavity contracted, and the discharge ceased. Two years afterwards rapid swelling took place in the same situation, suppuration occurred, and the matter was again discharged by incision; the tumour then subsided. Again inflammatory swelling occurred twelve months afterwards; the same course was followed and the patient relieved. A hard swelling now occupies the jaw from its angle to the canine tooth, it is increasing in size; the necessity for its removal is apparent, and has been decided upon. Very shortly after writing the above, the patient submitted to the disarticulation and removal of fully half of the jaw, represented here. He made a rapid recovery, and showed himself to me and the pupils at the hospital a short time since, and fully five years from the time of the operation, in remarkably good health, and very little deformed by his loss. His whisker effectually conceals the mark of the incisions.

But in general, after free evacuation of the purulent matter from a bony cavity, even of very large size, the space between the parietes diminishes rapidly, the distended and attenuated bone contracts and is condensed, the new deposition is absorbed, and the parts regain their natural and healthy appearance.

In the slighter cases of spina ventosa, removal of the offending teeth or portions of teeth, is generally sufficient; the matter escapes freely enough from the sockets, and the discharge soon ceases. When the cavity is considerable and its parietes thin, a counter-opening at the base of the jaw is required; and it is often of advantage to introduce a small cord from the opening in the mouth through the counter-opening, and to continue its use for a short time, drawing it backwards and forwards in the cavity occasionally. For making the counter-opening and placing the seton at the same time, a strong needle in a fixed handle is most convenient. This practice I have employed in a good many instances, and can confidently recommend as successful. In a large spina ventosa, not complicated with solid growth, the parietes may be removed freely and with safety; the cavity is dressed to the bottom, and gradually fills up by granulation. The division of the integuments to expose the tumour must vary according to the circumstances of the case; the incision of the bone will generally be accomplished by a strong bistoury. Such procedure will seldom fail in procuring a cure, and is less severe, less dangerous, and productive of less deformity, than division of the jaw and entire removal of the diseased portions, an operation which can very seldom be warranted for spina ventosa. In the following case, the tumour was the largest of this kind which I have met with in the jaw, and yielded to the treatment just noticed. The patient was a male, æt. 48; he applied to me in 1821. The tumour had been of three or four years’ duration, equalled a large fist in size, and involved the left side of the lower jaw at the junction of the ramus with the body of the bone. The sac extended behind the coronoid process, and downwards, through the substance of the jaw, amongst the hyoid muscles. Several carious teeth and stumps were imbedded in the swelling; the projection was chiefly lateral, the parietes were yielding, and the line of the jaw could be traced from below. There was occasional slight discharge of purulent matter from the neighbourhood of the involved teeth. The cheek was laid open, and the bony and cartilaginous parietes of the cavity completely removed; the bleeding from the bony surface was arrested by cautery and pressure.

The soft parts united kindly, and the patient obtained a rapid, perfect, and permanent cure, returning home with the cheek united in ten days after the operation.

_Solid Tumour_ of the Lower Jaw—_Osteosarcoma_—commences in the internal structure of the bone, frequently in the neighbourhood of stumps. The origin may be traced to external injury of the part; or the disease may take place in the jaw, either along with osteosarcomatous tumours of other bones, or subsequently to their development; in such circumstances a peculiar disposition of the system is the only cause that can be assigned. The tumour generally occupies the lateral parts of the bone. Its growth may be either slow or rapid, and is attended with dull uneasiness, rather than acute pain. At first the morbid deposit is confined to the cancellated texture, but as it increases the external laminæ are distended, and at last give way at one or more points, and the tumour protrudes fungous into the mouth. The consistence of the mass is various, it may be soft and brain-like, or cartilaginous, mixed with bone and fibrous matter in various proportions; but the anatomical characters of these tumours have been already detailed, and need not be here repeated. The features are much deformed, the swelling seriously incommodes the neighbouring parts; the teeth loosen and drop away, and fungi arise from the sockets; a fetid, thin, sometimes bloody discharge is secreted copiously, and the health declines. The part protruding around the gums is deeply indented by the teeth of the upper jaw; it separates the jaws to a greater or less extent, prevents closure of the lips, induces salivation, and impedes the taking of nourishment. The tumour is one of those which are apt to be reproduced, and if unmolested, gradually undermines the system, and ultimately the patient perishes very miserably. At one time every instance of it was regarded as hopeless; but of late a great many tumours, in various stages of advancement, have been removed successfully by British and foreign surgeons. In some instances, the portion of the jaw containing the morbid growth has been sawn out; in others, one half of the bone, or more, has been removed by disarticulation, after being divided beyond the diseased part. A very few weeks ago, I had occasion to remove fully three-fourths of this bone, from the site of the first large molar on the left side to the condyle of the right. The patient, an elderly female, is convalescent. The operation is severe, and to a spectator shocking enough; but it can be undertaken with safety, and in most cases with almost a certainty of favourable termination. In no other way, assuredly, can the disease be eradicated. Partial excisions, applications of the cautery, &c., only hasten the malignant process.