Part 1

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THE MONTHLY REVIEW OF DENTAL SURGERY: _THE JOURNAL OF THE BRITISH DENTAL ASSOCIATION_

═══════════════════════════════════════════════════════════════════════ NO. VIII. OCTOBER, 1880. VOL. I. ═══════════════════════════════════════════════════════════════════════

The subjects rightly embraced in a Medical education, and the degree and manner in which those subjects should be respectively studied, have been freely discussed in many places during the last few weeks. Dr. Michael Foster in an “Address in Physiology,”[1] of unsurpassed interest, contends without contradiction that no medical subject—now that the entrance upon medical studies is preceded by a tested preliminary education—need be studied as heretofore as a mere mental training, and proposes that topographical anatomy, which has hitherto been so studied, should, to a certain extent, give way in favour of a more complete knowledge of physiology. The address must, and no doubt will, be read by all interested in medical education, whether general or special. The following quotation will answer our present purpose:—

Footnote 1:

Address in Physiology, delivered at the Annual Meeting of the British Medical Association, 1880.—Published in _British Medical Journal_, August 21st, 1880.

“I think I am not overstating the case when I say that, in the two years (or less than two years) which the medical student devotes to studies other than clinical, 60 or 70 per cent. of his time—in some cases even more—is spent on the study of topographical anatomy. That study may be regarded in two lights—as a discipline, and as practical useful knowledge. The late Dr. Parkes, in a remarkable introductory address which he delivered at University College, London, many years ago, insisted most strongly that its value as a discipline was far higher and more precious than its direct utility; and I imagine that the more one reflects on the matter, the more clearly this will appear. The details of topographical anatomy have this peculiar feature, that, though they can only be learnt with infinite pains and labour, unlike other things hard to learn, they vanish and flee away with the greatest ease. I would confidently appeal to my audience of practical men, how much of the huge mass of minute facts, which in their youth they gathered with so much toil, remained fresh in their minds two years after they passed the portals of the College; and how much now remains to them beyond a general view of the parts of the human frame, and a somewhat more special knowledge of particular regions, their acquaintance with which has been maintained by more or less frequent operations. I would confidently ask them what is the ratio, in terms of money or any other value, which the time spent in those early anatomical struggles—say over the details of the forearm—bears to the amount of that knowledge remaining after twenty, or ten, or even five years of active practice, or to the actual use to which that knowledge has been put.

“No, it is as a discipline, and not for its practical utility, that anatomy has been so useful; and this, indeed, may frequently be recognised in the questions set at examinations. When the candidate is expected to describe, within the error of a few _millimètres_, the structures traversed by a bayonet thrust obliquely through the neck, or is invited to reproduce written photographs no less exact of the parts which, from skin to skin, underlie a triangle or quadrangle drawn in ink on the front or back of the thigh, it is clear that the examiner has in view, not the needs of practical life, but an easy means of testing the proficiency of the student in mnemonic gymnastics. Of the value of anatomy as a discipline, there can be no doubt. In past years, it has served as the chief culture of the medical student—as the chief means by which the rough material coming up to our great medical schools were trained to habits of accuracy, of exactness, of patient careful observation; and their memories strengthened by exercise for the subsequent strain which would have to be put upon them by more strictly professional learning. In this aspect, the very sterility of the subject was a virtue. The mere fact that the separate details seemed to hang loosely, isolated in mental space, held together by no theory, by no ideas, inasmuch as it made the learning a harder task, increased its disciplinary value. Most wisely did the leaders of our profession insist that no trouble or expense should be spared to afford the neophyte this preparatory scientific training; and that, as far as examinations and the like can go, no pains should be spared to compel him to avail himself of the opportunities offered. Indeed, viewed as a branch of education, the machinery of anatomical instruction has for many years past not been equalled by any.”

Professor Burdon-Sanderson in his introductory lecture, says,—

“The precious years which immediately precede a man’s entry on professional duty, are far too valuable to be wasted in learning anything he does not intend to retain.”—_British Medical Journal_, October 9th, 1880.

The observations of these most distinguishing physiologists and teachers, support the view which has been taken respecting the education of the Dental Surgeon, from the time the College of Surgeons was in 1857 asked to establish a Dental department, up to the determination of the Dental curriculum by the Medical Council in 1879.

An education equal in degree, but different in kind to that of the General Surgeon—an education which embraces a knowledge of the general principles of Medicine and Surgery, and a special, precise, and practical knowledge of Dental Surgery, was asked and given, the degree of education progressing as the attendant circumstances allowed, up to its present advanced condition.

The place assigned by Dr. Michael Foster to topographical Anatomy in Medical education, will certainly hold good in the education of the Dental Surgeon. Physiology and Chemistry, subjects now inseparable and of surpassing interest, are equally necessary to the Special and General Surgeon.

The position of Medicine and Surgery is not quite parallel. The general principles of each must be thoroughly known, but it is not necessary that the Dental Surgeon should be practically acquainted with all the details that pertain to any other branch of either than that which he selects to practice. It is not needful that he should become a skilful midwife or oculist, or that he should be skilled in the treatment in any other class of diseases than those to the treatment of which he proposes to devote his life. For if he does acquire such detailed knowledge, it will, when no longer used, “fade like a raindrop upon a porous stone,” and the time devoted to the acquisition will have been wasted, and, perhaps, worse even than wasted, for the subject may have been studied at the cost of neglect of the practical study of his speciality. It does not admit of doubt that the high degree of manual skill, without which the professed dentist is but a shameless pretender, can be acquired best, perhaps can be fully acquired only during youth; that if the acquisition be put off till a medical education is completed, the golden opportunity will have been lost. Mr. Fawcett tells us that the blind may acquire manual skill sufficient to secure independence, but that it can be gained only during youth. The adult blind, he says, have a greatly diminished power of learning.

The time may come when the principles of Medicine and Surgery will be taught before their special application to any particular class of disease, and their modification resulting therefrom is entered upon. Till that time arrive, it will be in the interest of the Dental Surgeon to study with the utmost care the general principles and their application to his own speciality, and to acquire, while he can, a very full and perfect knowledge, practical, as well as scientific, of Dental Surgery, before he enters upon a detailed study of their application to any other branch or subject of Medicine or Surgery, the practice of which he does not propose to follow, and a trustworthy knowledge of which can not be retained or extended in the absence of continuous general practice.

The qualified surgeon who has devoted himself to the practice of dentistry, may be legally qualified to treat any and every kind of case, but would he be morally right in undertaking the treatment of a case, say of fever or of stone? all his knowledge of which diseases lies in a misty memory of facts brought before his notice, and studied for a pass examination in long past student days. As a matter of fact, the dental surgeon of necessity limits his practice to his speciality, and the general surgeon as a further fact, where selection is possible, declines to take Dental cases, though legally entitled so to do. In the absence of special training, he cannot be expected to possess the special knowledge requisite to successful treatment, and to add the Dental to the over loaded Medical curriculum, would be to greatly increase the rejections which, in the case of the College of Surgeons, have already risen to the formidable amount of upwards of thirty per cent. of the candidates for diplomas. Hence it is that Dr. Michael Foster, in asking for more physiology, asks for less topographical anatomy.

The Dental curriculum requires for its honest fulfilment, the whole of the assigned four years, and more must not be attempted in the same four years, for to repeat the words of Professor Burdon-Sanderson,—“The precious years which immediately precede a man’s entry on professional duty, are far too valuable to be wasted in learning anything he does not intend to retain,” to which may be added, or which his subsequent occupation will not allow him to retain. If then more medical knowledge is required of the student than is embraced in the dental curriculum, more time must be given for its acquisition.

Transplantation and Replantation.

(_Continued from page 425._)

At the period when transplantation was systematically performed, the operators kept themselves supplied with an assortment of dried teeth, _i.e._, sound teeth, obtained generally from the dead subject, to make use of in case the tooth to be transplanted should not prove adaptable to its new abode. The process is not spoken favourably of, as the results were mostly unsatisfactory, but at times such teeth became perfectly firm, and even resisted the greatest efforts at their removal. We can hardly for one moment suppose that teeth in the condition these were could have ever become attached to a living alveolo-dental membrane, and the difficulty of accounting for this firmness would have been great indeed, had it not been already solved for us. In Langenbeck’s Archiv. für Chirurgie, vol. iv., is a paper on “The Replantation and Transplantation of Teeth,” by Dr. A. Mitscherlich, which deserves to be better known, and which, apparently, cannot have come under the observation of those who recently contributed to the _Lancet_ on the subject, the excuse for which is less, since it has been translated into English.[2] The author, in addition to much interesting and original matter, records the following experiment. In the upper jaw of a dog of a year old, Dr. Mitscherlich inserted into the socket of an incisor he had removed, a similar tooth taken from a dog’s skull, and which he retained in _situ_ by means of a silver wire passed through a hole in the tooth, and a hole bored through the alveolar process of the jaw. “After six weeks the dog was killed, having been given during the last few days three grains of picronitrate of potash three times a day; the carotids were immediately injected. The muscles, like the gums, were coloured yellow: neither, however, in the implanted tooth nor in the sound ones was any alteration of colour perceptible. The silver wire was porous, and no longer held the tooth; it was removed. The tooth was quite firmly seated, and could not be moved in the least by the fingers. The gums, as in the remaining teeth, were accurately applied both to the alveolar process and also to the tooth itself, and nowhere could any alteration be found in it. The tooth was sawn through lengthways, together with the upper jaw, with a fine saw, so that the pulp cavity was laid bare in its whole extent. The latter was only filled with a little detritus, and no trace of the pulp was discoverable; none of the injection, too, had been forced into the cavity. The tooth was everywhere most intimately connected with the surrounding parts, and suppuration showed itself nowhere. Of the periosteum, on the other hand, there were only in a few places some small remains discoverable. On the posterior surface of the tooth two small cavities were visible; the larger of which lay more towards the point of the fang, and extended to the pulp cavity; they were filled with a soft substance, and their walls appeared roundish. These appearances were entirely confirmed by microscopical examination, inasmuch as only in a few places, especially on the anterior surface of the tooth, were traces of the periosteum to be demonstrated; where this was absent the tooth was eaten away, and its absorption had proceeded in such a manner, that a multitude of globular elements appeared on the section, resembling the fragments which we find in ivory pegs which have been bored into bones, and retained in them a considerable time; in the two above-mentioned cavities the absorption had proceeded farther and farther, and had at last attained its above-mentioned great extent. The cementum could still be demonstrated in certain places, it was, however, absorbed in the greatest part of its extent. In the cavities of the tooth substance, masses of bone were embedded, they were applied to the walls of the cavities without any kind of intermediate substance, and so held the tooth with such extraordinary firmness. This osseous deposit, which was directly connected with the alveolar processes, was freely traversed with blood vessels, which sometimes extended themselves close up to the tooth substance. It was also so fully developed, that the process had to be looked upon as fully accomplished, and therefore, a later exfoliation of the tooth was not to be expected. The dentine itself showed nothing abnormal.”

Footnote 2:

“Archives of Dentistry,” Edited by Edwin Truman, vol. i., p. 169.

We have quoted the author of the foregoing at some length, as some of his conclusions upon this interesting experiment might seem antagonistic to our own. Thus, whilst we agree with him in concluding that a dead tooth becomes united to a living jaw by a certain amount of absorption of its fangs by osteoblasts, and a subsequent calcification of such tissue, we do not believe such process as fully accomplished or permanent. The valuable researches of Tomes and De Morgan show that during life a continual process of formation and absorption is taking place in bone, whilst the former has also pointed out that the process of absorption in the fangs of temporary teeth is one alternating between absorption and deposition, though in the end in favour of the former, _i.e._, that the osteoblasts which effect the absorption of the dentine often become calcified, but are again eventually decalcified and become active osteoclasts. What determines these bodies to act, so to speak, in a positive or a negative capacity would be most interesting to discover, and, in considering the subject, we can hardly overlook the views of Mr. Bridgman, who compares the process of bone formation and decalcification to what occurs in an electrolytic cell, where, by changing the direction of the current, the electrodes assume precisely opposite functions.

If, then, we could discover the conditions that would preserve the bone tissue, in connection with the dentine, from undergoing decalcification, we might, with every prospect of success, transplant dead teeth, but which, as at present carried out, invariably, we believe, eventually, suffer the fate of ivory pegs introduced into the extremities of bones in disunited fractures. Indeed, this result, although more slowly effected, appears nearly always to follow in those cases where the transplanted or replanted tooth has lost much of its alveolo-dental membrane; whether the excising of a portion of the fang, as advocated by Magitôt, will prove beneficial or otherwise, remains to be seen.

Porcelain teeth having indentations in their fangs have been suggested, first, we believe, by Mitscherlich,[3] and again by a recent writer in the _Lancet_. The former actually attempted two cases, and with the success we should have anticipated, for when after four or five weeks the caoutchouc splint which retained them in _situ_ was removed they immediately followed the splint and fell out. “Ossification had not taken place; the entirely heterogeneous mass of stone had acted as a foreign body, produced granulation and suppuration, and so prevented union.”

Footnote 3:

_Op. Cit._

In conclusion, we think enough has been stated to show that transplantation or replantation of living teeth, or at all events, of teeth having living alveolo-dental membrane may be exceptionally carried out with benefit to the patient; if the chances of permanent success be not very great the chances of injury are, we believe, small, and have been greatly exaggerated. No such case has come under our observation, but then in all we have witnessed, the transplanted or replanted tooth has never been ligatured or otherwise forcibly retained in its alveolus. We believe many of the cases of failure, as probably those also of bone exfoliation, arose from this procedure. A tooth, after either operation, although at the time perfectly adjusted to its proper position, becomes, after a day or two, elongated from its socket and less firm; the result of effusion into the alveolo-dental membrane and about the tooth; as this material becomes organized it forms, no doubt, the medium of union between the dental and alveolar portions of that membrane. At all events, after a week or so the tooth again recedes into its socket, and as it does so becomes firmer and less sensitive to pressure; if our view be correct, the employment of a ligature or forcible retention of the tooth can only be objectionable. A very different matter, however, will be the adjustment of a plate contrived so as to protect the transplanted or replanted tooth from violence or pressure until its attachment is ensured.

Mercurial Amalgams.

BY M. G. CUNNINGHAM.

After twenty-five years of stubborn fight supporters of gold as a filling for decayed teeth accept the possibility of plastic material being in certain cases its superior; throughout this period I have been content to hold my peace and act entirely on my own judgment in the selection of material, as however, it seems to be the fact that a man who uses plastic filling without danger of being termed a “quack,” may speak, I would, through your kind agency, convey to brother Dentists my method of preparing metallic amalgams, which has saved me much trouble and my patients a large number of teeth.

In using amalgam, the first thing we ought to take into consideration is whether that which we are using and calling by that name is such, and I venture to say that in a very large number of cases it is no amalgam at all, but a concrete admixture of solid metals with liquid mercury. In the early days, when metallic precipitate of silver was employed, perfect amalgamation was not difficult to obtain, provided the precipitate had been in the first instance properly washed and carefully stoppered, the minute sub-division of the metal and absence of oxidation aiding largely to this result. The fillings of the present day are of a totally different character, coarse in grain, and of a nature to oxidize on even momentary contact with air, they become difficult to amalgamate with mercury, which, in itself, is a highly oxidizable metal, so that recourse is often had to a glass tube and violent agitation to produce that which is at best only a semblance of what it should be—a thoroughly homogeneous mass, that upon setting will retain a uniform texture and density proportionate to the constituents of which the fillings are composed. If, however, to the fillings and mercury be added a drop or less of sulphuric acid, either in the palm of the hand or mortar, it will be found that the metals will almost instantaneously amalgamate, whilst the oxides combining with the acid leave a residuum which, by its quantity, clearly shows what a very imperfect body could have been a so-called amalgam containing only a small portion of them. Washing in pure water at once removes all trace of acid, and a thoroughly reliable stopping can be at once produced from materials otherwise worse than useless.

Introductory Lecture to Course on Dental Mechanics.

BY DR. J. WALKER.

GENTLEMEN,—The authorities of the Dental Hospital of London have entrusted to me the heavy responsibility of lecturing on Dental Mechanics for this present Session of 1880 and 1881. I have undertaken this post with many misgivings; the subject is so wide and comprehensive, the study so important to you now, and the effect of good or bad teaching will so deeply affect your whole life, that I might well have hesitated before finally accepting the duties that will now devolve upon me.

I have taken a great interest in this Hospital and School from its early foundation, when the pupils were few, and the School and Hospital had, so to speak, to win its spurs; but in passing, I may here remark that that small class of students, then a new feature in London life, by their diligence, learning and conduct, have established throughout the country a name and reputation that you will have to perpetuate. It was by the combined efforts of the whole profession, and by the fact that its senior members were able to point back to so many successful students of this School and Hospital, now earnest practitioners in nearly every large town of the British Isles, that the leaders of our department of Surgery were enabled to bring this special branch before the notice of Parliament, and obtain a Bill which now governs the method and extent of the classes and hospital practice of all our schools.

As your lecturer, I may perhaps without egotism mention that I was one of the six gentlemen appointed as the first Assistant Dental Surgeons to this Hospital, while it was struggling through its first year of active life. I remained at my post nearly ten years, until driven by increasing practice to relinquish the work, then, as now, carried on in your Hospital. It is the knowledge and experience I then gained, and the lessons I have since learnt as the result of treatment in private practice, that I have now to offer you—many failures and some successes, many abortive schemes, and some inventions that have stood the test of time.

My best thanks are due to the Managing Committee of this Hospital, for electing me to be the colleague of such men as Alfred Coleman, C. S. Tomes, and D. Lewis.