it is more necessary to educate the patient than to treat him; exceptions, of course, exist, where specific treatment is as essential as education, but such treatment alone will not accomplish success. In that group of cases where either apparent or proven allergy exists, and in which no or very little beneficial results have been obtained, if more care were taken in explaining the pitfalls of protein contact, better therapeutic results would surely follow. It may appear to be a trite truism, that the doctor himself must be alert to the innumerable possibilities of protein contact, in any given case, but it cannot be stated too emphatically that therein lies the therapeutic solution of many stubborn cases. It requires, on the part of the doctor, knowledge quite unrelated to medicine, and on the part of the patient a willingness and ability to divorce himself from his preconceived ideas as to the cause of his trouble.

Another point of interest in this case is the existence of a suppurative process in the naso-pharynx. That a focus of infection particularly in the naso-pharynx, could be the etiological factor in bronchial asthma, has been held by many. It is within the experience of all of us to have observed cases in whom improvement seemed to follow the removal of focal infections; however, we see many more cases who have had most excellent and thorough elimination of foci, in whom the asthmatic attacks persist. In our own work it has own work it has been customary only to identify such foci and to treat the patient for his sensitization. It is our conclusion that focal infection very rarely is the

primary etiological factor in bronchial asthma. However, in long-standing asthmatics, who have developed emphysema or who have attacks of dyspnea, usually with febrile reaction and more or less profuse purulent sputum, there are attacks of dyspnea closely simulating the true asthmatic attack. Questioning discloses the fact that these attacks are initiated by cough which brings on wheezing and difficult breathing, rather than the usual sequency of chest tightening first, and then cough as observed in the essential asthmatic. I believe the dyspnea in these instances is on a mechanical rather than an allergic basis, the inference being that such patients have chronic bronchial infection and bronchiectasis. Also, it is our experience, that the removal of nasal polypi, the resection of the nasal septum or the cauterization of turbinates are not productive of permanent benefit. In this connection, I want to make clear, that I am speaking of the true bronchial asthmatic, the patient giving positive reactions to protein, and not of that group of patients who usually have nocturnal dyspnea, usually with both inspiratory and expiratory wheezing and initiated or preceded by cough.

The age of onset of this patient is of interest. It is usual for bronchial asthmatics to have an early age of onset. At first thought the age of onset in this patient would be fortyfour years; a time when only a very small percentage of patients give positive cutaneous reactions. But the past history gives symptoms which can be interpreted as manifestations of allergy. For many years previous to the onset of the disabling complaint,

there is a history of sneezing with colorless coryza. When such a history is obtained and the coryza remains colorless throughout the course of the affliction it can be presumed with safety, that it is a manifestation of hypersensitiveness. Also, in this particular instance, the inability to breathe properly when in the vicinity of a threshing outfit should arouse a strong suspicion of an allergic reaction.

This patient also gave positive reactions to unusual proteins. In our own experience tobacco has been found to give positive tests and proved to be the offending protein by purposeful exposure in 3 cases, and green pepper in 7 instances.

In

Two of the tobacco cases' symptoms were caused by the use of cigars and in the third case allergic coryza was produced by inhalation of tobacco smoke. The symptoms in this latter case are in a non-smoker so that up to the present time I have been unable to determine whether symptoms would be produced by contact other than with the tobacco smoke. regard to the pepper sensitization, I would like to point out that such sensitization is not infrequent. Condiments are a very frequent constituent of ordinary foods and in our experience positive cutaneous reactions have been obtained not only to black and green pepper but also to paprika, mustard and ginger. Orris root also is a very frequent etiological factor. Orris root cases usually have a typical and classical clinical history so that in many cases from the symptoms alone, orris root can be

suspicioned as the causative agent. In our own experience orris root has been found to be the etiological factor in all types of allergy, that is allergic coryza, bronchial asthma, urticaria and angio-neurotic edema.

Unless there is a clue in the history, such unusual protein sensitization can only be found by routine use of all available protein. Sometimes adroit and intensive questioning will show a short cut to the diagnostic solution but such instances are infrequent.

In conclusion, I would like to stress that although we have been able to relieve many more patients than formerly of their asthmatic attacks, by means of the information derived from from diagnostic methods predicated on the belief that allergy is an etiological factor, there still remain many cases in whom no difficulty is experienced in proving an allergic etiological factor who remain resistent to all forms of treatment and for whom the benefit is slight; and also that there are others in whom it is impossible to prove an allergic basis, and yet who correspond exactly to the clinical picture given by such cases. These groups of cases require the most painstaking and searching histories, the most thorough, and repeated protein testing with all available proteins, and by all methods, checked by the production of the symptoms by purposeful exposure to the supposed etiological factor, the exercise of fine judgment as to the rôle of, or consequences of, focal infection, and above all, the intelligent coöperation of the patient.

IT

'T SEEMS to me a somewhat far cry between mouth surgery and internal medicine, except for two possible points: first, proper mastication of food is necessary for good digestion; and second, the mental happiness or unhappiness of the patient bears upon digestion. With these ideas in mind I shall relate certain cases which possibly may be of interest.

Among the most pertinent factors Iwith which we have to deal are the teeth. It is necessary to start with the preservation of the teeth, and this start must be made in children. It is one of the most common things to find that the sixth-year molar has been lost from early decay. One of the lesser malresults of the early loss of this tooth is the backward inclination of all teeth in front of it which distorts the normal occlusion and which will be a predisposing factor for the early loss of the teeth. Much more serious is a pus infection entering through the root canals, a condition very common in children. Sometimes a child loses the toothbuds on one side from infection, and as a result the jaw will not grow normally on that side. Furthermore,

1 Presented before the American Congress on Internal Medicine, St. Louis, Mo., February 18 to 23, 1924.

From the Department of Surgery of the Washington University Medical School.

if the infection has traveled around the jaw and destroyed all the tooth buds, the jaw will not grow at all. This makes a most noticeable deformity, and without correction precludes the wearing of artificial dentures. It is also recognized that a great many cases of cervical tuberculous adenitis can be traced to the entrance of tubercle bacilli through carious teeth. Actinomycosis may enter through the same portals.

Another point in the preservation of the teeth is to take care not to injure the tooth-buds mechanically. Formerly in the repair of cleft palates the practice of putting wires through and drawing the jaws together was most frequently employed. Such a method has been known to

a loss of the alveolar process, and consequently the teeth are lost. Repairing the lip over the open alveolar cleft will eventually bring about as good or better closure of the cleft than forcing it together and holding it there with wires, without risk of subsequent deformity or loss of teeth.

Injury to the epiphyseal cartilage in the neck of the lower jaw, scarlatinal, or gonorrheal infection of the joint in the order named have been the causes of ankylosis of one or both temporo-mandibular joints, with the resultant or accompanying lack of growth in the length of the ramus. This in turn causes a distal occlusion

of the teeth and lack of prominence of the chin, in addition to the inability to open the mouth. The ankylosis is corrected by resecting the joint; this will restore the movement of the jaw. The backward position of the chin can be partially corrected by dragging the body of the jaw forward and wiring the teeth in this position for several weeks, and further help can be obtained from implanting a piece of costal cartilage between the bone and the soft tissues of the chin. These operations have resulted in most wonderful improvement, especially in the more marked cases. Sometimes following the ordinary operation for closure of a cleft there has been an extensive slough. This destruction may have been so great that in order to make a repair it was necessary to turn in a flap from the neck or forehead.

The ability to close the lips properly and firmly is essential to the patient's peace of mind, and for proper speech and mastication. Ectropion of the mucous membrane of either or both lips most frequently results from burns. This particular deformity can be relieved by freeing the scar and planting "Thiersch" grafts.

Except where the mucosa of the mouth is directly attached to the underlying periosteum, as on the hard palate and gums, the healing of a loss from its full thickness is accomplished largely by the drawing together of the edges of the membrane bordering the raw area. The lining of the cheeks, lips and the floor of the mouth is bedded upon a somewhat loose areolar tissue and is capable of great stretching and sliding. This permits of the surface

obliteration of defects of considerable size but may entail permanent derangement of the contour or function. Therefore, in planning a surgical correction the distortion and fixation of the neighboring tissues, not the size of the scar, is the guide to the amount of lining to be replaced.

Following a loss in the mucosa, or of mucosa and underlying structures, the tongue may be bound down to the floor of the mouth or to the alveolar process, or where the latter is missing it may become adherent to the alveolar process or to the palate thus obliterating the normal tibular sulcus. A destruction in the mucosa of the pharynx may be followed by adhesion of the velum that causes partial or complete atresia of the naso-pharynx, or adhesion of the tongue that partially obliterates the lower pharynx; while loss of the faucial covering will cause the dorsum of the tongue to be drawn up toward the velum.

Partial atresia of the naso-pharynx will affect nasal respiration and voice quality. Total obstruction not only compels mouth breathing, but lack of posterior drainage of the nasal fossae and of aeration may prejudice the function of the Eustachian tubes. Fixation of the tongue to the fauces or posterior wall of the pharynx may interfere with swallowing, while fixation of the anterior part may affect speech, the intra-oral manipulation of food during mastication and the natural hygiene of the mouth. A scar within the cheek may limit or prevent separation of the jaws, which latter will, of course, preclude mastication. Attachment of the tongue, lip

or cheek to the alveolar process for even a small distance may handicap the hygiene of the teeth and give rise to serious difficulty in the fitting and wearing of a dental plate. Any considerable fixation of the lip or cheek may affect contour or expression.

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The surgical correction of any of these conditions is the release of the acquired fixation by cutting or excising the binding scar and the immediate epithelialization of the sulting raw surface. In doing this allowance should be made for some subsequent scar contraction, and the raw surface should be stretched to the physiological limit while the newly applied "Thiersch" graft or epithelial bearing flap is healing in place.

The skin covering a flap that has been transplanted into the mouth becomes pink in color and somewhat resembles mucous membrane. In a few cases it raises up in wart-like ridges; this is interpreted to mean that an excess of skin has been used and the condition is relieved by removing part of the transplant.

The simplest and a widely applicable plan of epitheliating freshly made raw surfaces within the mouth is by means of a "Thiersch" graft draped over a form that holds the graft in close contact with the bare area. When properly done this type of skin graft usually "takes" throughout regardless of the fact that the raw surface has almost necessarily been contaminated with saliva. Even pressure that controls oozing and prevents

accumulation of the fluid between the graft and the bed seems to insure prompt healing in the vast majority of cases.

In some conditions the inlay graft can be used supplementary to the pedicle graft or vice versa, or mucous graft may supplement a pedicle skin graft. A pedicle skin graft turned in to form the lining of the cheek may heal perfectly and yet leave a binding scar at its anterior border that will still limit the opening of the mouth. This might subsequently be released by incising the band and then covering the resulting raw gap with an inlay graft, or a mucous pedicle graft, the mouth being blocked open while the latter is healing in place. If the buccal scar is attached directly to the alveolar process, either above or below, the obliterated fornix will not be restored by simply lining the cheek with a pedicle flap but will require, in addition, a deep inlay graft after the pedicle graft has healed in place. The scar at the posterior part of the flap may require the same treatment. The inlay "Thiersch" graft may be used to immediately cover the raw surface from which a pedicle mucous flap has been raised and this inlay graft can be used in combination with mucous pedicle grafts in correcting atresia of the nasopharynx. We have successfully used this plan to cover the raw surface immediately after excising an epithelioma of the cheek with a cutting cautery.