does not disprove the pre-existence of a perforating ulcer; for how frequently do we not observe even considerable-sized ulcers disappear without leaving finally any trace behind. How much more likely, then, is it to be the case when the perforation has been so minute as it must have been to produce capsular cataract; for, had it been considerable, the adhesion between the cornea and lens would have been too firm to have yielded, and an adhesion would have resulted. gently; this may have to be repeated several times. If perforation has taken place, and there is prolapse of the iris, the latter should be pricked with a needle, and on the aqueous escaping the prolapse will collapse, and then a firm compress bandage should be applied. It may be advisable to repeat the pricking of the prolapse several times. If the prolapse is large, it should first be pricked, and then snipped off with a pair of scissors. When the perforation of the cornea is extensive, and the lens is bulging into it, an incision should be made in the cornea, and the lens be allowed to escape, a firm compress bandage being at once applied. We may thus succeed in saving a sufficient amount of clear cornea to permit of the formation of an artificial pupil at a subsequent period, and thus perhaps save a certain degree of vision. Original Papers. ON IRREGULARITIES OF THE TEETH. Dentist to the West London Hospital, &c. MANY subjects connected with dentistry are necessarily of great interest to general practitioners, and more especially to those who, living at a distance from London, are compelled to act on emergency as dentists. Irregularities of the teeth constitute one of the most important of these subjects, and a subject upon which the advice of the practitioner is most constantly sought. At the period of second dentition the child's mouth usually presents an unsightly appearance owing to the absence of temporary teeth and the slow advance of the permanent set. Unable to judge whether the apparent deformity be transient or not, and anxious that the teeth shall, at least, not be a source of disfigurement, the parents, in the absence of a dentist, are naturally led to consult their medical attendant. Not unfrequently they bring children with the request that some particular temporary or permanent tooth may be extracted, the removal of which they consider will avert or cure an irregularity. The first indication in the treatment of ophthalmia neonatorum is cleanliness. The infant's eye should be washed directly after birth, and the greatest care be taken that the same sponges, cloths, water, &c., are not used for the mother and child. The latter should not be exposed to cold winds or draughts, or bright, glaring light, &c. If its eyes are red and irritable, and there is a little muco-purulent discharge, a weak collyrium of sulphate of zine or alum (one or two grains to an ounce of distilled water) should be applied two or three times daily. But if the inflammation runs high, and the discharge is thick, creamy, and copious, stronger astringents must be employed. In out-patient practice, where we cannot see the patients daily, the use of the following injection will be found the best mode of treatment:-Sulphate of zinc, 2 grains; alum, four grains; distilled water, one ounce. Some of this is to be injected, with a small glass syringe, between the lids every fifteen or thirty minutes during the day, and every two or three hours at night; the frequency of the application and the strength of the injection varying with the exigencies of the case. Before it is employed, the eye should be cleansed with an injection of lukewarm water, so that the discharge may be washed away. Every day or two a drop of a strong solution of nitrate of silver (from four to ten grains to the ounce) may be applied. If only one eye is affected, the other should be protected against contagion by a firm pad of cotton-wool and bandage, this being removed twice daily so that the eye may be washed. If the patient can be seen once or twice daily, I prefer to apply the mitigated crayon of nitrate of silver (one part of nitrate of silver to one or two parts of nitrate of potash) to the conjunctiva, as we can regulate and localise its effect better. The lids being well everted, the crayon is to be lightly applied to the palpebral conjunctiva, its action being at once neutralised by a copious application of salt and water. If there is great swelling of the conjunctiva, the latter is to be freely but very superficially scarified with a small scalpel directly after the neutralisation of the caustic. Then cold (perhaps iced) compresses should be applied to the lids, to diminish the inflammatory reaction, and assist in the contraction of the bloodvessels; but great care and circumspection are re-impair the general symmetry of the face. By juquired in their employment; for if they are continued too long they may prove very injurious. If the edges of the lids are sore and excoriated, a little citrine ointment should be applied. When the disease presents the cyanotic character, and the discharge is thin and flaky, the nitrate of silver must be used with great caution. Wecker recommends small doses of mercury in such cases. Should the cornea become cloudy or ulcerated, atropine drops (two grains in an ounce of water) are to be used three or four times daily, the astringent treatment being continued as before. If the ulcer threatens to perforate, it should be pricked with a fine needle and the aqueous humor be allowed to flow off very In a great number of these cases all appearance of deformity passes away as dentition becomes completed, but in a considerable proportion malplaced teeth retain their abnormal positions, and so give rise to permanent irregularities. Such irregularities tend to cause or accelerate premature decay of the teeth, and are, also, often alone sufficient to dicious treatment, however, they may, as a rule, be prevented or cured; but, on the other hand, by unnecessary interference both injury and sufferings are inflicted upon the patient. It will be understood, therefore, that an acquaintance with the causes and nature of irregularities forms a necessary acquirement of those who undertake to deal with them. Where mechanical apparatus is required, the treatment of irregularities passes beyond the province of the surgeon. The surgeon, however, ought to be able to judge when he may interfere with advantage by extracting teeth, or when he may refrain with safety, and thus avoid inflicting unnecessary pain. He should also be able to recognise the cases which require to be promptly referred to the dentist, in order that they may not, by delay, be rendered difficult of cure, or irremediable. It is impossible to lay down rules which shall serve the surgeon in every instance, since exceptions constantly present themselves. Nevertheless, by a brief discussion of the general characters of these affections, and by a reference to some of the more common examples, practical knowledge may be imparted to the surgeon which, as well as guarding him against error, will enable him to deal successfully with many cases. It cannot be expected that, in addition to the numerous and extensive subjects with which one in general practice has to be thoroughly acquainted, he will burden himself with complex points in dentistry. If therefore the part which the practitioner should take in such cases can be concisely and clearly indicated, the objects of this contribution will be fully achieved. It may be well to premise that in speaking of irregularities, reference is made to the permanent teeth only. No object would be gained by the treatment of irregularities of the temporary teeth, since they are shed in early life; but, indeed, they are rarely, if ever, malplaced. The number and characters of the temporary teeth, and their relations to the permanent set at the period of eruption, may be usefully remembered. The temporary set consists of ten teeth in each jaw-namely, four incisors, two canines, and four molars. These are afterwards replaced by the permanent incisors, canines, and bicuspids. The developing incisors and canines may be roughly stated to occupy bony crypts in the upper jaw above and behind, and in the lower jaw below and behind, the partly absorbed roots of the temporary teeth which they respectively succeed. The bicuspids replace the temporary molars, and are contained in crypts within the divergent fangs of those teeth. The permanent molars are situated in that portion of bone altogether posterior to the deciduous teeth. The age at which second dentition commences, varying from the fifth to the eight year, is of little or no importance; but the order in which the teeth are cut is invariable, and is as follows: first molars, central incisors, lateral incisors, first bicuspids, second bicuspids, canines, second molars, and lastly, after the lapse of a few years, the third molars or wisdom teeth. With a knowledge of the order of eruption and of the following characteristics which distinguish the permanent from the temporary set, the surgeon will not be likely to sacrifice a valuable tooth by mistake—an accident which happens by no means rarely. An error of this kind is, however, hardly possible, except in the case of the incisors and canines. The permanent molars will be known from their position posterior to the temporary teeth; whilst the bicuspids may be easily recognised, since no such tooth exists in the deciduous set. The permanent incisors, if present during the persistence of the temporary set, will be found posterior to the teeth which they replace. They are larger in size, firmer and denser in structure, and have along their cutting edge three small tubercles, which give them a serrated appearance. Their enamel, extending beneath the surface of the gum, terminates in an imperceptible slope towards the fang, whilst in the temporary teeth it ends in an abrupt ridge, which can be defined by the finger-nail, at the level of the gum. This distinction applies equally to the whole series. The permanent canines may be distinguished by their great size in comparison with the corresponding temporary teeth, and by their position, which is external and prominent. In the case of these teeth, also, a characteristic ridge may be felt along the external alveolar wall, which corresponds to the fang of the tooth. In terminating these preliminary remarks, it is desirable to refer to a somewhat popular error. It is commonly believed that the premature extraction of temporary teeth may act as a cause of deformity of the jaw, and thus of irregularity of the teeth. This belief is not substantiated by physiological facts, and is, moreover, disproved by practical experience. Whilst, therefore, we should guard against uncalled-for interference, we should at the same time not hesitate to extract those temporary teeth the removal of which is necessary for the cure of deformity, or for the relief of disease. I now come to speak more particularly of the different varieties of the irregularities. They may be divided into two classes:-First, those in which the jaw is well formed, but in which, owing to retention of the temporary set, permanent teeth are forced into unnatural positions. Secondly, those due to deformity of the alveoli, or of the body of the jaw itself. In the first class, if the temporary teeth be removed sufficiently early, those that are displaced tend spontaneously to assume their proper positions. Should, however, the deformity be allowed to continue for any great length of time, the teeth become fixed, either by the consolidation of the bone, or by the advance of the contiguous teeth, or by the locking together of the upper and lower sets when closed. The nature of these cases will be made clear by a reference to the most common example, illustrated in Fig. 1, where the permanent incisors of the FIG. 1. upper jaw are seen to occupy a posterior position owing to the persistence of the temporary teeth. The prompt extraction of the latter would enable nature to effect a cure. If, however, this were delayed until the permanent teeth were fully protruded, they would pass, on closure of the jaws, behind instead of in front of the lower incisors, as shown in FIG. 2. Fig. 2. A permanent obstacle to their forward movement would thus be opposed, which could only be overcome by the mechanical means of which I have afterwards to speak. A corresponding irregularity occurring in the teeth of the lower jaw is shown in Fig. 3, to which simi FIG. 3. lar remarks apply. Delay here, however, is not so dangerous as in the case of the upper set. The normal position of the lower teeth being behind those of the upper jaw, the danger of locking does not exist, and mechanical interference is rarely required. The extraction of the temporary teeth should, nevertheless, not be too long delayed, lest the adjoining permanent teeth, taking a forward position, prevent the advance of those that are displaced. This first class comprises a great variety of irregularities of the incisors. They may be crowded together so as to overlap each other, as in Fig. 4, in which it could not be expected to endure during many years. If, however, the first permanent molar be free from decay, the choice may fall upon the second bicuspid, the loss of which is but little damaging to the appearance. It may, perhaps, be asked how the extraction of a tooth situated so far back as the first molar can relieve crowding at the front of the mouth. It is found that on the extraction of such a tooth the pressure is very rapidly relieved, that the crowded teeth spread equally apart, and that in a comparatively short time the space previously occupied by a large tooth becomes obliterated. After the general observations that have been made, the bicuspids may be dismissed with the remarks, that they are sometimes displaced by the retention of portions of the deciduous molars, that this displacement is usually in an inward direction, and that the treatment is similar to that of the incisors. Irregularities due to malformation of the jaw constitute the second class. In the recognition of these the point of the greatest value obviously is a knowledge of the exact form of a well-shaped maxillary arch. The anterior portion of this arch, containing the incisors, canines, and bicuspids, forms an almost perfect semicircle, whilst those portions containing the molars continue the arch backwards in slightly curved and divergent lines. Flattening or contraction of this arch, or abnormal development of any portion of it, gives rise to irregularities of the teeth. This class of irregularities is most frequently congenital, and at the same time hereditary, a peculiar abnormality of the jaw being, in this manner, reproduced in many members of a large family. twisted on their axis, as in Fig. 5, or, indeed, may They may, however, be due to injury or to other FIG. 5. accidental causes. The nature of this class will be rendered evident by a few typical examples. Fig. 6 represents an extreme instance of a common variety. be displaced in almost any direction. The duty of the surgeon is to promptly extract the offending temporary teeth, and, should the deformity not speedily decrease, at once to refer the case to the dentist. The canines are very subject to displacement, being commonly forced into an external prominent position. This constitutes a very unsightly irregularity. The common practice in such cases is to extract the projecting teeth. Such a proceeding cannot be too strongly denounced. The canines are the strongest and most durable of the teeth; they contribute most to the symmetry of the mouth, with the exception of the incisors, and they can, moreover, almost invariably be brought by treatment into their proper places. It may indeed at once be stated that the extraction of a permanent incisor or canine for the cure of irregularity is very rarely justifiable. Should it be absolutely necessary to sacrifice a permanent tooth, the choice will, as a rule, fall upon the first molar. This tooth, unfortunately, even in early life, is either so extensively carious as to require extraction, or is at least in a condition Here we see a protrusion of the central incisors, apparently due to abnormal development of the premaxillary bone. Fig. 7 illustrates a somewhat FIG. 7. similar deformity of the lower jaw, due to a maldevelopment of the anterior portion of the alveolar ridge. An individual affected with this deformity is said to be underhung, the four incisors, This gives rise to endless varieties of displacements of the teeth. The incisors and bicuspids are often forced inwards, the canines generally in the contrary direction; so that an irregularity exceedingly damaging to the expression of the countenance is the result. A somewhat rarer example, shown in Fig. 9, is FIG. 9. equally disfiguring in its effects. In this example the molars approximate on closure of the mouth, but the incisors remain apart and cannot be brought into contact. This is in consequence of an imperfect formation of the posterior portion of the lower jaw, by which the molars, being placed on a higher level than the front teeth, prevent them from coming into contact with each other. The distinction between the first and second classes of irregularity is rendered manifest by these examples, and nothing would be gained, did space allow, by multiplying them. It is evident that little can be done by the surgeon in the second class. In the treatment of this variety it is necessary to consider, first, the desirability of extracting teeth for the sake of obtaining space, and, under such circumstances, the teeth which can be removed with the greatest advantage; secondly, the extraction of malplaced teeth not amenable to mechanical treatment; and thirdly, the form of the mechanical apparatus required, and its construction. So many details are here involved, that none but those who make dentistry a special study can be expected to be practically acquainted with them. These cases must, therefore, be considered altogether beyond the province of the surgeon. A few remarks on the mechanical apparatus used in the treatment of irregularities may be of interest, and also of some service in determining those cases which are capable of being either improved or cured by its application. Instruments for the purpose of altering the position of malplaced teeth are constructed to fulfil two and palate, the molars being covered with sufficient thickness to prevent the front teeth from meeting. A fixed point is thus formed, to which springs or levers, elastic bands or wedges of wood, may be attached in any desired situation. These may be arranged to exert, with great nicety, any amount of force required, and to effect the desired result without exciting unnecessary inflammation. By similar contrivances the whole jaw may be modified in form. For instance, in the contracted palate, Fig. 8, an apparatus would be made to maintain equal pressure from within outwards along the alveolar margin. In time the required expansion of the arch would be accomplished. Other cases may be advantageously dealt with by instruments fixed externally. Thus the case represented in Fig. 9 would be treated by a constant upward traction of the chin, a cap of leather adapted to that part being attached to a strap across the head by strong elastic bands at each side. The almost marvellous manner in which the jaws may be modified in shape by the continued exertion of force in one direction, is not uncommonly illustrated in surgical cases. For example, the cicatrices resulting from extensive burns have a constant tendency to contract. When such a cicatrix exists upon the front of the neck, it draws the chin towards the chest, and in time causes the body of the bone in front of the ramus to curve downwards. In cases not unfrequently met with, the curvature is so great that the lower incisors become turned altogether outwards, and even downwards, the From a consideration of the principles upon which the mechanical treatment of irregularities is based, it will probably suggest itself that this treatment can be much more rapidly and effectually carried out in the child than in the adult. At the age at which the alveoli are in process of growth, and when they do not closely embrace the teeth, a malplaced tooth can be drawn into position in a short time, and with the exercise of but slight force; whereas in the adult, the bone being consolidated, the process is long and tedious. For the same reasons the cases in which the shape of the jaw has to be modified are much more amenable to treatment at an early age than at a later period, when the osseous system is fully developed. If therefore the opinion be formed that the treatment of a case of irregularity cannot be undertaken without mechanical aid, no time should be lost in the construction and application of the necessary apparatus. Wimpole-street, Cavendish-square, June, 1869. BEING ON "HOSPITALISM." A CRITICISM ON SOME PAPERS, WITH THE ABOVE TITLE, BY SIR J. Y. SIMPSON, IN THE EDINBURGH MEDICAL JOURNAL" FOR MARCH AND JUNE, 1869. By T. HOLMES, Surgeon to St. George's Hospital. son's facts as unsatisfactory and delusive; and I will endeavor, in as few words as possible, to show why I think so. Let me briefly recapitulate what, if I understand it rightly is Sir J. Simpson's argument. 1. He has collected figures which, as he believes, show that in rural private practice the mortality of all amputations through the bones of the upper and lower limbs is 10.8 per cent. 2. He contrasts with these figures a somewhat similar number which show that the mortality of the same operations in large hospitals, in the metropolis and elsewhere, is 41 per cent. 3. Assuming that the patients and the cases are in every other respect similar, he concludes that the cause of the difference in death-rate is the internal arrangement of the hospitals in which the second class of cases were treated. 4. He believes that a certain change in those arrangements, which he describes, is necessary, and would be successful in redressing the balance of deaths. This change consists in substituting movable iron sheds upon the ground for our present three- and fourstoried permanent brick buildings. I have thus divided Sir J. Simpson's argument into heads, for the purpose of conciseness and clearness, I hope I have stated it fairly. I will now proceed seriatim with each head. 1. Under the first head, I altogether deny that figures collected as those of Sir J. Simpson's first list have been, can represent faithfully the normal and actual average of deaths after amputation in country practice. The first list (published in the Edinburgh Medical Journal for March, 1869) comprises the experience of 374 gentlemen, and it extends back more than twenty years. It is comSIR JAMES SIMPSON's recent publications on "hos posed almost exclusively of two kinds of returns— pitalism" have brought a heavy charge against our viz., first, very small numbers of amputations for great metropolitan and provincial institutions-no disease (in many instances single cases), which less than that of deliberately sacrificing the lives have almost uniformly proved successful; and, sethey were instituted to preserve. This charge has cond, large numbers of amputations for injury, deattracted the attention of the public, with whom rived evidently from districts in which (as I will Sir J. Simpson's name weighs far more than his ar- presently show) the circumstances are altogether guments, and who accept the statistics which so different from those of London hospital practice, eminent an authority produces as being, of course, and displaying an amount of success quite excepsatisfactory; and consequently we see it every now tional in either London or the country. Now, in and then said in the public papers that our large both these classes of cases I am sure that a more hospitals have been found to be a mistake, and that thorough statistical inquiry, if it were possible to the charity of the public is being directed into other make one, would produce something to balance this channels towards village and other hospitals, tale of success. It was the impossibility of making which, it is said, have been proved to be more any such fair and complete statistical inquiry, and healthy. It concerns hospital surgeons very nearly of estimating and excluding the numerous causes to examine, as far as is possible, dispassionately, of difference which exist between hospital and whether Sir J. Simpson has proved his case; and, private practice, that induced Dr. Bristowe and perhaps, it concerns me in particular, since I was myself to abstain from any attempt at it in our Rehonored some years ago with the surgical part of port. My conviction from reading Sir J. Simpan investigation into our hospital system, on which son's figures is, that his list is composed of returns a "Report on Hospitals" was founded, forming a from surgeons, who, having been gratified by their portion of the Report for 1863 of the Medical Offi- success in the emergencies of practice, have treacer of the Privy Council. If such facts and statis- sured up records of that success, and have been tics really form the basis of a trustworthy compa- glad to communicate it. Nothing can be more narison, they were as accessible to Dr. Bristowe and tural, nothing more legitimate than this. If, like myself as to Sir J. Simpson, and it was my parti- the surgeons marked No. 92 and No. 171 in Sir J. cular province to collect them; for we were, in Simpson's list, I had amputated for injury 22 times; plain terms, directed "to ascertain the influence of or like No. 191, 29 times; or like No. 288, 52 different sanitary circumstances in determining, in times, without losing a single patient, I should be different hospitals (as compared with one another, most happy to take any proper opportunity to say and where practicable, with private practice,) more as much, and more particularly if the question was or less successful results for medical and surgical asked; but if, on the contrary, I had (as I know treatment, particularly among patients who are many surgeons in the country have) had one or two submitted to surgical operation." The same rea- unsuccessful cases of amputation in a long experisons which then inclined us to abstain from collect-ence, chiefly occupied in other branches of practice, ing such figures make me now regard Sir J. Simp and in which death occurred from previous disease |