[Lancet, London, July 6, 1918.]

Operative Treatment of Trigeminal Neuralgia. By J. HUTCHINSON.

This article is of great interest in connection with that of Frazier (Jl. A. M. A., May 11, 1918, and DENTAL COSMOS, September 1918, p. 829). Both surgeons agree that the only treatment affording lasting cure is an operation on the Gasserian ganglion. Hutchinson believes that the method of Frazier and Spiller (division of sensory root) is too hazardous and uncertain ever to come into favor; and moreover, it has the disadvantage of destroying the ophthalmic division. Primarily it is to save this division that Hutchinson devised his method. This is not only urgently desirable but is quite feasible, because in only 25 per cent. of cases of trigeminal neuralgia is the ophthalmic division materially involved.

The ganglion is removed by three lines of section: (1) Division of the inferior maxillary division at the foramen ovale; (2) division of the superior maxillary division at the foramen rotundum; and (3) a horizontal cut below the ophthalmic division, which is thus spared.

Of over sixty cases operated upon, only one has proved fatal, and in this the patient was a very bad risk. After removal of the ganglion, Hutchinson has followed up many cases for over ten years, some for nearly twenty years, and the neuralgia has not returned. This statement is true of the great majority, but there have been a few exceptions, difficult to explain. In only one case has the neuralgia returned to be localized in the ophthalmic division, some ten years after operation. In this case resection of the supra-orbital nerve was a complete success for the period of observation (three years). The complications sequent to Hutchinson's method are no other than those liable in any

other operations. The results are among the most satisfactory of any the surgeon will en

counter.

Hutchinson is very emphatic that the extraction of teeth with the view of relieving or curing true epileptiform neuralgia is a pernicious and useless practice. There exists in his opinion no valid evidence to regard trigeminal neuralgia as a spreading neuritis of dental origin.

In respect to alcohol injection, either of branches of the fifth nerve or into the foramen ovale and its neighborhood, Hutchinson is quite in accord with Frazier. To them it is but an indifferent substitute for operation on the Gasserian ganglion. Ocular and aural complications may result from alcoholic injection.

Cheatle (Lancet, London, July 13, 1918, p. 56) has seen two cases in which the middle ear has been badly and permanently disorganized, owing apparently to the alcohol entering the Eustachian tube.

[Journal of Infectious Diseases, Chicago, June 1918.]

sp.:

Streptothrix Interproximalis—nova An Obligate Micro-aerophile from the Human Mouth. BY ERIC A. FENNEL. The mouths from which this organism was isolated would be classed as "habitually unclean mouths with incipient caries and a liberal deposit of salivary calculus." The culture medium used was Martin's agar and ascitic fluid, on which macroscopically visible colonies developed in four or five days. Cultivation was conducted under the system of partial oxygen tension of Wherry and Oliver.

The organism is highly pleomorphic, growing in plaque-like colonies of intertwined and matted threads. Its morphology varies rather consistently with the age of culture. It stains with the ordinary dyes. A majority of the threads are Gram-positive. It is non-motile;

optimum temperature 35° C.; it does not grow at all at 20° C. or under anaerobic conditions, and only with the greatest difficulty aerobically. It produces neither pigment nor endospores.

Fennel details the cultural characteristics at some length.

[Le Progrès Médical, Paris, May 18, 1918.] Frequency of Vincent's Angina. BY J. CHALIER.

Before the war 2.26 per cent. of all cases of angina were due to Vincent's organisms. For twenty-two months Chalier was associated with the medical service to 2500 men. In his experience there occurred 46 cases of true angina, 13 (i.e. 28.26 per cent.) of which were of Vincent's type. In the latter months of his service there was a marked increase in the incidence of the disease.

On account of the possibility of contagion, it is advisable to isolate the patients for ten days. In from eight to twelve days, in cases receiving early treatment, cure has been complete. Successful results have been obtained from thorough washing out of the throat three times a day with 2 liters of boiled water to which a little HO, has been added. This is followed by a liberal application of powdered methylene blue to the craters of the ulcers.

T. J. Gallaher (Laryngoscope, St. Louis, July 1918, p. 551) has for a number of years been very successful in the treatment of Vincent's angina with trichloracetic acid. The pure liquid acid, after excess has been absorbed on an ordinary blotter, is applied carefully to the entire affected area by means of a small applicator wound with cotton. The parts turn white in two to three minutes. Then neutralize by applying a saturated solution of sodium bicarbonate. Repeat in two or three days if necessary. It is rarely necessary to make more than two applications.

[Surgical Clinics of Chicago, Philadelphia, June 1918.]

Tumor of the Gasserian Ganglion.
NELSON M. PERCY.

BY

This is a case history with commentary. The patient was a male, age thirty-one years; family and personal histories negative. Complained of pain in right forehead, right ear, and right side of the face, beginning about

two years before being seen by Percy. Simple tic douloureux was eliminated because of the paralysis of the seventh cranial nerve; also because the pain became continuous soon after the beginning of the trouble and has persisted since, while in tic douloureux the pain is never so persistent, but is intermittent-in spasms. A probable diagnosis of tumor of the Gasserian ganglion was made.

The surgical technique of the removal of the tumor is detailed. The growth was 3.5 x 2.5 x 1. mm., was closely connected with and apparently included the ganglion. The nature of the growth is still in doubt. Diagnoses suggested by different pathologists were neurofibroma, fibrosarcoma, and endothelioma.

Convalescence was rapid and uneventful. The pain had stopped. The patient had not been seen since leaving the hospital.

[American Journal of Syphilis, St. Louis, April 1918.]

Leukoplakia of the Tongue. BY DOUGLASS W. MONTGOMERY.

The case reported is of interest for several reasons: Because of its occurrence in a young man (age twenty-two years), because of its association with syphilis (contracted at the age of sixteen years), and because it almost entirely cleared up under the use of radium and anti-syphilitic treatment.

The patient denied the use of tobacco at any time or in any form. This is important, considering the usually and undoubtedly justly accepted view that one of the chief causes of leukoplakia is tobacco smoke.

The radium treatment was as follows:

A

dime-sized plaque containing 24.23 mg. of radium element, and screened with A 1.0.05, cotton, and rubber, was applied for ten minutes, and reapplied in ten days. Two days after this last application a rather severe and quite painful reaction was obtained. In two weeks the hyperkeratosis had entirely disappeared, leaving what appeared to be a slight scar.

The syphilis was treated with salvarsan intravenously and with intramuscular injections of gray oil. This extended over a period of ninety-five days. The tongue condition never entirely cleared up; there remained the opalescent haze and decided local sensitive

ness.

[Medical Record, New York City, August 24, 1918.] Relationship of Oral Sepsis to Systemic Disease, and Its Bearing on Treatment. BY H. B. ANDERSON.

In preparation of this paper, Anderson studied 257 private cases, of which he has full histories, and which could be followed more closely and for a longer period than cases in hospital practice. These cases have been tabulated, noting the principal disease and also other morbid conditions from which the patients suffered at the time of consultation or during the course of their illness. Anderson concludes that it is characteristic of oral infections that, as a rule, they do not produce a single systemic lesion, but a group of allied conditions, not all being manifest at a time.

The author cautions against too hasty and sweeping generalizations. He urges that each suspected case be carefully and critically investigated, to determine if oral infection is responsible for or contributory to the symptoms. In his opinion, teeth should not be sacrificed on the advice of the physician. A competent and experienced dentist is best qualified to advise as to the applicability or limitations of dental treatment.

[Indian Medical Gazette, Calcutta, April 1918.]

Autogenous Oral Streptococcal Vaccines in the Treatment of Seventeen Cases of Sprue. BY LEONARD ROGERS.

The author here reports a series of seventeen cases as unselected and as consecutive as possible which have presented during the last four years. The particular strain of streptococci was not identified in the great majority of cases. Cultures were made when the tongue or mouth presented soreness or even small ulcers, but success was sometimes obtained during a quiescence of oral symptoms.

The initial dosage was approximately 50 million, increasing to 200 million, at intervals at first of five days, ascending to ten days. In typical cases injections were continued three to six months.

The results of this vaccine treatment in cures and in marked improvement are strikingly superior to the results obtained by other methods. Rogers concludes that the data fur

nished in this report go far toward supporting the view that sprue is essentially a streptococcal infection, originating in the mouth and spreading down the intestinal canal.

The case histories afford very interesting and suggestive reading.

Within the body of this paper is a brief mention of two cases of diarrhea associated with pyorrhea alveolaris successfully treated with oral autogenous vaccines.

[Lancet, London, June 8, 1918.] Methods of General Anesthesia in Facial Surgery. By R. WADE.

[Journal of American Medical Association, Chicago, July 20, 1918.] Anesthesia and Antiseptics in Plastic Restoration of the Face and Mouth. BY A. E. ROCKEY.

Wade has found that there are two main difficulties in anesthesia for operations on the face and lower jaw: (1) Maintenance of good airway, and (2) the difficulty of avoiding interference with aseptic technique and field of view of the surgeon.

From the anesthetist's point of view, plastic operations may be divided into two main groups, those in which blood finds its way into the air-passages and those in which it does not. The following table gives a list of the various types of operations, together with the method of administration considered suitable for each case. Where there are alternatives the first is preferable.

Types of operations: Methods of
anesthetization.

Lip plastics. C., C.E. + O2; sitting up. intratracheal. Oil-ether per rectum, sitting

up.

Check plastics. (A) Involving oral cavity: Intratracheal. C. or C.E. + O.; sitting up. Oil-ether per rectum, sitting up.

(B) Not involving oral cavity: C. or C.E. by Shipway's warm-ether apparatus.

Chin plastics: Intratracheal; Kahn's tube. Jaw operations: (A) Wiring fractures; also (B) Bone-grafting: Oil-ether per rectum; sterile anesthetic.

(c) Either of above cases with jaws splinted together. Sterile anesthetic. Extensive burns of face: Oil-ether per

rectum.

Anesthetizing the patient in the sitting-up

position in cases in which the blood is likely to find its way into the mouth during the operation has been found to be very satisfactory. Out of nearly 300 cases there have been no bad after-effects or complications.

In connection with this subject, Lovett (Lancet, June 22, 1918, p. 885) advocates preliminary tracheotomy and anesthesia through a tracheotomy tube. Lovett has used this method several times in the worst types of jaw cases with comminution of the mandible, laceration of the soft parts, and when the field of operation includes the oral cavity. Mortimer (Lancet, July 13, 1918, p. 56) believes that for such purposes laryngotomy is usually preferable to tracheotomy, because by the former operation dangers of aspiration of blood from the wound and of opening up the deeper tissues are avoided. Wade (Lancet, July 13, 1918, p. 56) likewise prefers preliminary laryngotomy to tracheotomy, especially where there is much oral sepsis.

Rockey has been impressed with the difficulties signalized by Wade. The failure of surgeons to adopt the principle of an aseptic field in oral surgery is due to the inappropriate methods of anesthesia in general use. Rockey would remedy this condition. Ether inhalation by mouth through a large pharyngeal tube and a coffer-dam of gauze packing. when properly placed, is superior to any other method in a very large class of oral operations. It furnishes that efficient block between the operative field and the respiratory tract so necessary for the performance of ideal operations in this region, and makes possible a degree of asepsis in the operation not possible by any other method.

The apparatus devised and used by Rockey is shown in the paper by illustrations.

It is essential that the ether be given by someone competent to maintain safely such a degree of anesthesia as will prevent any attempt at vomiting, which might clog or displace the tube and break the asepsis of the operating field.

To secure that asepsis the following is essential: (1) Preliminary careful cleaning of the mouth by a dental surgeon. (2) After the introduction of the pharyngeal tube of the inhaler, and the careful placing of the gauze pack, the operative field is cleansed and sterilized as it is in any other part of the body.

[Surgery, Gynecology and Obstetrics, Chicago, August 1918.]

Aberrant Thyroid Tumor of the Tongue. BY MEYER A. RABINOWITZ.

This is an elaboration of a case report of this rare type of tongue tumor. The author estimates the total number of cases which have been observed to date to be about 70. These growths occur most frequently between the ages of fifteen and forty-five; 90 per cent. of all cases have occurred in females. The tissue of the growth is derived from persistent remnants of the anlagen of the thyroid gland.

These tumors are usually situated medially on the dorsum of the tongue, just below and behind the foramen cecum, varying in size up to that of a small apple, and almost invariably encapsulated. Clinically, local inconvenience is rare and constitutional symptoms are usually absent. The prognosis is favorable. Treatment is either thyroid feeding or surgical removal. The best operation is incision, with enucleation.

[Anatomical Record, Philadelphia, July 20, 1918.]

The Use of Sandpaper in the Preparation of Histologic Ground Sections of Hard Substances. BY J. I. FANZ.

Fanz found that by the introduction of sandpaper in ground-section technique the time required to obtain thin, complete, workable sections was reduced to about onequarter.

The object is clamped in an ordinary carpenter's wood clamp or small vise, and a section 1 to 3 mm. thick removed by sawcutting with a jeweler's saw. This coarse section is cemented with dry-scale orange shellac to one end of a rather thick microscopic slide. Within five minutes the shellac is set so that grinding can be begun.

Grinding is accomplished entirely on sandpaper of different grades of coarseness, and the section is never dipped in water or oil. Flint, sand, emery, or carborundum papers are selected according to the hardness of the material to be ground. The flint paper used was of the following grades, Nos. 2, 1, 00, or 0000. Sheets were cut into pieces 3 x 5 inches and were held over a smooth hardwood block 3 x 4 inches while grinding. Brittle substances (c.g. enamel) grind best