ARTICLE VIII. COCAINE.

WALTER W. ALLPORT, M. D., D. D. S., OF CHICAGO, ILL.

The introduction of cocaine as a local anæsthetic, and the more general use of peroxide of hydrogen (H₂O₂) in the treatment of dental and oral diseases, are the principal advance made in the medical department of this practice during the year for which this report is made.

The two forms of cocaine which have been most generally used in surgery are the hydrochlorate and the oleate.

In operations in the mouth, involving the mucous membranes, together with the immediately subjacent tissues, these preparations have proven so efficient there is little question of its value as a local anæsthetic in such cases. But its action on deeper structures, such as involve the roots of teeth, is so uncertain as to render its practicable benefits questionable in the operation of extraction. In the surgical treatment of pockets caused by pyorrhea alveolaris, the anæsthetic effect of this agent is often so great as to render this sometimes very painful operation comparatively painless, and its employment in such cases should rarely be dispensed with. In the treatment of hypersensitive dentine, as well as in the removal of tooth-pulps, its action as an anæsthetic has, under some circumstances, seemed to be all that could be desired. But in far the greater number of cases it has proved of little practical value. More recently, however, a new form of cocaine, known as the citrate, has been introduced in Germany by Merck, and is now being manufactured by McKesson & Robbins, of New York. In a series of experiments, conducted by Dr. John S. Marshall, of Chicago, it has been shown that for operations on sub-mucous tissues, or in the extraction of teeth, it seems to possess no special advantages over the preparations previously named. But when applied to dentine or the pulp, its action—though not always positive—seems to be more reliable, especially on the dentine, and gives promise of better results. Under favorable conditions it produces anæsthesia of the parts in from five to ten minutes, and the duration of the effect is of sufficient length to afford time for the preparation of the cavity. This effect has, in some cases been prolonged for more than an hour. The pulp has been extirpated without pain after the drug has been applied in from three to twelve minutes.

If the citrate of cocaine be kept in solution for more than three or four days it decomposes and loses its active properties. As introduced by Mr. Merck for dental purposes, it is made into pills by incorporating it with gum tragacanth dissolved in glycerine, each pill containing 1/8 grain of the citrate. In this form it keeps well. A pill is applied to the sensitive cavity and covered with a cotton pledget, moistened in tepid water. It should be allowed to remain from five to twelve minutes, when—if at all—the desired result is produced. In twenty per cent. of the cases where this remedy has been employed it has proven unsuccessful, but it is hoped that this percentage will be reduced by a better knowledge of the drug and the improved methods of its preparation and use.

With this in view, and at the suggestion of Dr. Marshall, McKesson & Robbins are now manufacturing granules containing one-sixteenth of a grain of the citrate of cocaine, without glycerine or any other saccharine excipient, so that the obtundent may act more promptly than it can in the presence of sugar.—Address at American Medical Association.

Editorial, Etc.

University of Maryland, Dental Department.—The fourth Annual session of this institution opened with a much larger number of matriculates than ever before in its history, and the number is so rapidly increasing that the present class of seniors and juniors bids fair to be larger than any preceding one.

The reputation of this school has never been sullied by the graduation of students for fees irrespective of professional ability, and the consequence of such a course as has been steadily pursued since its organization, has been to give a professional standing to its diploma which that of no other dental school excels. The present class consists of representatives from all parts of this country, and also Germany, France, South America, Canada, and even Turkey. Many states of this country are largely represented, such as New York, Georgia, Virginia, Pennsylvania, South Carolina and Maryland especially, and also the New England states, while nearly every other state is represented.

Students who have passed a session at other dental schools have entered on a second session at the University of Maryland, Dental Department, to complete their course of study and receive its diploma, and not one of the hundreds of students who have attended a course in this institution, has ever gone elsewhere to graduate. In matriculating the present class, the resolutions adopted by the National Board of State Dental Examiners have been strictly adhered to, and many applicants of this country and Europe have been refused admission who desired to make their attendance obligatory on graduation after ONE session's attendance.

The Infirmary and Laboratory practice is not excelled in size if equalled by that of any other dental school, and the records will show hundreds of gold fillings credited to the individual practice of students for both the regular winter and summer sessions. No other school can offer greater facilities for practical instruction, nor present more complete equipment as to building and appliances than this Dental Department. Dental practitioners are cordially invited to visit the University and inspect the specimen work of its graduating classes deposited in the museum. Large and valuable contributions from all parts of this country and also from Europe are almost daily being received for the Museum, which will compare favorably with that of any other dental school for valuable pathological specimens, which are also utilized for illustrating the lectures of each course.

Correspondence.—The following letter was received from a prominent dental practitioner of Georgia for publication:

Augusta, Sept. 30th, 1885.

Editor "Am. Journal of Dental Science":

Dear Sir: According to my knowledge of the proceedings of the organizations known as the "National Board of Dental Examiners," and the "National Association of Dental Faculties," it was determined that no dental school would be regarded as reputable that did not after June, 1885, require TWO FULL SESSIONS OF FIVE MONTHS EACH IN SEPARATE YEARS FOR GRADUATION. The only exceptions made being those who after graduation in medicine had passed one year in the study and practice of clinical dentistry, and also those who had attended a previous session at a reputable dental school. I believe that the American Dental Association also adopted the same rule. Am I not correct? I therefore ask how it is that the dental school of Vanderbilt University is permitted to offer graduation at the close of but one session, to a student of this city who has passed one session only, and that very irregularly, at the Georgia Medical College? I also ask how the same school can offer similar inducements to #/ it has done, and yet be declared reputable? Was it for the purpose of permitting such violations of the rules adopted by the different organizations referred to, that the "National Association of Dental Faculties" allowed the dental school of Vanderbilt University to abstain from becoming a member of that Association for the present year, and accorded to its Dean the privileges of the floor at its late meeting in Chicago? I cannot see why some schools should be compelled to conform to a rule that others may violate with impunity, and I think that the State Boards of Dental Examiners of both my own state and South Carolina should investigate the matter and act accordingly.

Respectfully, &c., "Justice."

We can only reply to the above letter by stating that several students who as we had learned from their preceptors, intended to matriculate in the Dental Department of the University of Maryland, on discovering that they would be required to attend two sessions in the institution, had, we are informed, been induced to go to Vanderbilt by the promise of graduation on one session's attendance.

Editor of "Am. Journal of Dental Science."

Bibliographical.

A Series of Questions Pertaining to the Curriculum of the Dental Student.—Embracing Dental Histology, Dental Pathology, Dental Surgery, Dental Prosthesis, Dental Metallurgy, Dental Materia Medica and Therapeutics, Anatomy, Physiology and Chemistry. By Ferdinand J. S. Gorgas, A. M., M. D., D. D. S., University of Maryland. Publishers: W. K. Boyle & Son, Cor. Baltimore and St. Paul Streets, Baltimore, Md. 1885. Price, $1.50.

This work comprises leading questions on all the branches belonging to the course of study pursued by the dental student, and its object is to facilitate the study of dental science and its collateral sciences.

Some years ago the author published a small work embracing in an abridged form, questions on Dental Science, and the favor with which it was received by the students of his class, was such as to rapidly exhaust the limited edition, and induce him to prepare, when opportunity offered, a more complete series of questions embracing the entire curriculum of the dental student, and even that of the medical student so far as related to Anatomy, Physiology and Chemistry.

The present work, therefore, is the result of such an intention, and is presented with the hope that it may accomplish the object for which it has been prepared.

Practical and Analytical Chemistry.—Being a Complete Course in Chemical Analysis. By Henry Trimble, Ph. G., Professor of Analytical Chemistry in the Philadelphia College of Pharmacy. Illustrated. Publishers: P. Blackiston, Son & Co., Philadelphia. 1885. Price, $1.50.

The object of this excellent work is to place before the student of pharmacy and medicine a compact course of analytical chemistry.

The distinguished author believing that the study of Qualitative Analysis should be preceded by some practical experience such as relates to the preparation of the important gases and a few of the salts, devotes Part First to the consideration of Hydrogen, Chlorine, Hydrochloric Acid, Oxygen, Nitrogen, Ammonia, Nitric Acid, Carbon Dioxide and the preparation of such salts as Potassium Chloride, Potassium and Sodium Tartrate, Ammonium Nitrate and Oxalate, Calcium Phosphate, Magnesium Sulphate, Carbonate and Oxide, Aluminium Hydrate, Ferrous Sulphate, Ferric Sulphate and Hydrate, Copper Sulphate and Lead Acetate. Part Second is devoted to Qualitative Analysis, and Part Third to Quantitative Analysis, together with a description of apparatus, and the processes of filtration, evaporation, crystallization, ignition, etc. The work extends over nearly one hundred pages, and is a valuable text-book for the student.

Chemical Problems.—By Dr. Karl Stammer. Translated from the second German edition, with explanations and answers, by W. S. Hoskinson, A. M., of Wittenberg College, Ohio. Publishers: P. Blackiston, Son & Co., Philadelphia. 1885. Price, 75 cents.

The text is in the form of questions to which answers are given at the end of the volume, which comprises one hundred and nine pages. Part First relates to the recognized elements, and Part Second to approximate ratios, temperature, atmospheric pressure and mixed problems, making a compact and useful text-book for the study of chemical problems.

Quiz Questions.—Course on Dental Pathological and Therapeutics, Philadelphia Dental College. Prof. J. Foster Flagg, D. D. S. Answered by William C. Foulks, D. D. S. Third edition, Revised and Enlarged. Publishers: The S. S. White Dental Manufacturing Company, Philadelphia, New York, Boston and Chicago.

This excellent series of questions and answers on Dental Pathology and Therapeutics is again offered to the dental profession as a work of reference in daily office practice, and is the only book that contains in a condensed and practical form the facts and principles of these subjects, as enunciated by Professor Flagg. Commencing with General Principles, these questions and answers relate to Deciduous Teeth, Pathological Dentition, Lancing, Permanent Teeth, Dental Caries, Sensitive Dentine, Galvanic Action, Pulp Protectors, Obtunding Applications, Pulp Capping, Pathological Conditions of Pulp, Dental Exostosis, Malformed Teeth, Periodontitis and Alveolar Abscess, the whole constituting a work of great value to all engaged in the practice of dentistry. The work is interleaved with blank pages for notes, etc., and gotten up in a neat and excellent style. We take great pleasure in commending this treatise as a valuable adjunct to the regular text-books of the profession.

Monthly Summary.

Peroxide of Hydrogen.—Dr. W. W. Allport, Chicago.—The peroxide of hydrogen (H2 O2), though not a new remedy, has only within the last few years gained much prominence in the treatment of surgical diseases. One of its uses in dental and oral surgery is in blind or deep-seated abscesses, such as arise from roots of diseased teeth. As the tendency of pus is always downward, when these cases occur in the lower jaw it is not infrequent that the abscess, if left to itself, and sometimes even after the tooth is extracted, will point through the external tissues at the lower margin of the jaw, and occasionally downward between the muscles of the neck, and open at various points, even as low down as the clavicle. The usual treatment is to extract the tooth and evacuate the pus through the alveolus, but it often happens that the formation of pus and the continuance of suppuration is not checked, and the abscess points, or is opened through the external tissue of the face or neck, leaving, when healed, a disfiguring scar.

By injecting peroxide of hydrogen into such abscesses before they point through the external tissues, this serious disfigurement can usually be averted, and the suppurative process is materially shortened. It is also a valuable aid for the evacuation of the purulent contents of the antrum of Highmore, in catarrhal and suppurative inflammations, and especially where the sinuses are divided into two or more pockets by bony septi. These cases are often protracted by the inability of the surgeon to perfectly evacuate them. But with this preparation it becomes a simple matter after access has been gained to the cavity by the extraction of a tooth or the perforation of its external wall in the proper place at the juncture of the cheek with the alveolar border. A free opening must always be made for the escape of the contents, in in order to avoid pressure from the rapid evolution of gas. Two or three applications of a dram each is usually sufficient to completely empty the sac.

It is used with the most gratifying results in the treatment of pyorrhea alveolaris, and is an invaluable agent in treating pulpless teeth, as by its action all decomposed matter from the pulp chamber and dentinal tubuli is readily ejected, thereby removing the most frequent cause of discoloring of this class of teeth, of inflammation of the peridontal membrane, as well as alveolar abscesses.

The efficacy of peroxide of hydrogen depends on the case with which it is decomposed into oxygen and water. Pus is one of the many substances which causes this decomposition. Hydrogen peroxide acts first chemically and then mechanically. When the decomposition takes place the oxygen is set free and escapes from a liquid to a gaseous form; this expansion of the gas distends the pus cavity, and as it escapes from the orifice, it carries much of the pus with it, and its application should be repeated till all purulent accumulations are evacuated. The liberated oxygen, being in a nascent or active condition, rapidly oxidizes the products of suppuration, and destroys many of the micro organisms of suppuration.[A] Hence it is a disinfectant and anti-septic.

Finally, peroxide of hydrogen, after its decomposition, leaves no material in the system which is foreign to the system, and it is, therefore, one of the most efficient and harmless disinfectants and anti-septics that can be used, in all forms of purulent inflammation.—Address at American Medical Association.

Alcoholic Paralysis.—The immediate and transient effects of an excessive quantity of alcohol upon the human nervous system, whether they are manifested in the form of drunkenness, or of delirium tremens, or of an acute attack of insanity, are well known. Scarcely less evident are the effects produced upon the nervous system by a less excessive, but a more prolonged, abuse of alcoholic drinks. These effects may be manifested either in a general failure of physical and mental power, or in a form of disease closely resembling progressive paralytic dementia, or in various forms of chronic insanity, or in epilepsy, or in neuralgia, or in paralysis. In the acute form of alcoholic poisoning, no change in the structure of the nervous system has been found, except that the meninges in common with the internal organs and the mucous membranes are the seat of a very decided injection and slight exudation. In the chronic form of alcoholism, a number of pathological changes have been discovered in the nervous system, which, however, vary greatly in different cases.

Of late years the paralysis which results from the abuse of alcohol has been accurately described by numerous observers, and the attempt has been made to discover the lesion of the nervous system which is associated with this form of paralysis. Two cases which are reported by Dr. Henry Hun, of Albany, in the American Journal of Medical Sciences for April, 1885, are typical examples of this disease, and contribute to a better understanding of it.

Dr. Hun has collected the recorded cases of alcoholic paralysis, and from their study he holds that we are justified in regarding it as a special form of disease with the following symptoms: After a number of cerebral and gastric disturbances due to the alcoholic poisoning, the symptoms of the disease proper commence with neuralgic pains and paræsthesiæ in the legs, which gradually extend to the upper extremities, and which are accompanied at first by hyperæsthesia, later by anæsthesia, and in very severe cases by retardation of conduction of pain. Along with these symptoms appears a muscular weakness, which steadily increases to an extreme degree of paralysis, and is accompanied by rapid atrophy and by great sensitiveness of the muscles to pressure and passive motion. Both the sensory and motor disturbances are symmetrically distributed, and the paralysis attacks especially the extensor muscles. In addition to these motor and sensory symptoms, there is also a decided degree of ataxia. The tendon reflexes are abolished and vaso-motor symptoms, such as ɶdema, congestion, etc., are usually present. Symptoms of mental disturbance are always present in the form of loss of memory and in transient delirium.

The lesion is in all probability a degeneration of the peripheral nerve fibres and of the nerve cells in the cerebral cortex, together with a chronic congestion or inflammation of the pia mater. This lesion explains well the symptoms, although it is curious that alcohol should not attack the spinal cord, but only the highest and lowest part of the nervous system, if one may so call the cortex of the brain and the terminal branches of the peripheral nerves.—Detroit Lancet.

Nourishing the Tissues of the Teeth.—Dr. Frank Abbott says: For a number of years past I have entertained the views that there was some difficulty existing not due to an insufficiency of lime-salts, which occasions so many faulty and imperfectly formed teeth. With that idea in view I have advised exercise in the open air and other kinds of treatment for some patients which would favorably affect their digestion. That the food ordinarily taken contains sufficient lime-salts to form and to sustain the teeth I have no doubt (except in cases of extreme anemia, during gestation and lactation). I believe the fault is beyond that. There is a lack of proper nourishment of the tissues, due to imperfect digestion, which depends again on the proper "nerve tone." I believe this to be the real cause of the difficulty. It is reasonable to suppose that any tonic, whether taken in the form of exercise in the open air, or in any other form, which affects favorably other portions of the body, will affect the teeth favorably as well. When we have ascertained the functions of the great nerve-centers, and those functions are assured, then we will probably have more perfectly formed teeth.—Items of Interest.

Footnotes