A Case to Diagnose. [Volume: 2, Issue: 6, January, 1861, pp. 312-314]

A CASE TO DIAGNOSE.

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nasi. The fullness extended out on to the cheek, and upward as far as the
floor of the orbit; and there was considerable induration a little external
to and above the ala nasi, corresponding with the termination of the fang
of the left cuspidatus; no fluctuation. Raising the lip, there was no
swelling of the gum; but I could just feel the edge of the induration
above the junction of the lip and gum, in the space between the lateral
incisor and the eye tooth; no evidence of pus that could be reached with
a lancet; the palatine arch normal. The tooth that was the most implicated, and that seemed to have produced the disturbance, was the left
superior lateral incisor. It was much elongated from periosteal inflammation or accumulated pus; very loose in the socket, and very sore;
had been plugged about ten years in both the anterior and posterior
approximal sides; plugs good, no discoloration visible either by direct or
transmitted light, that indicated a dead nerve. The left superior cuspidatus was slightly sore from sympathy, and the left superior central
incisor (a pivot tooth of four years standing) was also slightly sore,
but not loose in the socket or elongated; pressure or raps on it with
an instrument did not occasion pain or more irritation than they did
on the canine tooth. She could bite on it without difficulty; she said
it gave her no trouble now, and never had; but she could not bear to
have the lateral incisor touched, or to touch it herself. About three
months since, during my absence, she had suffered from a similar swelling, and had it lanced by a physician; it was opened in the space
between the lateral incisor and cuspidatus.
After this history and examination, I concluded that the nerve was
dead in the left superior lateral incisor, although the pivot tooth was
viewed with distrust; but every test I could devise failed to show that
it was more than secondarily implicated. My plan was to open the
canal of the lateral incisor, clean it, reduce the periostitis, and plug the
tooth and fang at the proper time. To this end, I removed the pivot
tooth, which was very firmly set, in order to gain access to the plug in
the lateral incisor. The pivot came away as dry as pivots usually are,
and there was no more offensive odor or escape of gas from the canal
than is usual in healthy pivot teeth. A broach passed up into the canal
as far as it would go, failed to show that the tooth was the primary
cause of the swelling, or that it was more than sympathetically affected,
and that but slightly.
Thus fortified in my diagnosis, I removed the anterior approximal
plug from the lateral incisor, which occasioned severe pain. With a
small drill I attempted to open the nerve canal, but it occasioned so
much pain I was forced to desist; proceeding again, she complained
that I hurt her very' much, that I touched the nerve. I placed the
point of the instrument in another part of the cavity, and proceeded as
before to see if there was local sensation; and, although painful, it was