ten years.

dustry which had then been introduced into London some In Germany, however (where lucifer manufactories were started some years earlier than in England), phosphorus-necrosis was recognised as early as 1839 by Lorinser, who published a paper upon the subject in 1845, and was followed by Strohl, Heyfelder, Roussel and Gendrin, and Sédillot, in 1846. In 1847 Drs. Von Bibra and Geist, of Erlangen, published a work ("Die Krankheiten der Arbeiter in den Phosphorzündholzfabriken, ins besondere der Leiden der Kieferknochen durch Phosphordämpfe"), which forms the basis of our present knowledge of the subject, and the conclusions of which further experience has fully confirmed.

In London the lucifer manufactories being principally at the East-end, cases of phosphorus-necrosis are most common in St. Bartholomew's, the London, and the Borough hospitals, and their museums, especially that of St. Bartholomew's, are very rich in specimens. The medical officers of these institutions having thus had special opportunities of study, have not failed to record their experience, and reference may be made to valuable clinical lectures upon the subject by Mr. Simon (Lancet, 1850), Mr. Paget (Medical Times and Gazette, 1862), and Mr. Adams (Medical Times and Gazette, 1863); and to the essay on Surgical Diseases connected with the Teeth, by Mr. J. Salter (Holmes' "Surgery," vol. iv.).

The cause of the disease is unquestionably the fumes of the phosphorus which are inhaled by the operatives during the process of " dipping" the matches, and in a lesser degree during the counting and packing them. When the disease first showed itself in Germany, it was thought that it depended upon the admixture of arsenic with the phosphorus ; and it is curious that in the Museum of St. Bartholomew's there are some bones of cows from the neighbourhood of Swansea, which, under the influence of arsenical vapour, have become enlarged and covered with a new bone formation closely resembling that around phosphorus-necrosis. It has been proved, however, that arsenic has nothing to do

with the disease; and if proof positive were wanting that phosphorus alone is the deleterious agent, it is supplied by a case quoted by Mr. Paget, in the lecture referred to, of a man who induced necrosis of his jaws by inhaling fumes of phosphoric acid as a quack remedy for "nervousness.'

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Lorinser and the earlier writers considered the disease to consist in blood-poisoning, the necrosis of the jaw being consequent thereupon, and Mr. Adams (loc. cit.) thinks that the theory of blood-poisoning should not be altogether discarded, since the local disease would not account for the constitutional symptoms experienced. The majority of surgeons agree, however, in considering the affection essentially a local one, the constitutional symptoms being only consecutive.

It is found that the phosphorus fumes produce no injurious effects so long as the teeth and gums of the workers are sound, but so soon as the teeth become carious, or if a tooth is extracted so as to leave an open socket, the disease rapidly developes itself. The experiments upon animals by Geist and Von Bibra, are amply confirmatory of this view, since they found that rabbits exposed to phosphoric fumes suffered no injury so long as the teeth and jaws were uninjured, but that if the teeth were extracted or the jaw broken periostitis and necrosis rapidly resulted. On the other hand, it may be mentioned that a case has been recorded by Grandidier (Journal für Kinderkrankheiten, 1861), of necrosis of the upper jaw from phosphorus fumes in a child but six weeks old, and in whom therefore the teeth were not developed.

The liability of the two jaws to the disease appears to be about the same, or perhaps with a slight preponderance in favour of the lower jaw. Of 52 cases given by German authorities, 21 were of the superior maxilla, 25 of the inferior maxilla; in 5 both jaws were involved, and one case is uncertain. (British and Foreign Medico-Chirurgien Review, April, 1848.) Mr. Salter (loc. cit.) says cases which I have witnessed, the lower jaw wa in four, and the upper in one; whereas four whic

in the practice of a surgical friend, were confined to the upper jaw. In seventeen instances of which I have obtained particulars or seen specimens, nine were connected with the superior, and eight with the inferior maxilla. The disease is therefore pretty evenly balanced between the two jaws." The St. Bartholomew's Hospital Museum contains excellent specimens of both jaws affected by this form of disease.

The Symptoms of Necrosis of the jaws, from whatever cause, are much the same, but as they present themselves in the most marked degree in phosphorus-necrosis, it will be convenient to describe them under this head.

Pain referred to the teeth is one of the earliest symptoms of the disease, and this, which was intermittent at first, becomes at length continuous. The teeth become loose, and pus is seen to exude from their sockets. At the same time the gums become swollen and tender, and are detached to a greater or lesser degree from the alveoli, giving constant exit to a purulent discharge. In all cases of necrosis the face is swollen, so that if only one side of the jaw is affected a peculiar lop-sided effect is produced. In the cases of phosphorus-necrosis, however, the swelling of the face is much more marked, the soft tissues around the bone being infiltrated and puffy to an extent which is not witnessed in other forms of the disease. One or more openings now form externally, through which pus constantly exudes, and the probe introduced through these, readily reaches bare and dead bone.

The patient's general health has by this time become seriously affected, owing both to the actual suffering he has undergone, and to the interference with his nutrition which the state of his mouth necessarily involves, it being impossible for him to take any but fluid or semi-fluid food, and that in small quantities. The constant presence of most offensive discharges in the mouth, and mixing with the food, must have an injurious effect upon the patient, though this is questioned by Salter, who remarks that these patients swallow daily many ounces of pus "without any obvious

detriment to health." The necrosed portions of bone project more or less into the mouth, and give the patient great inconvenience, and in very severe cases of phosphorusnecrosis gangrene of the cheeks and lips ensues with a rapidly fatal termination. In less severe cases, the patient may drag on a wretched existence for months, and sink at last from exhaustion, or may occasionally recover with considerable loss of bone and deformity.

CHAPTER IX.

REPAIR AFTER NECROSIS-TREATMENT OF NECROSIS.

IT has been already remarked under the head of Exanthematous Necrosis, that in young subjects a development of fibrous tissue takes place after loss of substance in the upper jaw. This is not the case when loss of part of the superior maxilla takes place in adult life, except in rare instances, it being remarkable that the periosteum of the upper jaw ordinarily makes no effort at repairing, by effusion, the mischief which has taken place. M. Ollier, of Lyons, in his recently published (1867) work "La Régéneration des Os," gives a case of phosphorus-necrosis of the upper jaws where a certain amount of new bone was produced, and also one of necrosis of the upper jaw from other causes, in which a development of osteo-fibrous tissue took place in a young woman of nineteen. He quotes also from the practice of Bilroth, of Zurich, the case of a man, aged twenty-seven, in whom, after phosphorus-necrosis, a development of plates of bone took place. These cases must be regarded, however, as quite exceptional, Trélat in his thesis (1857) having failed to discover a case of osseous reproduction of the superior maxilla. In the lower jaw, however, the case is very different, the periosteum and the surrounding tissues being very active in producing new bone to take the place eventually of that which is necrosed. So soon as the periosteum is separated from the jaw by the formation of pus around the sequestrum, it appears to take on an active condition which leads to the effusion of plastic lymph. This becomes rapidly converted into fibro-cartilage and then into bone, which forms a more or less complete shell around the necrosed portion.