;v , *- ^ t> V, V -7^ * -*> ; ' // O *** . ^ ^ V / / ^ im^^'f , N -o- * 0> . o A V .v... ,0 0. X* * '7-' - W % \> s •,S- >o\ ^ x %^ Entered, according to Act of Congress, in the year 1852. BY LINDSAY AND BLAKISTON, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C. SHERMAN-, PRINTER, 19 St. James Street. ■ 3Kt| fatfyix, THIS WORK IS RESPECTFULLY DEDICATED. BY HIS SON. PREFACE TO THE SECOND EDITION. The author of the present treatise gave it to the public with little expectation that it would meet a favourable recep- tion. Indeed, but for the urgency of a friend, in whose judg- ment he had reason to confide more securely than in his own, he never could have overcome his reluctance to risk the expe- riment of the publication. In the result, however, he has been agreeably disappointed. The unpretending volume was very generally noticed by medi- cal reviewers, in every instance, so far as he is informed, with decided commendation, and a practical evidence of its accepta- bility was given in the ready sale of the edition. The author is well aware that he is very much indebted to the personal regard of professional friends for some of the favourable notices of his book, and that, in other instances, he has shared the common urbanity and indulgent consideration with which the conductors of our best Medical Journals are accustomed to encourage all respectable efforts to contribute to the literature of the profession. Nevertheless, he thinks himself authorized to believe, that, after all proper allowance is made for the expression of personal kindness and profes- sional amity, he may, without vanity, ascribe some portion of XVI PREFACE TO THE SECOND EDITION. the commendation lavished upon the work, to its adaptedness to supply what is felt to be a want; and he, therefore, has determined to offer to the public a second edition. In preparing this for the press, it was not thought advisable to enlarge the book to an extent that would require a consi- derable increase in the price; nevertheless, some important matter has been added where the treatise seemed most imper- fect. A chapter upon Anaesthetics has been appended to the work as originally published. The great importance of the subject, and the interest felt in it, required that- it should be discussed in a treatise designed for the purposes for which this was written. The arrangement has been altered where perspicuity and connexion required it. A great number of verbal errors have been corrected; and the typographical execution very much improved. A copious index has also been added. The author sincerely hopes that the book may prove useful to all who may do him the honour to read it. Baltimore, September 13th, 1852. PREFACE TO THE FIRST EDITION. The Baltimore College of Dental Surgery was organized with the design of teaching Dentistry as a regular branch of Medicine, in which relation, only, it can be regarded as a scientific pursuit, and the practice of it esteemed as a pro- fession. With this view it was arranged that the Faculty should con- sist equally of Dentists and practising Physicians, and to the author of this treatise was intrusted the chair of Special Pa- thology and Therapeutics. Commencing the performance of his duties with no larger amount of knowledge of the subject than is commonly possessed by medical men, he has been led to discover much more importance in it than at first he could have supposed to exist. Endeavouring to avoid the very na- tural error of exaggerating the value of isolated facts or doubtful statements, upon matters at once novel and from the circumstances peculiarly interesting, he has found that many things which at first he was disposed to regard as unlikely, are, nevertheless, well-attested and established facts ; and, after mature investigation, he has become fully convinced that the relations of the teeth and their appendages with other and even with vital parts, are sufficiently important to be carefully studied both by the Dentist and Physician. XV111 PREFACE TO THE FIRST EDITION. After ten years' experience as a teacher of these subjects, he has found it absolutely necessary that a compendium of medicine should be furnished, in which might be brought to- gether, in a small compass, such selected information as the wants of the Dental Surgeon demand ; — and as none has been prepared by another, he has reluctantly undertaken the task. The difficulty of performing it will readily be conceived, when it is observed how much was proper and how much irre- levant ; how cautious it was necessary to be, that no needless matter should be introduced, and how careful that nothing pertinent should be omitted. Without the pretension of having done it well, the author is yet gratified that it has been done at all. Though particularly intended for the Dentist, the author flatters himself that he has presented the subject in such a form as will render it deserving the attention of the general practitioner. It is not the custom of our profession to consider anything unworthy of attention that has a bearing, however remote, upon the benevolent pursuit to which we have devoted our lives, but to the most fastidious it may be said, that subjects which have been thought worthy the attention of Hunter and Bush, may be investigated by any without fear of degrada- tion. The Author. Baltimore, Dec. 31, 1850. CONTENTS. PAGE Introduction, ........ 25 CHAPTER I. Preliminary Considerations, ..... 31 CHAPTER II. Etiology, ........ 34 The Atmosphere, ...... 36 Heat and Cold, ....... 37 Malaria, ....... 41 Chemical Causes, . . . . . . .44 CHAPTER III. Symptoms of Disease, ...... 48 Progress of Disease, . . . . . .49 CHAPTER IV. Diagnosis, ........ 52 CHAPTER V. Treatment of Disease, . . . . . „ ,59 CHAPTER VI. Nature of Disease, ...... 61 Inflammation, . . . . . . .63 Consequences of Inflammation, .... 71 CONTENTS. CHAPTER VII. PAGE Inflammation op the several parts composing the Mouth, and op the parts adjacent, . . . . .81 Phlegmon, ....... 81 Erysipelas, ........ 82 Tonsillitis, ....... 82 Stomatitis, ........ 88 Inflammation of the Gums, ..... 83 Antrum, . . . . .85 Inflammatory Fever, ...... 86 CHAPTER VIII. Treatment of Inflammation, . . . . . .87 Treatment of Inflammation and Abscess of the parts composing the Mouth, ...... 88 Mercurial Salivation, . . . . . .91 Cancrum oris, ........ 93 Chronic Inflammation of the Gums, . . . . .93 CHAPTER IX. Caries and Mortification, Caries, Mortification or Gangrene, Necrosis of the Teeth, 95 95 96 100 CHAPTER X. Ulcers, 103 Local and Constitutional, . 105 Simple Purulent Ulcer 105 Vitiated Ulcer, . . 106 Callous Ulcer, . 107 Fungous Ulcer, . 108 Sinuous Ulcer, 109 Carious Ulcer, . . 110 Cancerous Ulcer, 111 Ulcers Dependent upon Constitutional Cause, . 115 Venereal or Syphilitic Ulcers, 115 Scorbutic Ulcers, . 119 Scrofulous Ulcer, 121 CHAPTER XL Tumours, 128 CONTENTS. XXI TUMOURS. PAGE Malignant — Osteo-Sarcoina, . 128 Fungus Hsematodes, Bleeding Fungus, Spongoid Inflammation, Soft Cancer, Medullary Sarcoma, 128 Polypus, .... 129 Benign Tumours, . . 130 Sarcomatous or Fleshy Tumours, . 131 Encysted Tumours, 131 Bony Tumours, . 132 Exostosis of the Teeth, 135 Osteo-Sarcoma, 137 Spina Ventosa, 138 Aneurismal Tumours, . . 138 CHAPTER XII. Diseases of the Teeth and Face dependent upon Morbid Condi- tions, EITHER GENERAL OR OF OTHER PARTS, . .139 Neuralgia, ....... 139 Neuralgia Faciei, or Facial Neuralgia, .... 141 Intermittent Neuralgia, ..... 144 CHAPTER XIII. Morbid Secretions of the Mouth, Dyspepsia, Syphilis, Exanthemata, Mercurial Salivation, Scrofula, Pregnancy, . 149 153 160 160 161 162 163 CHAPTER XIY. Morbid Effects of Conditions of the Teeth and Gums upon the General System, . . . . . .165 CHAPTER XV. Morbid Effects of First Dentition, 168 CHAPTER XVI. Sympathetic Diseases of Dez^tition, Cholera Infantum, . Convulsions, Cutaneous Eruptions, 2 179 180 183 184 XXU CONTENTS. PAGE Intertrigo, . . . . . . . 184 Crusta Lactea, or Milk Crust, ..... 185 Strophulus, Tooth Rash, Red Gum, .... 185 Second Dentition, ........ 187 Third Dentition, . . . " . . 187 CHAPTEE XVII. Effects of Diseased Teeth and Gums upon Adjacent Parts and the GenepvAL System, . . . . . .188 CHAPTEE XVIII. Wounds of the Mouth and Face, .... 229 Burns, ........ 242 Fractures, ....... 245 Fractures of the Jaws, ...... 247 Dislocations, or Luxations, ..... 249 Dislocations of the Lower Jaw, ..... 250 CHAPTEE XIX. Particular Affections of the Mouth and adjacent parts, . 253 Diseases of the Gums, ...... 253 Epulis, . . . . . . 253 Parulis, ........ 257 Fistula of the Gum of the Lower Maxillary, having an Exterior Opening at the Hollow of the Chin, .... 259 Spongy or Fungoid Inflammation of the Gums, . . 260 Hemorrhage from the Gums, ..... 262 CHAPTEE XX. Diseases of the Lips, . . . . . . 264 Hare-Lip, ........ 264 Adhesion, ....... 268 Contraction, . . . . . . . 268 Cancer of the Lip, ...... 272 CHAPTEE XXL Diseases of the Glands and Gland-Ducts, .... 277 Salivary Tumours, . . . . . . 277 Tumours of the Submaxillary Gland, • . . . .280 Notes of the Operation, . 284 Tumours of the Parotid Glands, . . . . .290 Salivary Fistula, ...... 292 CONTENTS- XX111 CHAPTER XXII. PAGE Tumours requiring Amputation of a part or the whole of the Upper Jaw, ....... 294 Amputation of the Lower Jaw., .... 296 CHAPTER XXIIL Diseases of the Antrum, or Maxillary Sinus, . . 305 Dropsy, or Retention of Mucus, .... 80G Inflammation, . . . . . . .311 Suppuration, ....... 312 Caries, Necrosis, and other Morbid Conditions of the Bony Walls, 313 Softening of the Bony Walls, . . . . .320 Exostosis, ....... 320 Fistula of the Superior Maxillary Bone, .... 322 Ozaena, ........ 32G Polypi and other Tumours, ..... 327 Insects in the Cavity, ...... 332 CHAPTER XXIY. Diseases of the Palate, . . . . . 334 CHAPTER XXV. The Use of Chloroform and other Anesthetic Agents, . 346 Effects of Chloroform, . . . . . .353 Modus Operandi of Anaesthetics, .... 354 Conditions Forbidding the Use of Anesthetics, . . . 355 Anaesthesia in Dental Operations, . . . . 355 INTRODUCTION. The body of every animal is wisely contrived and perfectly fitted for the purposes it is intended to subserve. Every part, however minute, is necessary to the complete performance of the work of the whole ; and a beautiful unity of purpose, and a necessary dependence of parts, are observable throughout the organization. So remarkable is this unity, and so certain this dependence, that a naturalist, by examining a fragment of any one of the bones of an animal, may determine the character of the indivi- dual it represents. Having ascertained the size, figure, &c, of any bone, he may infer, with infallible certainty, that every other part of the body to which it belonged was formed in perfect proportion to this part, and with strict reference to the purposes for which this particular portion was designed. Should a naturalist ascertain that a single bone presented to him was constructed for purposes of prey, he would immediately infer that a beast so provided must have had strong muscles and bones of the neck and jaws, to enable it to hold and tear the animals upon which it was intended to subsist ; hind legs of such a formation as to enable it to spring upon its prey ; claws to seize and hold it, and a digestive apparatus suited to the re- ception and assimilation of the food thus procured. Those who are familiar with the writings of Cuvier, will not need to be reminded of his beautiful reasoning upon this sub- ject. The body of man must then be regarded as a unit, and though, for the convenience of description, we speak of its mul- 3 26 INTRODUCTION. titude of parts, it is a single organization, fed by one aliment, nourished by one blood, vitalized through one nervous system, directed to a common purpose, subject to one sovereign will, and pervaded by a general law of continuance, decay, and dis- solution. As one part of the body is identified with all the others, it is necessary that a certain organic consent shall subsist between the several parts, in order that they may act in concert in car- rying on the business of life. For instance, the eyes must act together : the muscles of the trunk must aid the muscles of the limbs, and many more agreements of motion, infinitely compli- cated and astonishingly rapid, must subsist between different members of the body. The body has more to do than to perform certain acts by which it may be continued in being. It is, from its nature liable, and from its condition exposed to injuries. It is con- tinually assailed by enemies from without and within. It has, therefore, certain signals of suffering, and is endowed with cer- tain aptitudes, through which any part more particularly attack- ed may receive succour from the rest. Moreover, the parts being connected together by extension of common tissues, by blood- vessels and by nerves, the morbid conditions of one may readily be propagated to another. All this concert of parts, whether healthy or morbid, is called sympathy ;* though, in the case of healthy action, improperly so — and constitutes one of the most interesting and beautiful peculiarities of organized structures. In many instances the dependence of one part upon another is so direct, and the mode of communication so obvious, that there is no difficulty in detecting the process of sympathetic action or suffering that may be observed between them. In other cases, this concert of action depends upon undiscovered links of union, and is known to exist only upon the evidence of common observation. Besides this sympathy of parts, there is a general interest of the whole organism in the welfare of all its parts ; and severe or long-continued suffering in any one, * Syy, with, 7ra8o;, suffering — fellow-suffering. INTRODUCTION. 27 however comparatively unimportant, will commonly induce a general derangement of health, and may involve the whole body in serious and even fatal disorder. Although in many cases no change in the structure of mor- bidly sympathizing parts might be discovered upon autopsic* observation, yet there is good reason to believe that sympathy is in fact a transfer or propagation of actual molecular change ; and every physician knows that a disorder, primarily of little importance, may prove fatal by involving vital organs in a sym- pathy of disease. It cannot therefore be predicated of any organ, that its suf- fering is necessarily unimportant to the health of the whole system, since experience shows that the danger of almost all disorders depends very much upon the sympathies likely to be established in the course of their progress, and that the impor- tance of these sympathies is not always determined by that of the organ originally involved. The facts above stated are universally admitted by the medi- cal profession, and for the most part are recognised as impor- tant practical truths ; so much so, that the study of particular parts as isolated from the rest, with a view to treat certain local affections as independent phenomena, has long since fallen into disuse, and every physician and surgeon is expected to become conversant with all of medicine, as necessary to the proper care of any one of the organs of the body. An oculist, unless a thorough physician, would be utterly unqualified to treat dis eases of the eye : the obstetrician must extend his knowledge far beyond the uterus, if he would claim any participation in the fellowship of science. Until very recently, however, the treatment of diseases of the Teeth seems to have been considered less a proper specialty of medicine, than a mere mechanical craft, requiring in the operator little more than manual dexterity and physical force. Surgeons and physicians were generally profoundly ignorant of the importance of these organs to general health, and were con- * AuTij — a>4, one's own eye — actual sight of the parts of a dissected body, 28 INTRODUCTION. tented to leave them to the care of any who were willing to take charge of them. Even now diseases of the teeth are rarely mentioned in the medical schools, and an eminent professor of surgery has publicly confessed himself incompetent to teach students how to extract them. In the course of time, however, men of inquiring minds and studious habits, finding themselves in the practice of a rude and imperfect art, the deficiencies of which were continually forced upon their observation, have been constrained to investigate the relations of the teeth to surrounding and distant parts. Well- read medical men, waiving the general practice of the profes- sion, have turned their attention to dentistry, and of necessity have applied their previous information to the augmentation of dental pathology and therapeutics ; and, finally, the manage- ment of the teeth has come to be an acknowledged specialty of medical science, and is rapidly advancing in public and profes- sional consideration. It is thus that other departments of the healing art have gradually won their way to their present position and impor- tance. Within a period comparatively recent, surgery in all its branches was regarded by physicians with sovereign contempt- Barbers were the operators, and mountebanks and old women dressed the sores. Midwifery was, if possible, held to be yet more despicable, and even within a few years, an eminent body of scientific physicians have declared obstetrics to be un- worthy the attention of a polite gentleman. It is unnecessary to say that surgery and obstetrics are now the leading branches of the profession, and are zealously prac- tised by men of the first talents, and greatest scientific and literary acquirements. To our country belongs a large share of the honour of placing these two departments of medicine upon their proper level with other professional pursuits. The depressed condition of surgery and midwifery was the consequence of the vulgarity and ignorance of those who prac- tised in these departments of medicine, and the bad reputation thus acquired was a formidable obstacle in the way of those INTRODUCTION. 29 who attempted to elevate them to the dignity of scientific pur- suits ; but patient continuance in laborious and honourable effort has eventually succeeded in accomplishing the desired result. The practice of Dental Surgery was long degraded, from causes precisely similar to those evil influences which so long depressed kindred branches of the art. Disregarded by edu- cated men, it necessarily fell into the hands of the ignorant and rude, and precisely as surgery and midwifery have gradually emerged from their barbarous state and attendant disrepute, dentistry is now winning its way against all opposition, to its proper consideration. It is a matter of honest pride, that our country is again foremost in this laudable work. The purpose of the present work is to treat of Dental Surgery as a distinct and proper specialty of medicine, and to present to the reader a digest of information, prepared with particular reference to the morbid connexions certainly existing between the teeth and the rest of the body. These connexions are far more important than is generally supposed by physicians or dentists. The reader of the following pages will probably be surprised to find so large a variety of disorders treated of as directly or indirectly concerned in the production of pathological conditions observed in the mouth ; and his surprise will perhaps be greater to find so many and so serious diseases of other organs traced to their primary seat in morbid conditions of the teeth. Yet the object of the author has been to condense this treatise as much as consistency would permit, and to admit nothing foreign to the subject properly under consideration. 3* TREATISE ON DENTAL MEDICINE CHAPTER I. PRELIMINARY CONSIDERATIONS. The human body is liable to changes which more or less disturb the regular and healthful performance of the many functions* necessary to the completeness of its life, or in other words, to disease. These changes are commonly attended with alterations of the phenomena which experience autho- rizes us to regard as natural or normal, or in other words, by symptoms^ which indicate the character and seat of the change which produces them. When parts thus diseased are inspected, we generally per- ceive alterations in their usual appearance and structure. Not unfrequently, however, the changes are too obscure to be de- tected by our present means of investigation. Many attempts have been made to define the essential nature of disease, but all have necessarily failed. It is impossible to frame with philosophical accuracy a definition of disturbed or altered conditions, since we do not perfectly understand the nature of the organs, and the mode of their acts. We cannot understand the ultimate cause of morbid phenomena, while * By function is meant the particular part which each organ performs in the mechanism of life. The liver is an organ, its function is to secrete bile. f Symptoms are those observable differences from the healthy performance of function which lead us to suspect and often to detect disease. 32 PRELIMINARY CONSIDERATIONS. ignorant of the essential nature of life itself, as manifested in the healthy performance of function. It is important to the student to know that medical lan- guage does not pretend to the precision of abstract philosophi- cal science. Medical definitions are not to be regarded as ac- curately stating the nature of things, but simply as descrip- tions which may serve for practical purposes. This fact has been forgotten by many eminent medical writers, and their efforts to be absolutely accurate have often led to serious mis- takes, and always to confusion of ideas and contradiction of facts. The study of essences belongs to metaphysics, not to practical science, and having failed to reach any important truth by analyzing mind, it will hardly prove successful in its attempts upon the body. We wish it then to be clearly understood, that medical terms are to be received in a conventional sense, and that, while they serve sufficiently well to convey what knowledge we have of curative science, they will not bear the test of strict philosophi- cal examination. For example, the word life, as used by medi- cal writers, does not mean the essential vital principle, but the aggregate of the functions of the body : not the ultimate cause which sets the machinery in motion, but its effect in the pro- duction of organic acts. Disease means all the morbid phe- nomena observed in a case, together with the structural changes upon which these phenomena depend, and any other more remote injury which may be concerned in their pro- duction. Thus a patient may complain of nausea ; this sick- ness may be consequent upon defective digestion ; the defective digestion upon interruption of the function of the liver ; the interruption of the hepatic* function upon change of structure in that organ ; and that change of structure upon more minute pathologicalf conditions. Strictly speaking, we might regard all this train of evils as symptoms merely of some obscure and inappreciable change which constitutes the disease, but in * Hepar — the liver. f Pathological — fl-etfio?, suffering, xoyos, discourse; that -which relates to diseased conditions. PRELIMINARY CONSIDERATIONS. 33 that case the word would be of no practical use. These in- stances may suffice to illustrate our meaning, and the student may be saved from much embarrassment by keeping the fact thus presented always in his mind. Many false theories and much bad practice have resulted from attempts to philosophize in medicine. It is an experimental science, embodying the results of long experience and protracted investigation. As such it is true, and worthy of all confidence. It is impossible to tell why any medicine produces its effect — we do not under- stand the philosophy of it ; but we know what effect it does produce, and that knowledge is sufficient, and very much more important. I will not trouble my readers with a recapitulation of the many definitions of disease proposed by eminent writers ; let it suffice to say, that all of them are improper, and many of them strangely absurd. We can describe disease readily enough, but we cannot detect and exhibit its primary elements. Pro- bably we would not be practically wiser if we could do so. Life, then, may be considered as the effects produced by or- ganization. Health, the regular and orderly development of these effects. Disease, disorder and irregularity in their mani- festation, or impediment to the accomplishment of one or more of them.* Physiology^ has to do with the performance of healthy or natural acts, and physiological medicine or hygiene with the preservation of health. Pathology is the science of diseased conditions. Therapeuties,% the art of applying remedies for the cure or relief of disease. Anatomy§ is the study of the body as an organized machine. Surgery, || manual or mechanical medicine. Etiology, \ the science of morbific causes. In the present treatise, it is our purpose to examine the etiology, pathology, and treatment of morbid conditions, with a special reference to practical dentistry. * Roche and Sanson, Nouveaux Elements, f Qutris, nature, xoyo?, discourse. % @ipa.7rivcc, I cure. § Avctn/uvto, I cut up. || Xup, the hand,«/3^ox, work. ^ Eto?, cause. CHAPTER II. ETIOLOGY. Causes of disease may be external or internal. By external causes we mean all those agents which are independent of our own organization, whether they produce their impression upon the outward or interior parts of the body. Thus, poison, in- haled or swallowed, would be an external cause, though acting upon internal surfaces. By internal causes we mean all such as are produced from our own organization ; as by the action of one part of the body upon another ; or by the connexion and dependence of parts ; or by the influence of the intelligence itself, which often em- barrasses and sometimes overwhelms the physical machine. By general causes, we mean such as affect simultaneously a large part of the corporeal system. By local, those which are very much circumscribed in their sphere of action. These terms, like most others used in descriptive science, are not philosophically precise, since every cause must be supposed to act upon some structures to the exemption of others ; but they are sufficiently accurate to convey the meaning intended. It must not be supposed that general causes necessarily produce general diseases, and vice versa. A local cause, acting only upon a very small surface, may produce universal disorder, while a general cause may beget a strictly local disease. A plunge into cold water, drenching the whole surface, may pro- duce nothing more serious than a toothache ; while a prick of a finger may cause serious general disorder and even death. Further subdivisious of causes are based upon the character of the effects which they produce. Some stimulate or increase the action of the blood-vessels ; others debilitate or lessen such ETIOLOGY. 35 action. Some act mechanically, dividing, tearing, bruising, &c; others chemically, burning, corroding, or decomposing. Predisposing causes are those which exert an influence suffi- cient to make parts more liable to disorder, without actually disordering them. This term, again, is not absolutely accurate, for we cannot conceive of these causes acting in any other way than in the production of disease, which doubtless they do, but in so feeble a degree as to give out no symptom of its existence. Exciting or efficient causes are those which immediately pre- cede disorder, and are reasonably inferred to have induced it. It must not be supposed, however, that these divisions are abso- lutely descriptive of certain agents which permanently belong to either of them. A cause which predisposes in one instance may excite in another, and vice versa. For example, a man may be exposed to intense cold, and while extremely chilled he may drink a large quantity of ardent spirits, and fever may ensue. In this instance the cold would be regarded as predis- posing and the alcohol exciting. On the other hand, a man may become intoxicated, and while thus enfeebled he may be exposed to cold, and fever or inflammation might result. In this case, the alcohol and its effects would be the predisposing, the cold the exciting, cause. Some causes are utterly unknown, but are inferred to exist as agents differing essentially from known causes, from the peculiarity and uniformity of their effects. These are called specific. The causes of scarlet fever and of whooping cough are examples. Almost everything without and within us may be in some way or other productive of disorder to the human body. The air we breathe may carry into the inmost recesses of our system invisible poisons, to injure the delicate tissues of the lungs or impair the vivifying quality of the blood ; it may withdraw our heat too rapidly, or it may fail to relieve us of our excess of caloric ; it may itself undergo chemical changes which deterio- rate its qualities and render it more or less unfit for respira- tion. The food we eat may pain or sicken or convulse us. It may suddenly prostrate, or gradually destroy us. Water, even 36 ETIOLOGY. when pure, may irritate the disordered organs of digestion, and •when impure may carry unsuspected drugs into the stomach. Even the light of heaven may harm the delicate eye, and the sun's heat exhaust the strength or inflame the brain ; while that all-pervading and powerful agent which we call electricity, en- tering our bodies at will, and playing upon our nerves at plea- sure, may work in us fearful but inscrutable changes. We are constantly exposed to the rude contact of bodies harder than our own, by which our tissues may be divided, broken, torn, or penetrated: while other substances possess a mysterious power, to combine chemically with the elements which compose our bodies, and form of them new products, thus altering and disorganizing the parts subjected to their action. Nor are the enemies of health and life within us less active or efficient. The exquisitely organized body is continually un- dergoing change, and in all its parts is at work an irresistible law which impels the whole to decay and dissolution. Linked together by exquisite sympathies, traversed by numberless nerves and blood-vessels, performing most delicate and import- ant functions, and pervaded by a powerful moral intelligence, whose passions and appetites excite and depress the physical system to its utmost limits of endurance, the parts of the body are continually liable to become diseased, and to radiate disor- der throughout the whole. It will be impossible for me to introduce into the present work a full examination of each of the many causes of disease which might be worthy of particular notice. I will only ask the attention of the reader to the consideration of such as are most important to us, as being concerned in the production of those diseases which the dental surgeon is expected to treat. THE ATMOSPHERE.* The air acts upon us in a variety of ways. By its pressure upon us it keeps us in form. Without that pressure the fluids * The atmosphere is composed of two great elements, called oxygen and nitrogen, with a small portion of carbonic acid. ETIOLOGY. 37 coursing within us would overcome the resistance offered by the coats of their vessels, and universal turgescence, interruption of function, and death would ensue. It furnishes us with the oxygen necessary to preserve the vitality of the blood. "Were the natural proportion of this ele- ment increased or diminished, we must suffer hurt. It is also the vehicle by which watery vapour acts upon our outward and inner surface, and the medium by which caloric or the matter of heat is brought into contact with us. It is therefore the means by which we feel those hygrometrical changes which have so much to do with our health, and the vicissitudes of temperature which, as morbific causes, are hardly less important. Increase in the density of the air has been known to produce serious epidemic affections. Persons who ascend high moun- tains generally suffer much from embarrassed respiration ; and hemorrhages and pulmonary affections have been traced to changes in the mechanical action of the atmosphere. Unless the supply of air be unequal to the want, the quantity of oxygen in the atmosphere has never been found deficient ; but where persons have resided or been confined in crowded and ill-ventilated rooms, the most serious consequences have often resulted. When the deficiency of air is not so great as to produce rapid and violent results, the health often languishes, the complexion fades, the strength fails, and diseases of various kinds make life wretched, and shorten its duration. In the gorges of mountains are often found decrepid, deformed, and even idiotic people, who bear sad testimony to the evil effects of depraved air, though the precise mode of vitiation is yet un- discovered. Heat and cold are universally recognised as having much to do with the causation of disease. Caloric or the matter of heat pervades all bodies, and constantly tends to an equilibrium. The animal heat which is elaborated by some obscure process, but little understood, obeys the common law of caloric, and constantly passes off to bodies less warm, or receives increase from those more heated. Our sensations of heat and cold are therefore nothing more than indications of the loss and supply 4 38 ETIOLOGY. of caloric to our surface. When it passes off in greater quan- tity than we can supply it with comfort to ourselves, we com- plain of cold ; when surrounding bodies draw less from us than we are in the habit of supplying, or communicate to us of their own excess beyond our wants, we feel heated. These variations in our state of calorification are not limited in their effect to the production of certain sensations. They are capable of causing great disorder in the performance of function, and creating morbid conditions of the most serious kind. Heat is an ex- citing, cold must therefore be a depressing agent. Heat induces increased action of the heart and arteries ; cold diminishes that action. But in considering the consequences of agents acting upon the human body, we must always remember that it is a living machine, and is not merely passive under modelling in- fluences. A thorn penetrating the substance of an inanimate machine, would produce no other consequence than the mere perforation ; but should it pierce the human body, it would in- duce a succession of phenomena, depending upon the vitality of the parts injured. Heat acting upon a bar of iron will expand it ; cold will contract it. Acting upon the human body, heat will not only expand its tissues, it will excite the parts to in- creased action. Cold will not only contract the tissues, but lessen action. Further, heat, if long continued, will exhaust the vigour of the nervous and vascular system, and thus debili- tate the whole frame ; for it causes the organs to work more rapidly than usual — consequently to consume more of the means of action, while it adds nothing to those means. It does not increase the amount of blood, nor enrich its quality, but it causes it to be more rapidly circulated and consumed; it provides no additional nervous energy, but causes greater expenditure of it. In the course of such unusual consumption and expenditure, the parts appear more than commonly vigorous, but the result must be that the supply of means shall soon fall below the usual consumption, and languor, depression, or exhaustion result. Heat,* in other words is an excitant or stimulant, and all agents * It will be perceived that we use this word in the popular sense, as con- veying the idea of a certain sensation. When we speak of heat as an exter- ETIOLOGY. 39 of this class will enfeeble as their secondary and ultimate effect. Cold, being the opposite of heat, is of course depressing, as being the withdrawal of an excitant. But there is in the living body a recuperative power which exerts itself energetically to overcome morbid influences. This power we call reaction, and its chief phenomenon is increase of vascular action, up to and beyond the natural standard. When cold is suddenly applied to the body, the first effect is to lessen vascular action and nervous sensibility; but unless the application be very long continued, the circulation will soon resume its vigour, a glow of warmth will succeed to the chill, and perhaps the heart and arteries may work with a force and frequency incompatible with health. In order to explain certain pathological conditions, of very common occurrence in every part of the body, it is also impor- tant to observe that when parts are suddenly chilled by the rapid abstraction of their natural heat, their nervous excita- bility, or the power of being impressed by agents, is increased.* Every one has remarked the extreme sensibility of the fingers on a cold day, and dentists are well aware that delicate pa- tients cannot endure protracted and painful operations in the winter as patiently as in the summer. To a man nearly frozen, it would be death to bring him to a blazing fire. Frost-bites are nothing more than burns inflicted at very low temperatures, upon parts unusually susceptible through the abstraction of heat. If this be true of cold, the converse is true of heat. Pro- tracted heat, as indeed the long action of all stimulants, wears nal agent, we of course mean the presence of caloric in a quantity so unusual as to create the sensation of heat. Caloric itself is absolutely necessary to life, and does not exhaust vitality when present in its normal or natural quantity. * This is true in the case of the sudden diminution of any of the essential means of life. If food be withdrawn for a considerable time, the accumu- lated excitability of the system will make it dangerous to give the starving man an ordinary meal. If blood be abstracted, the whole system becomes more easy to be acted upon by food, medicines, &c. 40 ETIOLOGY. out the excitability, and renders the body difficult to be im- pressed. Debility or weakness may be connected with both of the nervous conditions ; hence weakness alone is not a charac- teristic of any disease, it is merely a circumstance of it. A man half-starved would be very weak, and might be too much excited by a single glass of fermented liquor : another, ex- hausted by long-continued intemperate drinking, might be equally debilitated, but could not be excited by immense quan- tities of distilled spirit. These remarks, upon the effects of cold and heat will enable us to understand the mode of production of many particular affections, through the agency of atmospheric changes. Excessive moisture in the air is also a common cause of dis- ease, but only because the watery vapour withdraws our heat much more rapidly than dry air, at the same temperature, would do. Air is also the vehicle through which aerial poisons of various kinds are brought to act upon us. We have mentioned specific causes, as the unknown agents which produce peculiar and uniform disorders. Some of these causes can only produce their effects through the air when it is highly charged with the poison ; others can act at great dis- tances from their source, and apparently when much diluted by atmospheric mixture ; and others have never been traced to any local origin, and while apparently poisoning the air over immense spaces, produce no change in it which is appreciable to our nicest tests. Of the first class are the contagions, which may be propa- gated either by direct contact or by atmospheric infection within short distances ; of the second are the causes of endemic diseases ; and of the third are the inscrutable agents which produce those widespread disorders which we call epidemics.* * Endemic, ivfofxoc; epidemic, s7rt\ct%ts, — prophylaxis, from 7rpoipvxct fire. NATURE OF DISEASE. 69 stood, but which is attended with general disturbance of func- tion. Merely increased action of the heart and arteries is not fever, for such excitement may be purely physiological and attended with no functional distress. Violent exercise and mental emo- tions will frequently cause the vascular system to work with vastly greater energy than usual, while the individual who is the subject of the accelerated circulation will not be at all mor- bidly affected. But in fever, the increased vascular action is the effect of disturbing morbid causes. Often, perhaps always, the blood itself has undergone change, and the vital fluid thus altered, being supplied to all the organs, begets universal disorder of function. . Fever is either idiopathic,* or symptomatic. By idiopathic fever,, we mean that form of it which appears to us to present the primary, or original disorder, being the first observable effect of the morbific cause. Such fevers are not, so far as we know, preceded by a local disease, whose ex- istence and intensity are represented by the vascular action. We cannot, in the present state of our knowledge, go behind the fever to find out its immediate cause, structural change, or functional error. Symptomatic, or secondary fevers, or as they are often called, from the nature of the conditions they most frequently repre- sent, inflammatory fevers, are merely consequent upon local disease, having no independent existence, but rising and falling with the flow and ebb of the disorder they represent. These two conditions, though called by the common name, fever, are entirely distinct and different in their cause, nature, progress, and treatment, and are only allied together, by the fact, that each of them is attended with morbidly increased vascular action. Neither is symptomatic fever a unit ; for when it represents inflammation, it differs essentially from the vascular condition which is consequent upon another state, which is called irrita- *l£ — throughout the flesh. NATURE OF DISEASE. 73 tween inflammation and cure, and that the painful symptoms of inflammation abate or disappear after the copious secretion of pus, yet we must regard the formation of this matter, how- ever pure, as a great evil, though certainly preferable to others which occasionally affect inflamed parts, and it is one of the greatest cares of the surgeon and physician to prevent it. Pus may form in several situations. First : it may be found free upon the inflamed surfaces of parts, as the skin, the eye, and mucous membranes, without any other apparent change of organization than an increase of the natural vascularity. Se- condly : on the naturally unexposed surfaces of the body after they have acquired a new organization, by increase of red ves- sels, and usually, if not always, by the addition of coagulable lymph ; for it may be questioned, whether in any instance the surfaces of the cellular, synovial, serous, and medullary mem- branes, the pia mater, or periosteum, can furnish genuine pus, without the deposition and organization of some coagulable lymph. The third situation in which pus is generated is the sur- face of the peculiar structures called granulations, the vascu- larity of which exceeds that of all the natural surfaces of the body. The pus formed on the granular surface of an ulcer is the best example of this kind.* Some parts of the body have a much greater disposition to form pus when inflamed, than others. The cellular tissue, skin, and mucous membrane are very prone to suppurate, while the fibrous tissues manifest no disposition to it. Pus is modified by the nature of the part where it is formed, by the constitution of the individual, by various accidents, occurring in the process of its formation, and by certain ob- scure laws, which control the phenomena of those affections which are called specific. It will also present different ap- pearances, as it may be mixed with other fluids, as blood, saliva, bronchial mucus, &c. If pus mixed with blood, serum, &c, be long confined under * Macartney on Inflammation. 7 74 NATURE OF DISEASE. dressings, or in cavities, it becomes very offensive, and often irritating. If it be produced from the irritation of diseased bone, it is also very fetid. When thin, mixed with blood, and evidently "unhealthy," it is called "sanies." When pus is irritating, it is so, not to the surfaces which secrete it, but to the adjoining healthy structures over which it flows. Pus is heavier than water, and this quality frequently ena- bles us to distinguish it from mucus. It is coagulable by mu- riate of ammonia, which Mr. Hunter considered a peculiarity sufficiently marked to distinguish it from mucus, and all other natural secretions, but the accuracy of the test is disputed. From the fact that hard inflammatory tumours in the course of inflammation become soft and yielding, and filled with pus, it was naturally supposed that the original solid parts were converted into this fluid. It is now well ascertained that such is not the case, but that pus is secreted by the arteries. When pus is enclosed in a cavity formed in the progress of inflammation, the condition is called abscess.* The phenomena of abscess are very curious, and through them, nature succeeds in relieving the body of foreign matters, and repairing extensive injuries. When a part capable of suppuration is subjected to inflam- mation of the required intensity, some of the small vessels give way, and blood is effused into the surrounding parts. Simultaneously with this rupture, or nearly so, the arteries begin to throw out a peculiar plastic matter, which is called coagulable lymph. This is capable of becoming organized, and being thrown round the diseased parts, and between them and those which are healthy, it forms a barrier to the infiltration of extravasated fluids. By some strange process, to us altogether inscrutable, the walls of lymph become vascular, and capable of performing the vital functions of secretion and absorption, and by them the pus is furnished. As this secretion proceeds, the previous contents of the abscess, including the effused * Abscedo, I depart, denoting the loss of substance. NATURE OF DISEASE. 75 blood, are gradually absorbed, and fresh pus deposited in their stead, so that, if the tumour be opened at an early stage, the pus will be more or less mixed with blood, but if the opening be delayed, the cavity will be found to contain only pure pus. The process of suppuration is announced by some relief of local symptoms, and a change in the character of the pain. It loses its burning sensation and becomes throbbing, at the same time, the tumour becomes softer, and at last fluctuates readily under pressure of the fingers. Very often, and especially when the disease is extensive, or when it is seated in the vis- cera, the formation of abscess is announced by shivering or chill. While the arteries of the walls are depositing the pus, other processes equally obscure are moving the abscess towards the surface, and preparing for its evacuation. The bottom of the cavity is constantly contracting and filling up, while the oppo- site side is thinning and expanding. The absorbents at one side of the abscess are busily engaged in removing matter, while the arteries at the other, are as actively supplying new material ; at the same time, a temporary organ, made for the occasion, faithfully performs its peculiar functions, supplying pus, and removing mixed fluids from the cavity. The parts lying upon the summit of the abscess are rapidly thinned, the tumour is pushed towards the surface, the skin ul- cerates, an opening is made, and the pus evacuated. Though an abscess may discharge itself anywhere, there is evidently a strong disposition in such tumours to find their way to the out- side of the body. In order to effect this, they will often tra- verse dense opposing structures when a nearer opening through more yielding tissues might readily be effected. Sometimes when an abscess occurs in an important viscus, artificial adhe- sion will be formed between its surface and an adjoining struc- ture, and a continuous canal being pierced through, then the pus will be ejected upon the surface of the body, or into an- other organ which has external communications. These most curious and interesting facts are so conclusive of wonderful design and contrivance, that it is impossible to 76 NATURE OF DISEASE. regard them in any other light than as manifestations of divine and superintending Providence. Foreign bodies are removed precisely in the same way as pus. When the abscess has reached the surface, a thin point appears, which is soon perforated by a very small opening through which the pus slowly oozes. The appearance of this thin projecting spot is called "pointing." Sometimes the parts which surround the abscess are too dense to permit the passage of the matter. When this is the case, great pain is often caused by the pressure, and the irrita- tion produced by the vain efforts of nature to relieve the parts may occasion very serious disease in adjoining structures. In some instances of this kind, as in abscess of the gums, or gum-boil, the pus failing to be evacuated, is ultimately ab- sorbed. When the attempt is made to form an abscess by weak or scrofulous constitutions, and in situations where the cellular substance is lax, the progress of the disease is very different. The first extravasation is serum, which passes easily into the loose cells of the cellular membrane with little or no injury to their structure. The parietes of the tumour are not composed in the beginning of organized and vascular lymph; no genuine pus, therefore, is found in such cavities in the first instance ; the fluid they contain is serous, mixed with coagulable lymph ; parts of which are found as flakes floating in the serum. As the cavities of chronic abscesses are not provoked, either by severe tension, or the quality of the contained fluid, there is no preparation made for some time to remove their contents. These collections, therefore, often traverse a considerable dis- tance along muscles, or under plates of fascia, before they ar- rive at the skin, which ulcerates very slowly ; after which, the cavities may inflame, their interior surface become more highly organized, and secrete genuine pus.* Ulceration is the process by which solutions of continuity are effected by vital processes, and open secreting sores pro- * Macartney on Inflammation. NATURE OF DISEASE. 77 duced. Inflammation is by no means necessary to this result, and some of the best writers upon pathology have declined to recognise it as one of the consequences of inflammatory action. Nevertheless, as ulceration does frequently occur in the pro- gress of inflammation, and is an evil to be guarded against by the dental practitioner especially, it seems proper to consider it in this connexion. The process itself is very curious, and at first sight, the facts explanatory of it are hardly credible. It is not easy to comprehend how a body can destroy itself and take itself away, and the difficulty is not solved by the fact, that only small portions are thus removed. Yet, there can be no doubt that such is the case, and we may silence, if not satisfy, the objector, by suggesting the equal difficulty of understanding how parts form themselves ; both facts, as Mr. Cooper ob- serves, are equally well confirmed. Every part of the body is continually undergoing waste and reparation. It seems that the molecules of tissues are con- stantly becoming effete, and having undergone some mysterious change, are taken up by the absorbents and carried off to the several waste gates of the system, from which they are ulti- mately discharged. The bowels, the kidneys, the skin, the lungs, all the emiinctories* are continually at work, and all ultimately discharging the debris of the system. At the same time that this disintegration is going on through the action of the absorbents, another set of vessels, the nutri- tive arteries, are everywhere depositing new matter. Bone receives bone, muscle is supplied with muscle, and viscus with its peculiar organic matter, so that the integrity and form of each part, and of the whole, are exactly preserved. By some wonderful and inscrutable law, the balance of supply and de- mand is equally adjusted, yet not so positively as to lead us to infer that the action of the one set of vessels regulates that of the other. In childhood, the supply exceeds the waste, and the body grows ; in maturity, the supply is regulated more by * Emungcre, to cleanse — any organ "whose office it is to discharge excre- mentitious matter from the system. 78 NATURE OF DISEASE. the wants of the man than the activity of the absorbents. If his vocation calls for increased strength of arm, the very use of the organ, instead of consuming, augments its volume. In truth, the two sets of vessels seem to be independent of one another, yet, like other parts, they naturally work together for the production of the phenomena of life. It will readily be perceived that if any circumstance should increase the activity of the absorbents of a part beyond what is usual, and should not simultaneously stimulate the nutritive vessels; or, should any circumstances render parts unusually susceptible of absorption, that the result would necessarily be an obvious loss of parts, and the interruption of their conti- nuity. It is also obvious that the converse of these conditions would be attended with similar results ; for if nutrition be im- peded, either through defect of supply, or any cause rendering the part less capable than usual of converting blood into its own tissue, loss of volume, and breach of continuity might occur. Ulceration may result from any of these causes. Pressure is a common cause of ulceration, and acts probably by inter- rupting the circulation, and nutrition of a part. Pressure may produce absorption and waste without causing ulceration, and the dentist when fixing artificial pieces in the mouth must be careful so to adjust his plates and springs as to avoid both of these evils. Inflammation probably produces ulceration in a manner somewhat similar; viz., by causing such impediment to circu- lation, as prevents nutrition from being properly performed. It is also probable, that the blood itself undergoes changes under the influence of inflammation, which render it less ca- pable of supplying the loss of parts. Diseased parts, and those which from any cause have become useless, and these only, are liable to be wasted by absorption. Unhealthy products, such as fungus,* are often removed with wonderful rapidity, and even bone will be removed when, being * Fungus, a mushroom ; proud flesh. NATURE OF DISEASE. 79 no longer needed, it has become foreign matter. The roots of the deciduous teeth are thus entirely removed, and the dead fangs of permanent ones are subjected to continual waste from the same cause. That they too are not entirely removed, is due to the comparative shortness of time which the present term of human life allows for the process, rather than to any resis- tance they are able to offer to the action of these all-subduing lymphatics. Extraneous substances are generally removed by ulceration. Thus, a ligature will be separated from an artery, or a foreign substance from a wound : no more of the surrounding substance being absorbed than is necessary to loosen and dislodge the intruder. By ulceration, also, dead parts are separated from the living, and the decomposed fragments removed to make room for new matter. Sometimes ulceration seems to produce great devastation, and is then called phagedenic* In such cases, it is evident that the ulceration is only the consequence of the destruction, not the cause, for, until the parts have become too much enfee- bled to subserve their natural purpose, they will not be subject to this rapid absorption. Adhesion is often consequent upon inflammation, though like ulceration, it is not always dependent upon inflammatory action. It is a process by which nature unites parts, either naturally separate, or artificially divided. The bond of union is. coagulable lymph. This process is of immense importance, in checking hemor- rhage, closing fissures, and in providing means of safe transit for pus from the viscera to the surface. Both of these processes are sanatory. Mr. Hunter calls ulceration the natural surgeon, and declares that even in the spreading of an ulcer, there may be considerable advantage ; and another writer very properly observes, that the same remark would apply to the effusion of lymph. The one acts like the surgeon that unites parts ; the other like the one who * $xyu> } I eat. 80 NATURE OP DISEASE. removes them, because they are not fit to remain ; and it would not appear more justifiable to call adhesion and ulceration in- flammatory processes, than to consider the operations of sur- geons themselves as particular modes of inflammation. Inflammation may result in a permanent change of struc- ture. Parts may become denser and harder, or, indurated ; sometimes certain structures, under the influence of slow in- flammation, are softened ; sometimes a permeable cellular struc- ture, as the lungs, becomes changed into a dense impermeable tissue, like liver, or hepatized :* and sometimes accidental inflammation begets, in persons and parts inclined thereto, morbid growths of a specific character. The most disastrous result of inflammation is the absolute death of a part, reducing it to the condition of a foreign body, and subjecting it to the play of chemical affinities. When this takes place in soft parts, it is called gangrene or mortification ; in bones, necrosis. The dead soft part, when separated by ulceration from its connexion with living parts, is called sphacelus^ or slough; a fragment of dead bone is called sequestrum.% Caries is a condition of bone somewhat analogous to ulcera- tion of soft parts. Caries of the teeth is the result of chemi- cal agents acting from without, and decomposing their struc- ture ; they are, however, subject to necrosis, as other bony tis- sues, and the fact of their being liable to a peculiar erosion, does not probably exempt them from the kind of caries ob- served in similar structures. If, however, such idiopathic caries does occur in the teeth, it must be very rare, and is always confounded with the erosive caries peculiar to these organs. * Hepar, the liver. i 2$*£&<, I destroy. % Sequestro, I separate. 81 CHAPTER VII. AND OF THE PARTS ADJACENT. The mouth is very complicated and exquisitely organized. It subserves a variety of very important purposes. Speech, mastication, insalivation, taste, inhalation, and expiration, are all performed in this small, but admirably constructed cavity. Such numerous and complicated functions require the presence of various and delicate organs closely packed together, and a large endowment of nerves and blood-vessels. Glands are hidden in every part of the walls of the cavity ; their ducts perforate its floor, and open on its sides ; nerves and blood- vessels, of extraordinary size, creep along every bony channel, and spread in expanded network over the whole surface; while the mucous membrane, with its innumerable crypts and follicles, covers the whole, and connects every sentient part with the sympathies of the external and internal surface. Into the cavity thus constructed, and thus exquisitely en- dowed, air of different temperature is constantly rushing ; food and drink of various kinds are received ; secretions are poured out, remains of aliment and of the natural fluids undergo change, and medicinal agents of various kinds are made to pass. Besides all this, the mouth is the seat of the extraordinary process by which two sets of teeth are matured and evolved, and one of them removed by a physiological, and the other, to a greater or less extent, by a morbid disintegration. Under these circumstances, it is not wonderful that inflammation fre- quently occurs in the mouth, and that it should be attended there with severe suffering. As the cellular tissue enters largely into the composition of 82 INFLAMMATION OF THE MOUTH. the structures of the mouth, the form of inflammation most common in that cavity, is what is called phlegmon. Sometimes this form of disease occurs in the mouth, as the consequence of wounds, and even as an idiopathic affection. Sudden death is sometimes produced by the effusion of serum about the glottis — as the result of erysipelas affecting the la- rynx. This affection is called oedema of the glottis. Phlegmonous inflammation frequently occurs in the glands of the mouth, the tonsils, the gums, the pulps of teeth, the lining membranes of the alveoli and antrum, and the tongue. Erysipelous inflammation in these parts is rare, but sometimes occurs in the mucous membrane lining the gums, cheek, and palate. The submaxillary glands often take on inflammation from the effects of cold, and from the irritation produced by the presence of diseased roots in the alveoli of the lower jaw. The pain and difficulty of mastication, with the swelling of the gland, readily indicate the seat and character of the disorder. Unless the inflammation be speedily subdued, and especially if it be the consequence of diseased teeth, the gland readily suppurates, discharging a very fetid pus, either into the cavity of the mouth, or externally, under the jaw. When the open- ing takes place internally, the flow of pus into the mouth is very disagreeable, and the access to, and lodgment of, alimen- tary matters in the suppurating gland often keep up the in- flammation until an external issue is secured. Removal of the diseased teeth generally causes a speedy cure. Of other remedial means I will discourse hereafter. Inflammation in these, as in all glandular structures, is apt to leave permanent indurations. Inflammation of the tonsils is of very common occurrence. Its most common exciting cause is cold. The inflammation is generally very acute, rendering deglutition, and even speech, very difficult, sometimes impossible. It is generally attended by severe constitutional symptoms. Tonsillitis or cynanche* tonsillaris usually terminates by re- * Cynanche, from kvcov, a dog, and hy%u, I choke, is a name of a class of diseases of -which obstructed respiration is more or less a symptom. INFLAMMATION OF THE MOUTH. 83 solution, but very often by suppuration. Permanent enlarge- ment and induration often ensue upon repeated attacks of the disease, and the swollen tonsils sometimes offer serious obstruc- tion to respiration. When this is the case, they may be re- moved with little difficulty, and without subsequent inconve- nience. These little organs are also subject to a chronic inflammation and slow suppuration, which gradually waste them away. The palate and uvula are often the seats of inflamma- tion. The latter is liable to erysipelas and oedema. The parotid gland is rarely inflamed, except when it is the seat of a peculiar specific disorder, which is called cynanche parotidea, or mumps. Inflammation of the lining membrane of the mouth is called stomatitis. . Simple inflammation of this membrane is characterized by increased redness, swelling, and heat, but it rarely occurs ex- cept in connexion with inflammation of the tonsils, larynx, or pharynx, or as the consequence of the irritation of dentition, or of acrid, or stimulating matters taken into the mouth for the purpose of allaying toothache. In such cases it terminates by resolution. It is much more common to find this inflammation presenting the appearance called " aphthae."* These are grayish or whitish specks, which look like ulcers, and are described as such by some authors, but which are ex- udations from the inflamed mucous membrane ; w T hen these fall off, the parts beneath are red and irritable, the cuticle being peeled off, and the cutis vera exposed. This disorder is generally supposed to indicate a correspond- ing disease of the surfaces of the digesting organs. It attends some forms of constitutional disorder, and constitutes a pecu- liar infantile disease, called thrush, of which I will have occa- sion to say more in connexion with dentition. The gums are very liable to inflammation, which is charac- terized by redness, swelling, soreness, and often by very severe aching pain. * Attto), I burn. 84 INFLAMMATION OF THE MOUTH. The most common cause of inflammation in these parts, is the irritation produced by dead teeth. We have already ob- served that dead parts are subject to the same laws which af- fect foreign bodies lodged in the flesh, and that nature removes them, or attempts their removal, by instituting inflammation and ulceration around them. In other words, it is provided in the fundamental laws of the animal economy, that dead parts shall irritate the surrounding parts, and produce in them those conditions which naturally lead to the expulsion of the offenders. But dead teeth are firmly set in the jaw, and withal, are of too dense structure to be readily softened and absorbed. It hap- pens, therefore, that they remain long after their partial or complete disorganization, to plague the soft parts with which they are connected. The gums under these circumstances are kept in a state of chronic inflammation, and are rendered ex- ceedingly sensitive to the action of irritants. Cold, or any local application of an exciting kind, will, under these circum- stances, occasion aggravation of the chronic affection, and cause acute inflammation, of a severe character, which is remarkably liable to end in abscess. The chronic inflammation is often attended with ulceration around the decayed tooth; the soft parts being separated therefrom, in the vain attempt of nature to remove them. In consequence of the long-continued and unavailing ulceration, an imperfect attempt is made by the vessels of the gums to supply the loss of parts by granulations. These are unhealthy, spongy, loose, and incapable of cicatrizing; in other words, they are fungous. These fungous growths bleed freely upon being touched with a brush, or hard body, and being constantly destroyed and renewed, add much to the fetor of the fluids of the mouth, which under these circumstances, is often intolera- ble. Inflammation of the pulp, and the lining membrane of its cavity is commonly, perhaps always, the consequence of caries of the bony structure of the tooth, and exposure of its sensitive internal parts to the action of external agents. It gives rise to violent pain, which only subsides to be renewed again by contact with any hard body, or irritating substance. This inflammation may continue for a considerable length of INFLAMMATION OF THE MOUTH. 85 time, passing through successive suppurations, and, ultimately, completely destroying the vessels and nerves of the pulp, and with them, the vitality of the tooth. Sometimes the matter formed within the tooth perforates the alveolus and the gum, and forms a fistulous* orifice into the mouth, through which putrid fluids are continually weeping. This is what is called alveolar abscess, and can only be reme- died by extraction of the tooth. The matter of alveolar abscess will sometimes be discovered at a great distance from its source. The following case, which occurred in my practice, and which is related in Prof. Harris's Dental Surgery, as the most singular instance of alveolar ab- scess which ever fell under his observation, affords a striking instance of this fact. . The subject was a lady about thirty years old. She con- sulted me on account of a continual dripping of pus from be- hind the curtain of the palate, which she attributed to some disease of those parts, and which had annoyed her for a year previous. Upon a close examination of her mouth and throat, I could discover no tumour or any indication of a deposit of matter except two protuberances, each nearly as large as a hazelnut, situated behind the two superior central incisors. Being strongly inclined to believe that the matter came from these abscesses, I requested the advice of Prof. Harris, who fully coincided in my suspicions. Upon our joint advice, the pa- tient submitted to lose these valuable teeth, and was rewarded by the cure of the troublesome complaint which had caused her so much uneasiness. The maxillary sinus, or antrum, is covered by a membrane which nearly resembles the mucous covering of the mouth. This is frequently the seat of inflammation. From the pro- tected situation of this cavity, locked in on every side by bone, and covered by thick integuments, it is not apt to be affected by ordinary agents, acting from without, but the teeth of the * Fistula — a pipe, a canal whose sides and edges are hard and incapable of adhesion. 8 86 INFLAMMATION OF THE MOUTH. upper jaw frequently send their roots into it, and thus affect it readily, when, happening to become diseased, they are quali- fied to provoke disorder in neighbouring parts. Even when they do not penetrate the floor of the antrum, they are often separated from it by a partition so very thin as to afford no adequate protection to the antral membrane against the pro- pagation of inflammation. When the membrane of the antrum is inflamed, it pours out a vitiated secretion, which accumulates for some time before it produces sufficient uneasiness to excite the attention of the patient. The pain of inflammation depends upon the degree of pressure to which the parts are subjected, and the peculiar structure of the antrum prevents much suffering from this cause until the cavity is completely filled. Generally, however, some dull pain is felt in this region in the course of the inflammatory action, but the patient com- monly refers it to the teeth. After a while, however, the dis- tension of the walls of the cavity produces more serious suffering : matter escapes through the nose or mouth, and a hard bony tumour indicates the projection of the antral walls. The fluid thus accumulated is usually not pus, but vitiated mucus. The disease has been very improperly called dropsy* of the antrum, for the contents are by no means serous. The discharged matter, having been long retained, is gene- rally very offensive. Ulceration may also take place in the membrane of the an- trum, and pus of a very fetid quality be exuded through the nose, and when an opening exists, through the mouth. This condition forms one of those exceedingly distressing, and often incurable cases of disgustingly fetid breath, which are called ozcena.f Sometimes, when the disease is permitted to proceed with- out proper remedial means being used, the walls continue to swell, the bones soften, the tumour opens, and a fetid discharge flows through the aperture over the cheek. * rfa>p — water. Accumulations of extravasatecl serum are so called, f Oguv, to smell. 87 CHAPTER VIII. TREATMENT OF INFLAMMATION. In all cases of inflammation it is desirable to bring about the disappearance of the disease without any disorganization of structure. In other words, to accomplish cure by resolution. When this cannot be effected it is important to lessen suppu- ration, and if possible to prevent, or, at least, limit mortifica- tion. The first step towards accomplishing the cure of inflamma- tion is to remove, if we can, the cause which produces it. This will often render further treatment very simple and easy, or altogether unnecessary. Where the gums, or lining membrane of the antrum are inflamed through the irritation caused by diseased or dead teeth, no treatment short of their removal will do any good ; and this will generally be a sufficient aid to nature. Even when the soft parts are suppurating, they will speedily heal after the irritant has been removed. The treatment of inflammation proper, consists in general and local means. With the exception of a few employed to relieve chronic inflamed conditions, these remedial measures are comprised under the general name antiphlogistic,* and are all intended to lessen the vascular action, of the general or local circulation. Antiphlogistic treatment is negative or positive. The nega- tive consists in withholding every local application likely to excite the vessels, or irritate the morbidly sensitive nerves of the part ; and preventing the taking of such drinks or aliment as would tend to sustain the morbidly active circulation. In short, the withdrawing as far as possible of all local and gene- ral excitants. *Anti, against; phlogiston, the old name for the cause of heat. 55 TREATMENT OF INFLAMMATION. The positive treatment consists in the use of means which lessen vascular action and diminish nervous sensibility. The general remedies are bloodletting, purgatives, diaphoretics, and low diet; among the local are bloodletting, from the affected part, or its immediate vicinity ; cooling, emollient, sedative, and astringent applications, and counter-irritants. When pus has been formed in a cavity, it is often necessary to evacuate it by an artificial opening ; sometimes, even after the tumour has opened spontaneously, a counter-opening is necessary. TREATMENT OF INFLAMMATION AND ABSCESS OF THE PARTS COMPOSING THE MOUTH. It is rare that inflammation of these structures requires ge- neral treatment. Sometimes, however, it is sufficiently serious to occasion inflammatory fever, and call for decided constitu- tional remedies. When such is the case, the patient should be bled from the arm until a decided impression be made upon the circulation, and the operation must be repeated, until the de- sired effect be accomplished. If the bowels of the patient be constipated, saline cathartics should be employed. Nauseating remedies, such as tartar emetic, will also be found useful in lessening the general inflammatory action and withdrawing the nervous sensibility from the affected part. In most cases, however, the dental surgeon will only need to employ local remedies. We have already said that when the inflammation is conse- quent upon the presence of diseased teeth, or parts of teeth, they must be removed. This being done, the inflammatory action will commonly subside and speedily disappear. The teeth are liable to a peculiar calcareous deposit, called tartar,* or salivary calculus, which adheres with great tenacity * Tartar, or salivary calculus, is composed, according to Berzelius, of Phos. lime and magnes, 79 00 Salivary mucus and salivine, 13-50 Animal matter, 7-50 100-00 TREATMENT OF INFLAMMATION. 89 to them, and insinuating itself under the edges of the gums, detaches them from the teeth, and acting as a perpetual irri- tant, inflames, and often ulcerates them. This substance is deposited from the saliva under certain conditions of that fluid, and is most liberally deposited upon the teeth nearest to the salivary ducts and upon those of the lower jaw. When it contains a larger proportion of earthy salts, it is hard, and brittle ; when the animal matter is in ex- cess, it is soft and moist. Under whichever of these forms it appears, its removal is indispensable to the successful treat- ment of the disease of the gums which it causes. Sometimes this can be effected by the brush alone ; often the hard mineral substance requires to be broken up and elevated by an instru- ment of steel. When once removed, its subsequent accumu- lation must be prevented by persevering use of water and the brush. It often happens that the gums will be inflamed through the agency of teeth, the disease of which is not sufficiently serious to authorize their removal ; again, inflammation may occur in the gums from causes independent of the teeth, as from cold, irritating applications, bruises, &c. In order to prevent acute inflammation of the gums from passing rapidly to suppuration, it is necessary to use free local depletion. This may be done by scarification, or by leeching. Scarification is nothing more than slightly incising the gum and causing its superficial vessels to bleed. It is a remedy of doubtful utility, and often does more harm than good. It is obvious, that any wound inflicted upon an inflamed part must increase the inflammation to a certain extent, and unless the quantity of blood taken away be more than sufficient to counterbalance the additional evil inflicted, the patient will lose by the operation. Scarification produces copious bleeding for the instant, but the clean superficial wound is soon closed by coagulum and lymph, and the oozing of blood continues but a short time. 90 TREATMENT OF INFLAMMATION. When the gums present the condition called fungus, scarifi- cation will cause much freer bleeding, owing to the increased vascularity of the part. Under such circumstances it is an important means of cure. Leeching is a far more effectual process. It is true that wounds are made by the leeches deeper and more irritating than those inflicted by the lancet, but the flow of blood con- tinues very much longer and the quantity discharged is far greater. Two or three leeches placed upon a gum will often cause a bleeding which will continue for several hours, and will cure severe inflammation in almost as brief a space of time. In order to be effectual, leeching should be employed in the early stage of inflammation. If delayed until matter has be- gun to form, no benefit can be expected, except, perhaps, in the lessening of the quantity of pus. Other local applications are of little or no use in the treat- ment of acute inflammation of the gums. Their position pre- vents the continuance of any fluid upon their substance. Cold water, however, may be used by repeatedly filling the mouth with it. This remedy is serviceable only in slight inflamma- tions. All stimulating applications used to irritate the sur- rounding parts and thus alter and divide sensation so as to re- lieve pain, ultimately aggravate the disease. It is erroneously supposed that the increased flow of secretions which is occa- sioned by the irritation, must relieve the vessels and abate the inflammation, for the very irritation attracts to these parts a larger supply of blood than usual, and augments secretion only by increasing arterial activity.* Where the inflammation is excessive, leeching and blistering behind the ears or under the jaw may be resorted to. As great and long-continued suffering frequently attends this disease, full opiates at night may be given with great ad- vantage ; securing at once temporary relief and grateful re- * Ubi irritatio, ibi fluzus — where there is irritation, to that place will be the flow, is a well-known medical adage. The law applies to the nervous as well as the vascular system. TREATMENT OF INFLAMMATION. 91 pose, and aiding materially the efforts of nature to remove the inflammation. Inflammation from mechanical violence must be treated upon the same principles. The gums are liable to inflammation of a specific character. When mercurial preparations have been used to a certain ex- tent differing much in different individuals, a constitutional im- pression is obtained, which announces itself by a peculiar tenderness and inflammation of the gums and an increased secretion of mucus and glandular fluids into the mouth. This is called salivation or ptyalism.* The first symptoms of this mercurialization are observed in an increased tenderness and some swelling of the gums, which exhibit a pale rose-colour, except at the edges surrounding the teeth, where .they are of a deep red. The soreness and swell- ing now rapidly increase, the discharge of mucus and saliva becomes excessive ; and is accompanied by a very peculiar and disagreeable odour ; a metallic or coppery taste is constantly present in the mouth, and the tongue and salivary glands are inflamed and swollen. Such is moderate salivation, but it sometimes happens that from excessive dosing with mercury, or from peculiar suscepti- bility of the patient, all the symptoms above enumerated are greatly aggravated. The gums are very much swollen and covered with ulcers ; irritative fever appears ; the enormous tumour of the tongue pushes beyond the lips and hangs out of the mouth, preventing the closure of the jaws ; the flow of fluids is prodigious, the patient wastes excessively ; gangrene of the mucous membrane of the mouth and gums, and extensive sloughing of the soft parts and bones sometimes occur ; the teeth are loosened and sometimes drop from their sockets and occasionally the patient expires from exhaustion. A very frequent consequence of extensive mercurial saliva- tion and the attendant ulceration and sloughing, is contraction of the mucous membrane in the neighbourhood of the anterior * Ptyalism — salivation ; from wri/a, I spit. 92 TREATMENT OF INFLAMMATION. arches of the palate, whereby the patient is prevented from opening the mouth, except to a very slight extent. In one case this condition resulted from salivation produced by a few grains of blue pill. The patient was unable to open the mouth wider than half an inch. Surgical aid could give only tempo- rary relief. In another instance of a child four years old, the patient when seen several years afterwards, was obliged to suck food through the spaces left between the jaws by the loss of the alveolar process.* It sometimes happens as a consequence of salivation, that adhesions form between the mucous membrane of the lips and cheek and that of the gums ; very much deforming the face and lessening the usefulness of the mouth. A great variety of remedies have been suggested and em- ployed for the relief of excessive salivation, but there is no specific means of relief. No local applications of an irritating character can be borne, and no astringent but of the mildest quality can be used. Besides demulcent lotions and some very mild astringents, such as table tea, we have no topical applica- tions to recommend. The only rational treatment is to abate the inflammation by the use of antiphlogistics, to such extent as the strength of the patient will permit. Leeches under the jaws procure the greatest relief, and blisters to the throat and opiates are useful accessories. f A form of disease very nearly resembling salivation, occurs occasionally in children, and sometimes it is said even in adults. It is ulceration of the inside of the cheek, causing gangrene and a copious secretion of fetid saliva. It is called Cancrum oris. This disease is not properly inflammatory, being rather a consequence of debility ; but lest I should not have an oppor- tunity to describe it hereafter, I will do so now. * Pereira's Elements of Materia Medica and Therap. ■j- It is important to remark that salivation, however severe, does not ne- cessarily prove the previous administration of mercury. For some curious observations on this subject, see Pereira's Elements of Mat. Med. and Therap. 709. TREATMENT OF INFLAMMATION. 93 Cancrum oris is a foul, fetid ulcer, beginning upon the inside of the cheek and rapidly sloughing through it until it opens upon the outside. The gums and alveoli are often seriously involved ; the teeth become carious and loose, and drop out ; abscesses form in different parts of the mouth, and make open- ings for themselves in different directions. The progress of the disease is attended by a copious discharge of fetid saliva and mucus. Exfoliations of the bone are not unfrequent and extensive sloughing sometimes occurs. The disease generally occurs in ill-fed children, crowded in a hospital or living in low, swampy situations. The remedies must be tonic and invigorating. The principal, are fresh air and nutritious diet. The best local applications are diluted mineral acids ; burnt alum, sul. zinc, tinct. of myrrh, &c. . The disease is exceedingly rare in our country. Syphilis, or the venereal disease, often produces ulcerations of the throat, which are described in the many books upon that subject, and require no particular notice here, It is proper, however, for dental surgeons to know that a peculiar and destructive ulceration of the gums, which will defy all but specific remedies, sometimes, though very rarely, attends Syphilis. As it is impossible to describe the peculiar appearance of this ulceration by words only, so as to enable the practitioner to detect it upon sight, I refer the reader to an excellent delineation of it in Messrs. Carey & Hart's edition of Raver's Plates, PI. xxiv., Fig. 15. Chronic inflammation of the gums may depend upon any of the causes mentioned as productive of acute inflammation. It tends rather to ulceration than abscess. If there be no specific cause, after removal of any dead teeth, &c, the gums require the aid of astringent and somewhat stimulating lotions, such as port wine and water, weak brandy and water, myrrh, infusion of Peruvian bark, &c. There is a common form of disease which is usually called scurvy or scorbutus of the gums. This designation, however, is very improper ; for scurvy is a constitutional affection, de- pending upon long privation of fresh and acescent food, aided 94 TREATMENT OF INFLAMMATION. by the influence of cold, dampness, &c. It is a disease pecu- liar to ships and prisons, and the affection of the gums which attends it, is but one among many symptoms of the disorder. It is well, therefore, to abandon this term, scurvy, as applied to the local disease of the gums in question, and, following the example of Professor Harris, I will consider it as an idiopathic inflammation of the gums, attended by sponginess of structure, recession of their margins, and frequently, destruction of the alveolar processes. When affected by this disease, the gums present a swollen appearance. Their colour is dark-red or purple ; they feel elastic under the finger, and when pressed, pus oozes out be- tween the teeth and the margins of the gums, which are thick- ened and detached. The proper tissue of the gums, having become to a certain extent fungus, bleeds upon the slightest touch, and is very sensitive. The disease progresses with more or less rapidity, according to the constitutional health of the patient, and the capability of resistance natural to the organs attacked. Sometimes it is con- fined to a small portion of the gum, at others, it involves the periostea of the fangs and the alveoli, and presents a mass of complicated disorder and devastation. A deposition of bony matter sometimes takes place in the bottom of the sockets and the teeth are loosened and drop out. The treatment of this disease does not differ from that of the ordinary inflammatory conditions previously described. Indeed it is not specifically different. All irritating bodies, such as decayed teeth and roots, must be removed ; irregularities of denture corrected ; tartar also taken away ; the gums depleted ; and after active inflammation has subsided, astringent lotions may be used by way of cor- recting the habitual looseness of texture.* * For a more extended description of this disease and its treatment, than is compatible with the scope of this work, see Dr. Harris's Dental Surgery, a work which I will take for granted is in the hands of every scientific dentist, and every student of dentistry. 95 CHAPTER IX. CARIES— MORTIFICATION. * The term caries has different meanings when applied to the bones at large and to the teeth. Let us first consider the dis- ease of the bones thus called. Caries in the bones is analogous to ulceration of the soft parts, and is very different from necrosis or mortification of these parts. The bones are vital organs, supplied with arteries, nerves, veins, absorbents, and cellular tissue. Like soft parts, they grow and waste, undergo disease and accomplish reparation. The denser the texture of a bone the less liable it is to be attacked by caries, and for this reason the bones of children are more susceptible of it than those of adults. In caries, the bone undergoes a change by which its texture is softened and broken down; fungous flesh, which bleeds very readily, grows up in the interstices formed upon the surface of the diseased bone ; fetid, dark-coloured sanies finds its way to the surface through a sinuous channel, and a communication is thus formed between the diseased bone and the external parts. Caries may nevertheless progress for a long time without the formation of an ulcer and discharge of matter ; and these re- sults depend more often on necrosis than on caries. The treatment of caries consists in the removal of the dis- eased part by surgical means, and, as is often necessary, the application of the actual cautery upon the new surface. The latter means is not absolutely indispensable ; the former pro- bably is, unless, as sometimes happens, the separation of the * Ki^uv, to abrade. 96 CARIES — MORTIFICATION. unsound parts may be accomplished by the unaided efforts of nature. Caries of the teeth, is a chemical erosion of those organs by the action of the fluids of the mouth, and the accidental matters dissolved in them, upon the salts of which the tooth is mainly composed. It is yet 'a mooted question whether the teeth are ever subject to true caries, such as affects other bony structures. I have already remarked that this disease is not apt to occur in the denser osseous structures, and the close texture of the teeth renders them particularly unlikely to be thus affected. Yet it might be too much to say that they are never subject to the active disorganizing process in question. It is certain, how- ever, that caries of the teeth, as commonly met with, is a mere chemical erosion, resulting from the action of acids upon the earthy salts which principally compose them. A human tooth, inserted as a substitute in another mouth, will undergo this change as readily as a natural tooth ; showing that in this form of destruction the organs assailed are passive. MORTIFICATION OR GANGRENE. These two words are commonly used synonymously to express absolute death of a part, but by some writers the term gangrene is restricted to that condition which immediately precedes death, and Sphacelus* applied to the latter condition, while mortifica- tion is a general term covering both conditions. According to this use of the terms, gangrene represents the condition in which there is a sudden diminution of pain, if it has previously existed ; a livid discoloration and subsequent yellowish or greenish hue of the part ; a detachment of the cuticle with effusion of a turbid fluid beneath it, and a soften- ing and crepitation of the part. When the part has become cold, insensible, black, motionless, without circulation and life, the condition is called sphacelus. The state of bone analogous to this is called necrosis, and the dead part when detached, a sequestrum. * Iqaniiu, to destroy. CARIES — MORTIFICATION. 97 Mortification may result from any cause which prevents the nutrition of a part. Inflammation may so interrupt the circu- lation as to cut off the supply of blood, or the state of the pa- tient's digestion may not afford a supply of nutrient fluid suffi- cient for those parts which are least vascular or most distant from the heart, and certain obscure changes may take place in a part which may cause it to mortify, without the precedence of appreciable disease. When mortification is consequent upon inflammation, the quantity of fluids in the part causes a humid state of the spha- celus ; where death has taken place from deficiency of blood, the mortified parts are dry and shrivelled. These opposite con- ditions have given occasion to the distinction so generally re- cognised between moist and dry gangrene. This distinction, however, is not so absolute as to be without exception, yet it is correct to a considerable extent. Different parts assume different appearances when gangre- nous. " Tendons, muscles, nerve and cellular substance, look like dirty shreds of wet tow ; the skin sometimes looks as if it had been destroyed by caustic or the cautery." The arches of the mucous membrane are often of a grayish or whitish colour. Quesnay states that in one case he saw, the gangrened parts exhibited a remarkable transparency. The black colour cannot therefore be considered as characteristic of gangrene. It may exist independently of mortification, and the latter may exist independently of the other. The principal characteristics of gangrene are, 1st. Complete disorganization of the gangrenous parts, in which the elementary tissue can no longer be distin- guished. 2d. Softness and flaccidity. 3d. The fetid and cha- racteristic odour which it exhales. 4th. The sanies, ichor, and fetid gas which escape from it. In that variety of gangrene termed dry, the part presents a black colour, a hardness some- times like that of wood, and always a complete disorganization of the tissue. The treatment of gangrenous parts must be directed to the limitation of the mortification, and to the removal of the slouch. When a part has become dead, it seems to act as a depressing 98 CARIES — MORTIFICATION. or devitalizing agent upon the surrounding parts, and even upon the general system. If the gangrene take place in one of the viscera, the patient generally sinks rapidly and soon ex- pires. Immediately upon the gangrenous change, the pulse be- comes soft, weak, and frequent, the skin cold, and the nervous system seems to labour under a silent, but deadly influence, not to be resisted. It is difficult to account for this sudden and extraordinary result. It is generally supposed that the fluids of the gangre- nous part, being absorbed, prove poisonous to life ; but if this were the case, similar effects would result from the much more extensive mortifications which frequently occur in the skin, muscles, and bones, without those serious constitutional results. The effect must rather be attributed to the powerful sympathy which exists between the viscera and the nerves of organic life. Where nature makes an effort to check the spread of gan- grene, which, except in the instances referred to, she almost always does, a red line of inflammation is first drawn around the affected part. Ulceration soon takes place along this line, and a suppurating furrow separates the dead from the living parts. A similar process goes on beneath, and advancing gra- nulations gradually push off the gangrenous slough, and supply its place with sound flesh. Inflammation and ulceration, there- fore, are the means employed for the removal of dead parts, and for limiting the progress of devastation. In order to effect this, it is necessary that the vitality of the adjoining parts be sufficient to produce healthy inflammation, support the suppuration, and sustain vigorous granulations. It is also necessary, that the inflammation in the adjoining parts be not so great as seriously to impede the circulation in them. The surgeon takes his suggestion of remedial treatment from these necessary conditions. If the parts adjacent to the gan- grene be cold and livid, and if they show no disposition to throw out the inflammatory cordon sanitaire, he sees the neces- sity of stimulating applications to rouse the torpid energies of the threatened parts. Cantharides, turpentine, or other reme- dies of this powerful class, will then be put in requisition; and CARIES — MORTIFICATION. 99 should the parts under the slough be equally torpid, he will cut through the mortified covering, and apply his excitants to the flesh beneath. Sometimes, though not often, he will find it better to antici- pate the slow process of nature, and at once remove the gan- grene by his knife. The latter process is fraught with this difficulty, — that when the surrounding parts are feeble and dis- posed to gangrene, the use of the knife imparts to them no strength, while it necessarily inflicts injury. The result often is the appearance of the disease in the remaining parts. When the surrounding parts manifest more excitement than is compatible with their security, depleting and sedative treat- ment must be instituted. As a general rule, however, this will rarely be required, for the vicinity of gangrene is gene- .rally abundantly sedative to the surrounding parts. Necrosis, or mortification of bone, may take place from simi- lar causes to those which produce gangrene of the soft parts. As the bones possess less vitality, they are less capable of re- sisting disease, and therefore are more prone to die from inju- ries and internal causes than other parts. That they are not more frequently necrosed than they are, depends upon their protection from external violence by the soft parts, and the fact, that their limited vitality and simple functions involve less tendency to disease than is connected with the more ex- quisite organization and complicated functions of other organs. Necrosed bone is thrown off by a process very analogous to that which is instituted for the separation of sphacelus. Where the mortification is superficial, it is removed by exfoliation ; when it is deeper, a persevering effort is made by the surround- ing bone and soft parts, to detach and expel it in the form of splinters, or even of large masses, called sequestra. Owing to the density of bone and its deep-seated position, this is generally a very slow process, requiring months and years for its accomplishment, and often failing altogether. For, after long-continued fruitless efforts to get rid of the dead part, nature frequently attempts to supply the deficiency caused by its loss, and forms new bone around it, leaving orifices in this 100 CARIES — MORTIFICATION. bony case, through which the matter may find a vent. When this arrangement has been made, the sequestrum cannot be expelled by natural efforts, except in a fluid or very commi- nuted state. It is, therefore, generally necessary for the sur- geon to cut down to the diseased bone and liberate the seques- trum. Occasionally, however, nature, though unassisted, will accom- plish the expulsion of very large sequestra. In one recorded case, a piece of bone seven inches long, was thus expelled ; such cases, however, are very rare. The presence of necrosis, or caries, may be ascertained very satisfactorily after the formation of the external ulcer. Some- times the canal will be so straight as to permit a probe to reach the diseased part, and when this is not the case, the presence of an obstinate ulcer, evacuating dark-coloured and fetid sanies, will generally be sufficient evidence of diseased bone. It is rarely possible to distinguish necrosis from caries, until the sequestrum has become so fully detached as to be movable. The cure of necrosis, as of caries, if procurable by art, depends upon the removal of the part so diseased. In necrosis, the parts surrounding the sequestrum are generally in such a state as to return to health after its removal. In caries, the surface of the parts exposed by the operation, often require the appli- cation of the cautery, as before stated. We have already mentioned, that what is called caries of the teeth, differs very essentially from the disease of the bones which bears the same name. Caries of the bones, as we have seen, is a diseased vital ac- tion, in which the vessels, &c, are active ; caries of the teeth is simply a chemical erosion, which may be imitated upon teeth separated from the mouth, and affects dead teeth as readily as living ones. Caries of the teeth always begins upon their outer surface, and does not appear to be in any manner dependent upon dis- ease, except so far as it may be favoured by an unhealthy structure of the teeth, and a morbid condition of the fluids of the mouth. CARIES — MORTIFICATION. 101 In short, caries of the bones is a vital, that of the teeth, a chemical process. By instituting a comparison between caries of the teeth and that of other bones it will at once be perceived, that there is not the slightest analogy between the disease as it occurs in the one and manifests itself in the other. In the former, it consists simply in a decomposition of the earthy basis of the organs, whereas in the latter, it is analogous to ulceration in soft parts, and constantly discharges a fetid sanies, and fre- quently throws out granulations of fungous flesh. These are phenomena which dental caries never exhibits, and they esta- blish a wide difference between it and the disease as occurring in other osseous structures of the body."* The treatment of caries belongs to Surgical Dentistry ; and to works on that subject, and particularly to the excellent treatise by Prof. Harris, I refer the reader. Necrosis may take place in the teeth as in other bones, and from a similar cause, — the cessation of circulation in them. This may be effected by violence. The teeth, especially the anterior ones, are very much exposed to be injured by blows or falls, and it sometimes happens, that a shock thus inflicted is sufficient to break up the vascular connexions of the organ without displacing it from its socket. More commonly here, as in other bones, the necrosis takes place as a result of inflammation ; the pulp having been de- stroyed by this process. When a portion of bone dies, the surrounding bone sets up a process of removal and reparation. Nothing of this kind occurs in the teeth ; partly because the evil is generally shed over the whole organ at once, and partly because its low vita- lity does not permit of such efforts. After necrosis has taken place, the tooth having become a foreign body produces the usual effect of such causes upon the surrounding soft parts. The gums inflame, ulcerate, and de- * Harris's Dental Surgery, which see, for a thorough examination and ex- position of this subject, 102 CARIES — MORTIFICATION. tach themselves from the tooth ; but not being assisted by similar processes in the bone, they are unable to remove the evil. Chronic disease is, therefore, commonly the consequence. Necrosed teeth lose their colour, and become dark-brown, bluish, or dingy ; sometimes when presenting this appearance, their vitality is not completely destroyed, and therefore, they may remain in the mouth for years without provoking the dis- ease of the soft parts which would require the removal of the necrosed organs. 103 CHAPTER X. ULCERS. An ulcer is a running sore ; or, in medical language, a solu- tion of continuity in a soft part, with a secreting surface. Ulcers present a variety of appearances, depend upon very different causes, and exhibit dissimilar conditions of the parts implicated in them. A great many attempts have been made to classify ulcers. Some authors have endeavoured to arrange them by their appa- rent phenomena, others by their pathological conditions, and others by the modes of cure to which they severally yield, while some have seized upon accidental modifying circumstances as a reason for multiplying subdivisions already too numerous. It is impossible to systematize, in pathological science, so as to provide for all the numberless modifications which may be produced in disease by the causes which influence vital action. We must content ourselves with such an arrangement as will enable us lucidly to express what we know of the subject. Once more I remind my readers, that medical definitions are not philosophically complete and accurate. An important distinction between ulcers is found in the fact that some of them are the result of local injury or disease, and not in any manner dependent for their existence upon constitu- tional vice, while with regard to others the reverse is the case, the local sore being only a consequence of constitutional dis- order. As the treatment must differ essentially in these diffe- rent cases, it is very important to be able to distinguish the one class of ulcers from the other. Yet even this distinction, apparently so obvious and proper, is not without difficulty, for local ulcers sometimes involve the 104 ULCERS. general health, and are instrumental in setting up diseased con- stitutional action, in which they themselves participate, and, on the other hand, ulcers primarily induced by constitutional causes, may continue after the vice of the general system has been corrected. The causes of ulcers are various, but can generally be re- duced to the following classes : 1. Predisposing causes. All those conditions of the system, or of any of its parts, which debilitate structures, or so alter their vital action as to impede recuperative processes. Fever, scrofula, syphilis, and scurvy, are examples of this kind. 2. Exciting or immediate or local causes : such as wounds, bruises, abscess, suppuration, gangrene, abrasion of the skin from any cause. 3. From the combination of these causes. A slight scratch or excoriation, that in a sound constitution would heal without any trouble, in a habit tainted with disorders as above mentioned, will frequently produce a very disagreeable and tedious ulcer.* The prognosis of ulcers, must, of course, depend upon the results of a full consideration of the causes and conditions in- volved in any particular case. The constitution of the patient, his age and habits, the situation and duration of the sore and its peculiar condition of sensibility, &c, must all have due con- sideration in forming a prognosis. It is always proper to attempt the cure of ulcers, except such as are of a malignant character, known to be incurable through any means yet discovered. After ulcers have become chronic, it is sometimes dangerous to heal them until we shall have provided an artificial drain, by seton or issue. The system having once become habituated to the discharge of ever so small a quantity of matter, often suf- fers severely with a kind of plethora if the discharge be sud- denly stopped. The simplest, most practical, and most rational of all the classifications of ulcers I have seen, is that adopted long since * Benjamin Bell on Ulcers. ULCERS. 105 by Mr. Benjamin Bell, and generally superseded by more com- plicated arrangements, which beget confusion in the mind of the student, and are, after all, not more precise and accurate than the one for which I have professed my preference. Mr. Benjamin Bell classifies ulcers as follows : 1. The simple purulent 2. The simple vitiated, 3. The callous, 4. The fungous, LOCAL AND CONSTITUTIONAL. 5. The sinuous, 6. The carious, 7. The cancerous, 8. The cutaneous. 1. The venereal, 2. The scorbutic, 3. The scrofulous. It is not my purpose to describe in detail the appearance, nature, and treatment of each of the kinds of sore above enu- merated; but I will confine myself to the consideration of such as may occur in the mouth, and thus fall under the notice and care of the Dental Surgeon. The simple purulent ulcer is the simplest form of sore. It is always a local affection ; it is attended with little pain, and hut slight inflammation, and furnishes a healthy pus and firm granulations. A sore of this description needs little or no aid from art, but it is important that the student should be well acquainted with its appearance, because other ulcers, of a less simple and kindly character, must be brought to this condition before ultimate cure. The simple purulent ulcer is always produced by some local injury, as wounds, burns, &c, happening to persons of sound general health. In this kind of sore, the pus is white and thick ; the granu- lations small, firm, florid, and pointed. As soon as they have reached the level of the surrounding parts, those next the edges become smooth, and are covered by a whitish pellicle, or film, which afterwards hardens, advances, and forms the permanent covering of the parts previously ulcerated. The white, smooth margin, lost in the surrounding skin or mucous membrane, is 106 ULCERS. one of the surest characteristics of this kind of sore, but it is not infallible ; other qualities must be duly considered, before a conclusion is formed. Such ulcers require no treatment except to be kept clean, and protected from any interference with the natural process which is hastening to cure. A little dry lint will accomplish all that can be done by dress- ings. A simple purulent ulcer may very readily be converted into an angry and obstinate sore by improper local applications, or the occurrence of general constitutional disorder. I may remark here that no sores are cured by applications of any kind ; nature only can provide the means by which these breaches can be healed. Nothing is more incorrect or danger- ous than the idea that certain dressings have a specific or ma- gical virtue, by which they close wounds, and cicatrize ulcers. The surgeon may aid Nature — he cannot supply her place; and his business is, generally, so far as the cure of ulcers is con- cerned, to aid her in her efforts to bring any particular sore into that condition " which natural means will suffice to relieve." Simple vitiated Ulcer. — When, from any of the causes we have mentioned, nature fails to produce such a condition of ulcer as we have described, in any part which has been wounded, or when, from improper dressings, motion, and fatigue of the diseased part, or constitutional causes, the progress towards cure is arrested, the discharge from a sore may present one of the following appearances : 1st. It may be a thin, limpid, sometimes greenish discharge, termed sanies. 2d. A somewhat red-coloured, thin, and generally very acrid matter, termed ichor. 3d. A more viscid, glutinous kind of matter, called sordes* While discharging matter of a kind like any of these, an- ulcer will not heal. The granulations become dark and waste away ; the matter, especially that called ichor, is very acrid, and renders the sore very irritable and painful. It frequently excoriates the surrounding parts over which it flows. * Benjamin Bell. ULCERS. 107 These vitiated ulcers are more apt to occur upon tendinous and aponeurotic parts, than in situations abounding with cellu- lar membrane, owing to the frequent motion of these parts, and the continual agitation of the sore. Wherever an ulcer is seated upon a part of this character, absolute rest is necessary to preserve its simple and convalescent character. The cure of these ulcers depends principally upon removing the cause which has operated to change their character for the worse. If the vitiated condition depends upon constitutional causes, these must be combated by the means found most suc- cessful in the practice of general medicine ; if any local irri- tant has caused the evil, it must be removed as speedly as pos- sible ; if motion of the part has been indulged, it must be re- strained. The local treatment consists in soothing, emollient applica- tions, as it has been found that all those means which allay the pain in such sores, tend also to alter their condition to that of the simple purulent ulcer. When the sore is seated in the mouth, but little opportunity is afforded for local applications. The best, perhaps, is warm water, frequently taken into, and held in the mouth; or the vapour of hot water received into it repeatedly and for a con- siderable time. The dentist should look closely in such cases for causes of irritation in diseased teeth and fangs, and also ascertain whether constitutional causes are interested in the production of the troublesome sore. When the ulcer is small, it would be well under these circumstances to destroy its sur- face at once, with caustic. The difficulty of protecting ulcers in the mouth from the con- tact of its secretions, and the food and drink, and the imprac- ticability of dressing them with applications elsewhere service- able, should make the dentist extremely cautious lest a careless or awkward movement of an instrument in his hand, should produce a wound and sore extremely painful to the patient, and difficult of cure. The callous Ulcer. — When ulcers become inactive and sta- tionary, rather than progressive, secreting but little, and that 108 ULCERS. of bad quality, and being little sensitive, they are called in- dolent; if ? in addition, the edges become hard and thickened, they are called callous. Very often these callous ulcers are attended with an enlarged condition of the veins of the part, which is called varicose. This condition of the veins is very embarrassing to the surgeon, and sometimes produces fatal hemorrhage. Callous ulcers are most common upon the extremities, and owing to the mechanical difficulty in the return of blood from these parts, they are, in these situations, most frequently at- tended with varicose veins. The callous condition of ulcers is the consequence of neglect and bad management. Their cure consists in restoring them as soon as possible to the condition of a simple purulent sore. This can only be done by removing the indurated surfaces. The most expeditious way of effecting this, is to pare away the edges and surface of the sore with a scalpel, thus converting the lesion into a wound of the simplest kind ; but as few patients will submit to the pain of this procedure, the application of caustic is generally preferred. By freely touching the surface of the ulcer with nitrate of silver or caustic potassa, a slough is produced, which, coming away after some considerable time, leaves after it a healthy, granulating surface. Fungous Ulcers. — When granulations are large and pale, grow rapidly and rise above the level of the surrounding parts, bleed freely upon touch or slight pressure, and make no at- tempt at cicatrization, they are called fungus or proud flesh. Generally they are soft and spongy, but by very long continu- ance they may acquire considerable hardness. Fungus is not uniformly sensitive : generally it is not at all remarkable in this respect ; occasionally, however, it is very sensitive. It is but imperfect granulation, and may arise from any cause which tends to interrupt the convalescence of an ulcer. Long-con- tinued inflammation of cellular structures and caries of the bones are very apt to be attended by fungus. It sometimes occurs in young and vigorous subjects merely as a kind of ULCERS. 109 exuberant growth, -which can hardly he considered as giving an unfavourable appearance to a sore, as it is readily removed by mild escharotics. Where fungus depends upon a mere defect of action of the vessels of a part, and not upon the presence of any irritating cause vitiating the character of the ulcer, it may be destroyed very readily by sprinkling upon it some burnt alum, or touching it with lunar caustic. Fungus has not sufficient vitality to resist the impression made by agents of this class, and gene- rally the application of the escharotic will excite the surface of the ulcer sufficiently to cause the growth of firmer granula- tions. The Sinuous Ulcer. — This name is given to a sore communi- cating with long and narrow canals, penetrating the cellular membrane and running irregularly under the skin or between the muscles. These sinuses generally have more than one opening through which pus is discharged. Originally they are the artificial channels through which the contents of abscesses or the fluids produced from carious parts escape from situations deeply seated, or so placed as to be unable to pass off matter in a straight line ; but the sides of the canals themselves becoming inflamed and secreting matter, the whole presents the appearance of an irregular ulcer, connected with some primary source of matter, and forming openings wherever the nature of the part causes a determination of matter to the surface. Should the sinus remain for a long time without cure, its sides and the edges of its orifices become hard, and it is then called a fistula.* This term, however, is most frequently ap- plied to artificial canals which connect with some natural pas- sage. The cause of sinuses is the want of a free passage for matter, which, seeking the most dependent point, readily penetrates the yielding texture of the cellular membrane, and ultimately pro- duces ulceration at a point distant from its source. Fistula — a pipe. 10 110 ULCERS. The cure of these sinuous ulcers depends upon making a free passage for the matter in a direct line from its source, and then bringing the edges of the canals together and causing them to unite. If the edges and sides of the ulcer be too hard to undergo the necessary adhesive process, stimulating or caustic applica- tions may be used with advantage. Sometimes it is necessary to lay open these tortuous canals to the primary abscess, a process which at once gives free escape to the matter, and by exposing the sides of the sore to the influence of the air and proper medicinal applications, generally causes a wound which readily heals from the bottom with healthy granulations. Sinuses situated in the mouth should always be treated in this way, unless they are connected with diseased bones or teeth, or are so situated as to make the free use of the knife dangerous. Carious Ulcers are those which are connected with caries or necrosis of bony structures. They are often sinuous, but may be seated immediately upon the caries which causes them. The discharge from carious ulcers differs from good pus. It is thinner and fetid, and at last becomes blackish, and often very acrid and irritating. Mr. Bell thought that the fetor of carious ulcers always afforded a sufficient means of diagnosis. The surfaces of carious ulcers are usually softer and more flabby than natural; and instead of a florid red, they have ra- ther a dark brown with somewhat of a glassy complexion. The granulations generally grow rapidly, but are exuberant and fungoid. Should the orifice heal, either by the efforts of nature or the appliances of art, the apparent cure is of short duration, for the pent-up matter soon finds another vent and produces another ulcer. When a probe is pushed down to the bottom of a carious ulcer, it generally encounters a roughness of the surface of the bone, which plainly indicates its eroded condition. When obstinate sinuses are observed in the gums, discharging fetid matter, and containing fungous granulations, we may al- ways be assured that the cause is to be found in the presence ULCERS. Ill of some decayed tooth or root, or to caries of the alveolus, jaw, or some other bony structure. As a carious ulcer is nothing more than an accident attend- ing caries, the treatment of it must always be secondary to that of the disease which produces it. The removal of the carious or necrosed part, and the employment of the means which will best prevent a return of it, are to be regarded as the proper means of curing the carious ulcer. When the caries is seated in the cancellated structure of bone, it can only be thoroughly eradicated by the terrible energy of fire, and the actual cautery must sweep over the diseased surface and rouse it to the exer- tion of its vitality. When a tooth is the subject of caries, no such frightful treatment is necessary. The tooth being passive in the matter, and being acted on by chemical agents only, all that is required is to remove the caries and interpose between the fluids of the mouth and the parts of the tooth thus exposed a barrier which must be impenetrable to the action of the fluids which caused so much mischief. The only substance by which a cavity in a tooth can be successfully filled is gold, as it only, of all the metals, possesses both the physical and chemical qualities necessary to the purpose. If gold cannot be used, tin, though far inferior, is the best substitute. All the mercu- rial amalgams, are exceeding deleterious, both locally and con- stitutionally, and ought never to be used as dental fillings. The Cancerous Ulcer. — Cancer, or Carcinoma. This terrible affection occurs under two forms, called occult and open, or schirrus and ulcerative. The former variety generally, though not always, precedes the latter, and presents itself in the form of a hard, dense tumour, of slow growth, generally seated in a glandular structure, at first, in most cases, nearly insensible and subsequently causing very sharp darting or burning pain or twinges, which radiate from the schirrus as from a centre. As the disease progresses, the skin adheres to the tumour, cor- rugates or puckers, changes colour, becoming of a livid or leaden hue, then ulcerates and ushers in the second stage of the disease, the open or ulcerating cancer. The ulcer thus produced is exceedingly painful and irritable. 112 ULCERS. It discharges a thin, fetid ichor, sometimes very excoriating. Its edges are hard and irregular, reversed and contorted. Its sur- face is generally irregular, showing depressions or excavations. The sore manifests no tendency to form healthy granulations, but spreads among the surrounding tissues, which successively harden and ulcerate, and become cancerous. The lymphatics propagate the disease to the nearest glands, which are found swollen and indurated, and often ulcerated. The pain of cancer is a burning or scalding sensation, and generally exhausts and destroys the patient long before the devastation of parts can interfere seriously with the functions of life. As blood-vessels are destroyed in the progress of the disease, bleeding, more or less profuse, occurs. Cancer, however, presents various appearances. I have seen it occur without preceding schirrus, present an even smooth sur- face with little secretion ; and many other appearances of this ulcer have been observed, as it has been modified by accidental circumstances. The characteristics of cancer may be considered to be an irregular phagedenic sore, with hard reversed edges, exceed- ingly irritable under all common dressings, and causing a burn- ing pain. When such a sore has resisted the treatment which is found to be successful in ordinary irritable ulcers, and espe- cially when it is seated in a glandular part and follows a schir- rus, there can be no doubt of its malignant character. Cancer, in all its stages, is altogether intractable to any treatment which has yet been devised, and all but the most soothing applications are found to accelerate its progress and add to the intolerable acuteness of its pain. The only mode of cure now attempted is thorough extirpation, and this is confined almost entirely to the latent or schirrous state. The open cancerous sore rarely yields even to surgical remedies. It is even a mooted question whether the removal of schirrous tumours is advantageous. Some surgeons contend that where true schirrus is removed, cancer soon makes its appear- ance elsewhere, often in a more malignant form and in a worse ULCERS. 113 location, and that the life of the patient is often shortened by the painful operation endured in hope of cure. It is not by any means easy to settle this question. Surgeons are in the habit of removing all chronic tumours which are hard and painful, whether they present decidedly carcinomatous symptoms or not. Many of these are probably not cancerous, yet the operations by which they have been removed enter into the statistics of cancerous extirpation. Where but one possible hope is left, we should be very care- ful not to extinguish it, and we therefore may recommend the exsection of schirrous tumours. To be successful, however, the operation must be performed before the disease has manifested activity by changing the surrounding parts into its own pecu- liar texture. . The cause of cancer is also a matter of controversy. It is often excited by a wound, especially a bruise or pinch ; but this can only occur where there is a constitutional tendency to the affection. On the other hand, it frequently appears without any exciting cause. Some writers, in view of these facts, contend that cancer is primarily a local affection, having a strong tendency to infect the whole system with its own poison. They, therefore, very rationally conclude that if it be extir- pated in its latent state, the patient may be entirely relieved from it. Others believe that carcinoma is a constitutional dis- ease, manifesting itself in local changes of the kind described ; that it is, therefore, useless to remove the local effect, and the constitutional cause being beyond our control, they prefer, in the present state of medical science, to refrain from all at- tempts at cure of the disease. On each side of the question are presented observations and pathological demonstrations, and authoritative names, and with- out troubling my readers with a recapitulation of the facts and arguments brought to bear upon this subject, I will content my- self with suggesting the practical inference which seems most rational upon the whole ; which is, that eradication of schirrus may be attempted with good hope, though not with certainty of success; that the excision of open cancer will be an experiment 10* 114 ULCERS. very doubtful, yet if the reports of surgeons are to be believed not absolutely hopeless ; and finally, that under all circum- stances the operator must be prepared for a recurrence of the disease. Many specifics have been suggested for the cure of cancer, and many nostrums are yet vended for the purpose of curing these sores. All of them are useless, and most of them very hurtful. The medicine commonly resorted to by empirics for the purpose of corroding or " eating out" a cancer, is arsenic; an application which adds terribly to the suffering and violence of the disease, and probably often produces most serious con- stitutional effects. I attribute to the improper application of this poison, the sudden death of one young lady, who, having a sore, probably of an ordinary kind, upon her leg, was induced through exces- sive modesty, to subject it to the treatment of a famous female empiric. Although arsenic is useful in certain obstinate cutaneous affections, it does not control cancer when given internally. When externally applied to a surface so irritable as that of cancer, it necessarily does great mischief. Cancer sometimes attacks the tongue. I have seen a case of this kind, which seemed to have been provoked by the abra- sion of the organ against fractured teeth. The sides of the tongue presented a jagged edge, which gave out sanious matter. The whole body of the organ was schirrous, and the neighbour- ing glands manifested a similar condition. A cause so slight as the retention in the mouth of a broken or eroded tooth, seems, in this case, to have been sufficient to excite this fearful malady, in a part, too, where the greatest possible inconvenience and distress must result from its pre- sence. I have recently seen another instance of this kind, in which, the whole glandular structures about the lower jaw were frightfully involved, in which the first impulse to the dis- order was given by a diseased tooth. The lips, too, are very frequently the seat of cancer, and the dentist should be careful not to wound these very vascular and ULCEUS. 115 sensitive parts by careless or awkward handling of the sharp instruments he wields. As the several varieties of cutaneous ulcer are not likely to require treatment from the Dental Surgeon, I will not consider them, but refer the curious reader to the several surgical works in which they are accurately described, and their proper treat- ment pointed out. ULCERS DEPENDENT UPON CONSTITUTIONAL CAUSE. Venereal or Syphilitic Ulcers. — Impure sexual intercourse has engendered a poison which is capable of producing local and constitutional disease of a distressing and dangerous cha- racter. With the consideration of local or primary syphilis we have nothing to do, but as the secondary or constitutional dis- order often developes itself in the structures of the mouth, it is necessary that the well-instructed dentist shall be prepared to detect and treat it, when thus manifested. Syphilis usually presents itself in the form of ulcers, which are called chancres; it also causes cutaneous eruptions, swell- ing of glands and disease of the periosteum, fascia, and bones. The ulcers vary considerably. Generally they are remark- able for their hardened base, feeling like cartilage under the skin ; the borders are red and sharp, the bottom grayish, and the sores painful and not tending to heal. In the throat, tonsils, and mouth, the disease generally shows itself at once, without much previous tumefaction, so that the tonsils are not much enlarged ; for when the venereal inflam- mation attacks these parts, it appears to be always upon the surface, and it very soon terminates in an ulcer. These ulcers of the throat are to be carefully distinguished from all others of the same parts. The disease in the throat is uniformly ulcerative ; this being the first appearance of disease in that part.* The syphilitic ulcer always begins superficially, and is not * Hunter on the Venereal Disease. 116 ULCERS. preceded by observable, or at least, by any notable degree of inflammation. This fact will be sufficient to distinguish these sores from the ordinary open abscess of the suppurating tonsil. There is also an indolent swelling of the tonsil, accompanied by an exudation of lymph, which at first sight might be mis- taken for an ulcer ; and indeed such exudations, when they ac- company scarlet fever, are often miscalled sloughs. They may be detached from the subjacent membrane, which is found un- broken. There is another complaint of those parts often mistaken for venereal, which is an ulcerous excoriation running along the surface of the parts, becoming very broad and sometimes foul, having a regular termination, but never going deep into the surface of the parts. Mr. Hunter says that there is no part of the inside of the mouth exempted from this ulcerous excoria- tion, but it occurs most frequently about the root of the uvula, and spreads forward along the soft palate. The same writer observes that the true venereal ulcer in the throat is a "fair loss of substance, part being dug out as it were from the body of the tonsil with a determined edge, and is commonly very foul, having thick white matter adhering to it like a slough, which cannot be washed away." These ulcers never heal spontaneously, and generally spread rapidly. When the sores are seated upon the pharynx, they produce great distress in deglutition, cough and puriform expectoration, and rapid sloughing of the soft parts, exposing the bones and destroying them even as far as the vertebra by caries. The palate is frequently destroyed, throwing the nose and mouth into one cavity, preventing distinct speech, and causing great discomfort and distress. The dentist will often be required to supply this serious loss of bone by an artificial substitute. "At other times, especially in cases of long standing, these sores extend not by sloughing, but by rapid ulceration. The aspect is less formidable, but its progress is scarcely less de- structive. This variety is most commonly seen on the soft palate. The surface is foul, but the slough which occupies it is of little depth. The sore is edged by a very narrow fringe of ULCERS. 117 yellow slough, and beyond this for the extent of a quarter of an inch, there is an inflamed margin of a deep crimson colour ; but there is not much general sloughing of the surrounding parts. Yet the sore extends daily with extraordinary rapidity. The substance of the part seems to melt away under the ulceration, and the greater part or the whole of the soft palate, is often destroyed before it can be arrested, though no distinct slough can be seen to separate through the whole of its course."* Phagedenic venereal ulcers, like cancerous sores, have thick- ened edges ; a characteristic rather of an unhealthy character and spreading tendency, than of any specific quality of the sore itself. There are several kinds of venereal affections observed in the bones. The periosteum maybe thickened and inflamed. This is a very painful affection, the pain being greater at night ; and may be mistaken for rheumatism, when the bone is so deeply seated as to prevent the distinct feeling of the swelling. This periosteal disease generally ends in permanent enlargement of the bony structure from deposition of osseous matter. Sometimes the periosteum suppurates and causes exfoliation of the bone. Caries of the bone frequently commences in the cancellous structure, and gradually perforates the external plate, and then appears as a soft tumour, which may be seen and felt externally. If this tumour be laid open, a glairy fluid is evacuated ; the periosteum is found to be somewhat thickened, and the bone beneath is denuded, and in the centre of the denuded part, is found a small hole which perforates the cortical plate and com- municates with the interior of the bone. This affection is very common in the skull, and may be seen in the tibia, jaw, and ulna. In its worst forms, it constitutes the worm-eaten ca- ries.* In determining whether a sore in the throat or a caries of the bones be syphilitic, it is absolutely necessary that the ob- server shall obtain all the collateral information which may aid the diagnosis, for it is often impossible to decide positively * Babington. 118 ULCERS. from the mere appearance of the ulcer, whether it be venereal or not. Very often cutaneous eruptions of a syphilitic character attend the venereal sore throat, and the presence of such erup- tions would be sufficient to decide a doubtful case. Unfortunately, however, it is not easy to detect with cer- tainty all forms of syphilitic eruption ; yet, when suspicion is aroused by the appearance of the throat, and corroborated by that of the skin, or vice versa, there must be extraordinary reasons for inferring the cause not to be venereal. Syphilitic eruptions may be tubercular. That is, they may appear in the form of hard lumps, covered by red inflamed skin, and often by dead cuticle. These often ulcerate and leave behind them a peculiar copper-coloured blotch. Another form of syphilitic eruption, is that of small, red, accuminated pimples, sometimes scattered regularly over the surface, at others arrayed in groups. Scaly eruptions are also common, and sometimes a pustular affection, attended with a large, hard, conical scab or crust (rupia), is observed. These may all be due to other causes, but when occurring together with a suspicious sore throat, they very much strengthen the probability of venereal origin. Mr. Hunter says, when syphilis attacks the tongue, it some- times produces a thickening or hardness in the part ; but this is not always the case, for it very often ulcerates, as do the other parts of the mouth. If the character of the disease be clearly venereal, or if it be probably so, it is important that proper remedies be at once administered ; for, when the virus has become so generally dif- fused as to produce the remote symptoms observed by the Dentist, the life of the patient is in imminent peril. There has been much controversy as to the means of curing syphilis, one party contending for the use of mercurial prepa- rations, and the other denying the necessity of these medicines. Without pretending to any claim to decide a question so ably supported on either side, I will briefly remark, that mercury will certainly cure the disease, except in a few uncommon cases, ULCERS. 119 where it exists in a kind of combination with scrofula ; and secondly, that mercury will do this without injury to the pa- tient, and generally with as little inconvenience as can attend the use of less certain remedies. Without hesitation, there- fore, I recommend its use ; especially in constitutional or se- condary syphilis, where no time must be lost, and no risks must be run. As to the particular preparation of mercury most proper for the purpose, there also is difference of opinion. As a general rule, however, I prefer the proto-chloride, or calomel, to any other preparation. It is more certain than blue pill, and per- haps than any other mercurial medicine, and can be used with more safety than the deuto-chloride (corrosive sublimate). My common practice is to give a grain of calomel, to which is added one-twelfth of a grain of opium, night and morning, until the ulcer disappears, or the gums get sore. It is rarely necessary to produce salivation : a mere tenderness of the mouth will generally indicate the predominance of mercurialization in the system, and be attended by healing of the venereal sores, and disappearing of other symptoms of that disorder. Corrosive Sublimate, in the dose of a twelfth part of a grain three times a day, will often succeed ; and in secondary syphilis, is thought by some to be superior to calomel. When calomel acts too freely upon the bowels, as it some- times does, even when administered together with as much opium as it is prudent to give, corrosive sublimate or blue pill may be tried. Should these purge also, resort must be had to inunction ; the patient being rubbed with mercurial ointment until his mouth begins to acknowledge the mercurial influence. When scrofula exists in union with syphilis, the iodide of mer- cury may be used. When after several successive constitutional impregnations with mercury, the periosteal swellings, and other chronic syphi- litic conditions remain, I have found great benefit to ensue upon the use of loci. Potass. Scorbutic Ulcers. — Scorbutus is a barbarous half Latin name, given by medical writers to scurvy, a constitutional affection 120 ULCERS. depending upon privation from vegetable food, under circum- stances calculated to weaken the energies of the system, and which was long a terrible scourge to seamen, soldiers, and the inmates of prisons. It has frequently been confounded with other affections, a mistake which has led to serious conse- quences. In the year 1700, the celebrated Boerhaave treated with mercury four hundred soldiers thus affected, and killed them all. The term scurvy, is applied to spongines3 and ulceration of the gums from any cause, but this is an impropriety. Scorbu- tus, or true scurvy, is always a constitutional affection, never occurs when patients have lived upon diet sufficiently vegeta- ble, and in short can only be expected to occur in ships, camps, or prisons. Happily, since its character has become known, it is rarely seen now even in these places. As it would be of little use to my readers, I will not intro- duce here a full discussion of this subject, which has ceased to be of much interest, even to the general practitioner ; but will content myself with a very few remarks upon it, referring those who may be curious to know more of it to a very in- teresting article in the Cyclopaedia of Practical Medicine, writ- ten by Mr. Kerr. Scurvy is a general disease, characterized by debility, foetor of the breath, sponginess and turgidity of the gums, livid sub- cutaneous spots, particularly of the roots of the hair, ecchy- moses, spontaneous hemorrhages, and frequent contraction of the limbs. The face becomes bloated, early in the disease, and the lips are of a pale greenish hue. The countenance looks sad ; the patient complains of extraordinary lassitude, and becomes breathless after slight exertion. The gums soon become swol- len, itch and bleed upon touch ; they are deep red, soft and spongy ; soon fungous and putrid. Bleeding occurs frequently from the mouth and other parts, and the breath is very offen- sive. The skin is usually smooth and shining, with a suffusion of black or livid spots. Old wounds or sores break out afresh, and ulcers frequently occur. ULCERS. 121 These sores secrete a thin fetid sanious fluid; their edges are generally livid and puffed up ; a coagulum soon forms, which, with great difficulty, can be wiped away or separated from the subjacent parts. These are soft, spongy, and putrid.* A soft bloody fungus, of considerable size, soon rises from the ulcer. When scurvy approaches its fatal termination, the livid and painful swellings break and assume the fungous appearance characteristic of scorbutic ulcers. The hemorrhage becomes more profuse and general ; the increasing dyspnoea is accom- panied in some cases with pain under the sternum, but more frequently in one of the sides. In others, however, without any complaint of pain, the respiration becomes suddenly quick and laborious, and death unexpectedly puts a period to the disease. • The prevention and cure of scurvy consist simply in provid- ing a proper vegetable diet, and keeping the patient warm and dry. Where this cannot be done, as is the case at sea, the purpose can be effected by administering lemon juice freely, and making the men as comfortable as possible. Medicine has little to do in the matter, though it may render occasional aid. It is always important to distinguish the symptoms of scurvy from those of other diseases ; fortunately there is no longer much danger of mistakes in this respect. The subject does not belong to practical dentistry, though the disease of the gums connected with it makes it proper for me to mention it ; my chief purpose in doing so, however, is that my readers may have a proper knowledge of the meaning of a word which is continually misused by dentists by applying it to a local fungous affection. Scrofulous Ulcer. — Scrofula. This word is derived from the Latin word Scrofa, a hog — why, it is not easy to perceive ; but it is singular that the corresponding Greek word is also derived from a word (x u 'p°£) signifying a hog. Whether those who originally described the disease were aware that swine are subject to it, or whether, as is most pro- * Cyclop. Prac. Med. 11 122 ULCERS. bable, they intended to portray the dirty appearance of those afflicted by it, we have no means of determining. Scrofula is also known as Struma, and the word Strumous is frequently used instead of Scrofulous. Scrofulous tumours and ulcerations are also vulgarly called King's Evil, from the loyal superstition which for many years attributed to the touch of a sovereign the miraculous power to heal the disease. Multitudes of cases were touched by the monarchs of England, from Edward the Confessor to Queen Anne. A similar practice existed in France. Many got well after this process, as they do after all quackery, except the severer kinds. The king's physicians took care of the royal reputation by selecting from the candidates for the manipula- tion, the best-looking cases. Scrofula is a constitutional disorder which manifests itself in a great variety of local affections, and is among the most distressing, and in some of its forms, the most fatal of all the ills that flesh is heir to. The pathology of scrofula is not well understood. It seems to affect particularly the lymphatic system ; the glands, espe- cially the subcutaneous and mesenteric, being most frequently the parts which first manifest the local influence of the consti- tutional vice. Very often, however, its ravages are confined to other organs. The lungs are especially liable to be affected by it, assuming that well known and so far incurable diseased condition, which is called phthisis* or pulmonary consump- tion. Although persons of all temperaments are subject to scrofula, yet those who possess what is called the lymphatic tempera- ment, are much more liable to it than others ; and as this sys- tem is predominant in children and women, they are more ex- posed to scrofula than adults and men. * Phthisis, from — I consume — Consumption. There are several chronic diseases of the lungs, which are vulgarly known as consumption. Most of these are inflammatory affections and their consequences. Phthisis, or consumption proper, is an entirely different disorder in its cause and character. It is, with few exceptions, incurable from the commencement. The inflammatory affections are all curable if promptly and rightly treated. ULCERS. 123 Yet men are by no means exempt, but those of the male sex in whom the lymphatic temperament predominates, are most liable to it. It is common to distinguish the scrofulous disposition by certain external marks which doubtless indicate, with con- siderable accuracy, the presence of the constitutional vice. These appearances, from the strong disposition to phthisis which they manifest, are frequently called "consumptive." These marks, are a fine white skin ; light hair ; rounded plump figure ; delicate complexion, with rosy cheeks ; large lips; large lower jaw ; yellowish teeth, or teeth, whatever their colour, which are soft and easily attacked by caries ; a large head ; straight and narrow chest ; large abdomen, and soft and flabby flesh. Persons presenting these external appearances are generally amiable, and often very sprightly and intelligent, and among them are found the loveliest and most attractive of the female sex. The strumous diathesis is exhibited, in another class of per- sons, very differently. In these the complexion is dark, the skin harsh, and the habit indolent; the countenance is swollen and pasty, and all the functions of the body are sluggish and imperfect ; the nervous energy is feeble ; the feelings are ob- tuse, and the moral and intellectual powers occupy a very low rank. Scrofulous cases of this character are not by any means uncommon in Britain or the United States, although far more rare than the other variety, but extreme instances are frequent in some districts of Switzerland and France ; and in these, human nature appears reduced almost to the level of the brute creation, assuming forms which awaken feelings of humiliation and disgust.* Appearances, such as described as characteristic of either of the two classes of scrofulous subjects, are not necessary to the development of scrofula ; but when these marks present them- selves, nothing but the action of circumstances most favourable to counteract the threatened evil, can prevent its appearance. * Cumin. 124 ULCERS. Scrofula is the consequence of damp, cold climates, bad diet, and want of exercise and fresh air. These circumstances, "when combined, may engender the disease in any child, but in most cases it is hereditary, being transmitted from the parent ; whole families being frequently destroyed by this fatal legacy. In one recorded instance, in which the father and mother were both strumous, eight children out of nine died in childhood, of scrofulous affections. The scrofulous disease manifests itself in a variety of ways ; in glandular swellings, sluggish ulcers, distorted bones, cu- taneous eruptions ; but the most common and the most cha- racteristic attendant upon scrofula, is the production of a soft, cheesy, unorganized matter, which is found mixed with the pus of abscesses or deposited in rounded masses of different degrees of firmness, and of various sizes, called tuberculous matter. Sometimes this is enclosed in cysts, sometimes diffused through- out a part, and sometimes it is found in the natural canals or cavities of the body. To the depositions of this matter and the irritation and inflammation which it produces, are due the most serious consequences of scrofula. Scrofulous ulcers are generally consequent upon tumours of the same character. These, after having been indolent for a considerable time, at last ulcerate and discharge their softened contents. Instead of healing, the orifice enlarges, and an ulcer is established, discharging a thin glutinous fluid, occasionally intermixed with the peculiar cheesy or curdy substance already described. Commonly, scrofulous sores are not painful; occasionally they are so. The skin around them is livid and slowly ulce- rates ; the granulations are flabby and pale, and their margins are usually overlapped by the thin unhealthy looking skin. The matter often hardens about the sore, and presents a dis- gusting appearance. The ulcer heals slowly, and the cicatrix is irregular, puckered and wrinkled, " with small portions of projecting skin and even complete bridges, admitting a probe to pass beneath them ; features by which their origin, long after a cure, may be readily discovered." ULCERS. 125 As one ulcer heals, another is often ready to break out, and the patient is gradually debilitated and worn down by the in- cessant irritation and drain. Sometimes the disease manifests itself in a vital organ, and by speedy death curtails the suf- ferings of the patient. To scrofula seems properly to belong a very serious ulcera- tion of the lips, nose, &c, which is called lupus, or nolle me tangere. This disease commonly commences by the appearance of a hard, livid tubercle, which, after being indolent for a longer or shorter time, ulcerates, and produces ichorous, wasting, ill-con- ditioned sores, which, in some instances (lupus exedens), rapidly destroy the adjacent parts ; in other cases, lupus induces a sort of hypertrophy of the skin. Sometimes the first appearance of the disease, is a mere violet red colour, tending rapidly to ulcerate and destroy the surrounding parts. The tonsils of scrofulous persons are very prone to chronic, indolent swellings, which, upon slight provocation, take on acute inflammation. The glands in the neck, and the sublin- gual and submaxillary glands, are often affected by scrofula, forming hard, painless, indolent tumours, which sometimes suppurate, causing intractable ulcers, which, after pouring out the glutinous and flocculent matter peculiar to this kind of sores, heal with the irregular, puckered, ugly cicatrix before described. Dr. Cumin says that scrofula occasionally attacks the tongue. It sometimes assumes the form of aphthous ulcerations, and fissures of the margin, but its most characteristic features are small knots or nodules, superficially imbedded in the substance of the organ, varying in size from that of a small shot to that of a horse bean. They cause no uneasiness, unless when firmly pressed, and then the pain is slight and pricking. The mucous membrane covering them, is red and prominent, and soon breaks in the centre, giving rise to an ulcer, which spreads and destroys by sloughy erosion, with much pain, profuse sali- vation, furred tongue, and fetid breath. The ulcers, under proper treatment, become clean, contract and heal; but the 11* 126 ULCERS. hardness remains : fresh nodules form in other parts of the organ, and the same train of suffering is gone through, after a longer or shorter interval, according to the state of the pa- tient's health and the regularity of his mode of life, until a decided improvement be produced on the constitution by time, change of climate, or the employment of remedies. The mucous membranes of scrofulous persons are apt to in- flame, and generally pour out mucus in large quantity, and often of an acrid quality ; not unfrequently the mucous mem- brane of the mouth presents aphthous exudations, excoriations and small ulcers. I have already mentioned that the texture of the teeth of scrofulous persons is of that character which makes them an easy prey to caries. When we remember that teeth thus little capable of resistance are continually exposed to the action of unusually abundant and acid mucus, we may readily account for the ravages of caries upon the mouth of persons of scrofu- lous taint. Scrofula sometimes attacks the bones of the face, especially the nose, causing, when the disease is confined to a very small portion of the osseous tissue, the intolerably fetid sore called ozena, and when acting upon a large surface, horrible devasta- tion and deformity. The bones of scrofulous subjects are more slender, the outer wall thinner, and the inner softer and more vascular than the bones of others. Syphilis, however, is the more common cause, both of ozena and osseous destruction, but it is in subjects of scrofulous constitution that it produces its most fearful and irresistible effects. The cure of scrofula depends much upon hygienic treatment. As experience shows that cold, humid climates are most favour- able to it, one of the best means for preventing and curing its disorders, is evidently removal to a warm, dry climate. Be- sides this, which is often impracticable, exercise in the open air, generous diet, and the use of such medicinal remedies as are calculated to invigorate the frame, are the best means by which to combat this obstinate and most serious affection. ULCERS. 127 Iodine is the best medicine we possess for removing the superficial glandular obstructions, and healing the ulcers of scrofula. It often exerts a sanitary influence upon these and similar external manifestations of scrofula. Unfortunately the high hopes entertained at one time of the power of this medi- cine to cure the radical constitutional evil, or even the most fatal form of its development, tubercular phthisis, have been totally disappointed. This terrible form of scrofulous malady yields little to therapeutic agents, and, for the most part, is checked only by the hygienic means before referred to. Cod- liver oil is now much used in scrofulous, and especially phthisi- cal cases, and seems to benefit them, either through some un- known medicinal principle, or, as is more probable, through the concentrated and highly nutritious aliment it affords to the wasting tissues. 128 CHAPTER XL TUMOURS. The term tumour,* literally means a swelling, and is often used in this wide sense, but it is more properly restricted to such enlargements as depend upon morbid growth, either of the natural parts, or of organizations not natural, formed in the tissues of the body. This definition rejects such swellings as are produced by the presence of free fluids and gases. Tumours may be divided into malignant, and those which being comparatively innoxious, may, for want of a better term, be called benign. The malignant tumours are such as depend upon some con- stitutional vice, and, resisting all remedies, tend to convert the surrounding tissues into their own substance. These spread rapidly, ulcerate, destroy the blood-vessels of the part, pro- duce frequent and exhausting hemorrhages, are sometimes very painful, and if permitted to remain, ultimately fatal. Cancer, or carcinoma, and fungus nematodes, or bleeding fungus, are the general names for these tumours, though distinct names have been given to varieties of each of these disorders. FUNGUS HilMATODES, BLEEDING FUNGUS, SPONGOID INFLAM- MATION, SOFT CANCER, MEDULLARY SARCOMA. This disease is almost uniformly, perhaps always, a constitu- tional one, and therefore beyond the reach of any local means. Unfortunately we have no antidote to the poison shed through- out the whole body, and, therefore, there is no disease more intractable and hopeless. * Tumeo, I swell. TUMOURS. 129 It generally makes its appearance in the form of a small elastic tumour ; at first painless, but subsequently very pain- ful. As it grows, its elasticity becomes more remarkable, a peculiarity which has originated the term spongoid inflamma- tion. When ulceration takes place, fungus shoots forward, and the bleeding which results from these irritable and morbid granulations, has occasioned the name of the disease. Patients who suffer from fungus hsematodes, have frequently a peculiar appearance which indicates their constitutional pravity. Their skin is sallow, or has a greenish cast, they are often bedewed with clammy perspiration, and are troubled with cough and dyspnoea. Should the tumour be extirpated, the disease soon appears in some vital organ and proves fatal. . When the tumour is examined after death, it is found full of a grayish greasy substance, somewhat like that of the brain, mixed with a thin bloody matter. Polypus.* — This is the name given to a variety of tumours which have their seat in certain cavities, particularly the nose and uterus, and by their growth distend and break up the sur- rounding parts, and otherwise mechanically impede the per- formance of function, even to a fatal extent. Some surgeons distinguish polypi as benign and malignant. Others deny that any such essential distinction exists. Pro- bably the disease is never malignant in the proper sense of that term, unless the constitutional tendency of the patient to some of the forms of carcinoma engrafts the latter disease upon the polypoid tumour, in which case it may present the appearance of cancer or fungus nematodes. As a general thing, polypus, however dangerous, has no ma- lignancy about it. The harm it does is due merely to its bulk and unfortunate position. Polypus is very often seated in the nose. According to Mr. John Bell, every polypus, here seated, is in its early stage a small movable tumour, attended with sneezing and watering * Polypus — ttcxvc, many — ttous, a foot — from a supposed resemblance to the radiated animal so called. 130 TUMOURS. of the eyes ; swelling in moist weather ; descending with the breath, but easily pressed back with the finger. It causes no pain, and generally begets no alarm ; yet this small, innocent looking tumour may become most distressing and fatal. As it increases, the pressure it exercises upon the delicate structure of the cells, &c, where it is seated, begins to cause serious suffering. It fills the nostrils and obstructs the breathing. The eyes become watery from the pressure upon the lachrymal sac ; the hearing impaired by the obstruction of the eustachian tube, and the voice changed by the stoppage of the nostril. The swallowing begins to be impeded by the depression of the palate ; the bones become carious from the steady and increas- ing pressure ; the tumour projects from the nostril before and over the arch of the palate behind ; the nose is twisted ; the countenance distorted ; the patient suffers with terrible head- aches — a foul and fetid matter is discharged from the nostrils ; alarming hemorrhages ensue ; the floor of the antrum begins to give way ; the teeth fall out and matter issues through their sockets ; the still increasing pressure constantly aggravates the sufferings of the patient until death closes the scene. Though all polypi, from their tendency to grow, may in time produce the terrible train of symptoms above enumerated, yet I cannot agree with Mr. Bell, that all are essentially similar. They differ very much in colour, density, and tendency to re- turn. Some are pale and so loose in texture as to be almost vesicular ; others are red, hard and resisting, &c. But in all cases they must be removed, and it is of little use to distinguish between them. There are four ways of extirpating nasal polypi : extracting them with forceps ; tying them with ligatures ; cutting them out, and destroying them with caustic. The manner of per- forming these several operations is described in the books on general surgery. It is not within my province to recapitulate them. Benign Tumours. — Are those which have no tendency to spread by converting adjacent tissues into their own substance ; wmich do not depend upon constitutional vice, and may be con- TUMOURS. 131 sidered as mere local aberrations from healthy growth. Of these there are several kinds, which may be reduced to two classes, the Sarcomatous* and Encysted Tumours, and Exostoses. Sarcomatous or fleshy tumours are known by their firmness, redness, and fleshy feeling. (Some of the malignant tumours are arranged by Mr. Abernethy under this class.) There are several varieties of them, of which the common Vascular and the Adipose or fatty are, by far, the most common. These tumours grow to great size ; are not painful, and may be handled with impunity. Their size and situation, however, often make it necessary to remove them. If permitted to pur- sue their natural course, they sometimes suppurate, and then subside. This mode of cure, however, involves so much incon- venience, that it is commonly better to extirpate them. . Encysted Tumours, or as they are commonly called, Wens, have this peculiarity, that their contents are contained in a cyst or sac, or bag. The contents of the cyst are various. Sometimes the contained matter is fatty, in which case the tumour is called a Steatoma.~\ Sometimes it is a yellowish, thick substance, somewhat like honey or a mixture of honey and wax. Tumours of this kind are called MeIUceris.% When the contents are like fluid cheese or pap, the tumour is called Athe- roma.% The contents of these tumours, however, are not always of such a quality as will permit them to be classed under the names above mentioned. It is not necessary, however, to be more precise. Perhaps, for all practical purposes, it had been as well to have permitted them all to wear the popular desig- nation, Wens. These encysted tumours are common about the head, and frequent upon the eyelids. They are generally globular, not sensitive, and cause no inconvenience beyond what is insepa- rable from their weight and size ; and the trouble from these causes will, of course, depend upon their location. They usually grow slowly, but sometimes attain great size. Some- * Z*g — flesh. f Snug — fat. % Mm/, honey, and K»gac, wax. \ Ab.^a. — pap or pulp. 132 TUMOURS. times the skin above them ulcerates, and the tumour is thus evacuated. This does not very frequently occur. These tumours should always be removed by dissecting them out, be- ing careful not to leave any portion of the cyst behind — for if this caution be neglected, the disease is liable to return, and does not always present, upon its second appearance, the benign character which characterized it originally. For obvious reasons, the operation should always be performed when the tumour is small. The mode usually adopted in the extirpation of these tumours is to dissect out the sac with the contents entire. Owing to the yielding nature of the contents, this is a tedious and trou- blesome process. Sir Astley Cooper recommended to cut through the sac at once, and then to dissect it out ; and doubt- less this is the more easy method, inasmuch as the divided edges of the cyst may then be held by the forceps. Encysted tumours occurring in the mouth should be attended to as soon as they are perceived. Bony Tumours — Exostosis.* — An enlargement of the bone by the addition of osseous matter within its cavity or upon the surface. There are several varieties, denominated ivory, lamel- lated, &c, according to the density of the tumour and the dis- position of its particles. The bones are liable to other forms of tumefaction, which differ from exostosis, although often confounded with it. When the bones are enlarged by mere distension or separation of their parts, the disease is not at all similar to the dense tumour produced by the presence of an unnatural quantity of bony substance. Thickening of the periosteum sometimes occasions an appa- rent enlargement of the bone, when in fact the osseous matter is not at all increased or distended. Sir Astley Cooper described exostosis as having two different seats, viz.: between the external surface of the bone and the periosteum, constituting periosteal exostosis; and in the me- dullary membrane and cancellated structure, forming medul- * E|, out of cc-tscv — a bone. TUMOURS. 133 lary exostosis. Sometimes he found the production of bone preceded by cartilage, in which it was deposited; at other times connected with a fungus of a malignant character, con- taining spicula. This latter form of disease seems to have been a variety of osteo-sarcoma. Exostosis may occur upon any of the bones, and the cause of the disease is generally inscrutable ; depending upon irregu- larity of ultimate nutrition, a process which cannot be compre- hended. The structure and consistence of exostosis present great dif- ferences. Sometimes, especially when the tumour is not very large, and when situated on the surface of a cylindrical bone, one may trace with the eye the diverging of the osseous fibres, in the interspaces, of which we might say that there is deposited a- new bony substance, the organization of which is less distinct. Sometimes the tumour is entirely cellular, and formed of a few broad, laminal, intercepting, extensive spaces, which are filled with matter, different from the medulla, and of various quality. This case is denominated the laminated exostosis. Sometimes the enlarged portion of bone makes a sort of hollow sphere, with thick, hard walls, the cavity of which is filled with fungous granulations, more or less extensive and indolent. According to Boyer, this variety of the disease differs essentially from osteo-sarcoma, notwithstanding external appearances. The case here alluded to, Mr. S. Cooper considers the same as that which Sir Astley has named cartilaginous exostosis of the me- dullary membrane.* In this last-described form of exostosis, Sir Astley Cooper says that the original shell is absorbed and a new one deposited, and within the ossified cavity thus produced, a very large mass of elastic, firm, and fibrous cartilage is formed. This form of disease is not malignant, but often ends in very extensive dis- ease. A true exostosis, consisting of dense bony matter, and of moderate size, may exist without much inconvenience to the surrounding parts, provided they be of a kind to endure the * Cooper, Surg. Diet. 12 134 TUMOUKS. degree of pressure without distress. But where the exostosis is so situated that its bulk can only be accommodated by press- ing upon dense and unyielding structures, or upon nerves or blood-vessels, or where the enlargement impedes muscular mo- tion, these tumours may occasion very serious consequences. The action of the flexor muscles of the leg has been seriously interfered with by an exostosis in the neighbourhood of the knee. An exostosis of the orbit has displaced the eye. Sir Astley Cooper narrates a case of this kind, where two exosto- ses, growing from the antra, pushed out both eyes, and finally produced death by pressure upon the brain. In another in- stance an exostosis of the sixth or seventh cervical vertebra, stopped the circulation in the radial artery by pressing upon the subclavian, and in another a cartilaginous exostosis of the medullary membrane of the lower jaw extended so far back, that it pressed the epiglottis down upon the rima glottidis, and destroyed the patient.* The causes of exostosis are various, and, for the most part, little understood. The venereal disease is frequently attended with the formation of bony enlargements, or nodes, but this cannot by any means be considered the ordinary, or indeed a frequent cause of other forms of exostosis. In some individuals there is an unusual tendency to the ir- regular deposit of bony matter, and provocations, otherwise trivial, will often determine local osseous enlargements. Some- times these provocations are perceived, as when they consist in some form of external force, as blows, pressure, &c. ; more fre- quently the determining cause is as obscure as the constitu- tional vice. Exostosis is always very hard, sometimes painful, often in- sensible. The firm resistance of the tumour, and its adhesion to a bone, will generally enable us to distinguish it from other tumours. Exostosis is commonly gradual and slow in its growth, but the fungous, or medullary swelling of the bones, is often rapid in its development. The latter form of disease is attended * Surgical Essays. TUMOURS. 135 with very severe pain, and often with much constitutional irri- tation. EXOSTOSIS OP THE TEETH. The fangs of the teeth are more frequently the seat of exos- tosis than any other part of the osseous structures. This affection often causes great suffering to the patient, and the dentist finds in it one of the most common and troublesome im- pediments to safe and easy extraction of the teeth. The disease is always developed upon the root ; generally at the extremity, sometimes at the sides ; frequently the whole fang is involved, though not so equally as to present a symme- trical enlargement. Mr. Thomas Bell says that the substance thus added, differs from the natural bone, being harder, yellowish, and slightly transparent. As the swelling progresses, the pressure on the alveolus causes the latter to be absorbed, and thus, as the growth is very slow, room is continually made for the enlarged fang. The wasting, however, being propagated to the tooth, soon exposes the cavity to the action of external agents, and toothache leads to extraction. Mr. Bell says that the con- tinued irritation sometimes occasions thickening of the peri- osteum and suppuration, and the case becomes one of simple alveolar abscess. Exostosis of the fangs sometimes occasions neuralgic suffering of a very serious grade and long duration, the cause of which is rarely discovered by an ordinary observer. Sometimes the adjacent parts become functionally disturbed, and multiply the points of suffering. Mr. Fox relates the case of a young lady, who had suffered long with this affection of the fangs, which her medical attendants had entirely overlooked. The eyelid of one eye had not been opened for two months, and the secre- tion of saliva was so abundant from the irritation that it flowed out whenever the mouth was opened. Professor C. A. Harris has recorded the following case :* Mr. S., of Baltimore, having suffered from pain in the left superior bicuspis, applied to a dentist in 1843, for the purpose * Dictionary of Dental Science, article Exostosis. 136 TUMOURS. of having his tooth removed. In the operation the root was fractured, about three-sixteenths of an inch from its extremity, and the upper part left in the socket. The pain continued, and at the expiration of twelve months the gum over the upper part of the alveolus became very much swollen, puffing out the up- per lip to half the size of a hen's egg. The tumour was opened, and a large quantity of dark-coloured, very fetid matter was discharged, which for a short time afforded considerable relief. The tumour, however, soon re-appeared, and was opened four or five times in as many months. In the fall of 1845, he called on Dr. Harris for advice. The gum was swollen, and the lip and cheek protruded in the man- ner above described. The tumour was opened again, and about three tablespoonfuls of black matter, resembling thin tar, were evacuated. Upon farther examination, the outer wall of the antrum, immediately over the upper part of the alveolus of the bicuspis, which had been fractured, was destroyed, leaving an opening large enough to admit the end of the forefinger. Believing that the extremity of the root left in the socket was the cause of the mischief, Dr. Harris cut away the outer Wall of the alveolus, and removed the fragment. The root of the tooth was found exostosed. The patient recovered com- pletely in a few weeks. A great number of cases, illustrating the variety and extent of mischief occasionally resulting from exostosis of the teeth, are recorded by writers upon the subject. The dentist when consulted for the relief of pain in the teeth or jaws, especially if of long continuance and obstinate persistence, should always seek carefully for evidence of bony enlargement of the fang. It is a very common disease, and in some individuals affects many, or even all their teeth simultaneously. Sometimes ex- ostosis unites several teeth together. In a specimen presented to the Baltimore College of Dental Surgery, by Dr. G. R. Hawes, of New York, the three superior molar teeth of one side, are thus united. In another specimen, presented by Dr. Blandin, of Columbia, S. C, two upper molars are united ; and in a third, presented by Dr. Ware, of Wilmington, N. C, there is a deposition of bone on the roots of a first superior mo- TUMOURS. ■ 137 laris, as large as a hickory nut. Similar specimens are in the museum of the Institution. The disease admits of no cure, and the exostosed tooth must be extracted. In performing the operation, caution is neces- sary lest in the effort to tear away the enlarged bulb, the alve- olus, or adjoining teeth, or a fragment of the maxillary, be brought with it. It is often necessary to cut away the socket in order to liberate the root. OSTEO-SARCOMA. By osteo-sarcoma, is meant a malignant disease of a bone, in which there takes place within it a growth of fleshy matter, which distends the bony walls, and gradually converts the structure into a medullary, cartilaginous, or cancerous-looking substance. Osteo-sarcoma announces itself by severe, deep-seated pain, which is often felt for a considerable time before any swelling of the bone is perceived. Sometimes the pain is so great and unmitigated as seriously to impair the patient's health, before there is any perceptible disease. The tumour is at first deep-seated, general over the part, hard and tuberculated. It does not yield to pressure, nor is the pain aggravated by it. The soft parts, for a considerable time, may manifest no diseased condition ; indeed, it is not necessary to a fatal result that they should be implicated. Sometimes, however, as the swelling advances and the pain increases, the skin inflames and ulcerates, and assumes a can- cerous appearance. As the disease progresses, hectic fever is set up, and the patient soon succumbs under accumulated suffering. When the sarcomatous bone is examined after such a termination, it is found transformed into a yellowish, cheesy or lardaceous sub- stance, and all the surrounding parts which have participated in the disease, are found to be changed into the same homoge- neous matter. The prognosis of osteo-sarcoma is decidedly unfavourable. No medical treatment is of avail in checking it. Extirpation is the only means which promises relief. 12* 138 TUMOURS. Spina Ventosa is a swelling of the bones with diminution of their density. It is most common in the lower jaw, and in the metatarsal and metacarpal bones and phalanges of the fingers and toes. These tumours are the result of inflammation or of scrofulous degeneration in the cancellated structure of the bones, produc- ing matter, generally fluid, purulent, and mixed with the dark- coloured matter of osseous disorganizations. Sometimes, ac- cording to Dr. Gibson, the contents are cheesy, and Mr. Liston says, curdy. It is questionable whether these scrofulous swell- ings of the bones are reducible to the same pathological de- nomination as the fluid tumours properly known as spina ven- tosa. They are not malignant, but for the most part require to be removed by an operation. ANEURISMAL* TUMOURS. A tumour caused by the distension of the walls of an artery, or of the heart, is called a true aneurism ; if the swelling be due to the rupture of an artery and the extravasation of blood in the surrounding tissue, it is called a false aneurism. If an artery be wounded through a vein, so as to permit the arterial blood to pass into the vein, the condition is called varicose aneurism. An aneurismal tumour may generally be detected by the throbbing or pulsating sensation which it communicates to the hand upon pressure. Sometimes, however, when an abscess happens to be seated over an artery, the pulsation of the latter will be communicated to the former. The pulse often indicates the existence of an aneurism of the heart, or some large artery, by a peculiar thrilling sensation, which has been aptly com- pared to the feeling of a "shattered quill." As fatal acci- dents have occurred from thoughtlessly opening tumours of this description, it is always important to examine every tumour carefully before thrusting a lancet into it. The pathology and treatment of aneurism does not come properly within the scope of the present work. * Avivpwuv, to dilate. 139 CHAPTER XII. DISEASES OF THE TEETH AND FACE DEPENDENT UPON MORBID Neuralgia.* — Certain nerves are the organs of sensation, and like other parts of the body they are liable to disease. When such is the case, unless the affection be of a kind to lessen their sensibility, they become the seat of very severe suffering, which is called neuralgia. It maybe asked whether all painful sensations are not seated in the nerves? I answer that they are'; yet the distinction between neuralgic and other pains, is that in the case of the former the nerves are concerned primarily rather than as in- struments; or in other words, they transmit intelligence of their own suffering (for such is pain), not that which is only shared by them with adjacent parts. We must not expect philosophical definitions in medicine. The term neuralgia is not precise, but it is sufficient for practical distinction. The superficial nerves being by far the most sensitive, and withal the most exposed to injury, are very much more fre- quently affected with neuralgia than those which are deeply seated. It is not certain whether the seat of the disease is in the neurilemma or the nervous pulp. In fact the ultimate na- ture of the nerves is too little known to permit us to hazard an opinion upon this subject. Neuralgia is a very acute pain, which generally commences suddenly, and occupies a single spot, from which as the attack progresses in violence, it radiates by pangs or flashes to the surrounding nerves. The pain is generally sharp and darting * Nsugtv, a nerve, and ahyoc, pain. 140 NEURALGIA. or burning, and may be distinguished, among other character- istics, by this, that in its radiations it follows the threads of the nerves without extending to the adjacent structures. There is no heat, redness, or swelling, the absence of which is suffi- cient to distinguish the disease from inflammation. The pain after continuing for a longer or shorter time, rarely longer than a few hours, abates, generally suddenly, and disappears, to re- turn with equal rapidity if the proper provocation be re- peated. The proximate cause of neuralgia is unknown, as indeed is its pathology. There are two varieties of it, which may be termed pure and intermittent. By pure neuralgia we mean that variety which is not, so far as we know, connected with or dependent upon any other affec- tion, general or local. This disease generally occurs in pale, thin, and feeble per- sons, and seems to be a disease of debility. The pain for the most part comes on suddenly, and gradually increases to great intensity, when either through the efficacy of remedies, or in obedience to unknown laws, which regulate the ebb and flow of nervous influence, it abates rapidly and leaves the patient en- tirely free from suffering. It does not return until some pro- vocation be applied, when it will suddenly reappear, and will not be appeased for several hours. Nor is it necessary that any powerful irritant be applied in order to rouse the nerve to renewed agony. Often the slightest cause will be sufficient; the gentle movement or touch of the part, and especially the slightest breath of cool air, will often be sufficient to renew the terrible pain. The intermittent neuralgia is a symptom, and often the only one, of ague, or intermittent fever, as it is commonly called, but which in this case must drop the latter word, as there is no fever present. Of this disease I must speak at length pre- sently. Neuralgia of each kind may be located in various nerves. The scope of this work makes it necessary for me to notice but one speciality of the disease. NEURALGIA. 141 NEURALGIA FACIEI OR FACIAL NEURALGIA. To this subject I would particularly invite my readers, as it is one which it is most important for all dentists to understand. The reason will be seen in the sequel. Neuralgia faciei is sometimes called tic douloureux. The word tic means a sudden twitching or convulsive movement, and as this is sometimes noticed in the faces of persons suffer- ing with neuralgia of that part, the term tic douloureux or pain- ful tic, was given to the affection. Neuralgia faciei occurs in some of the branches of the fifth pair of nerves, and the first and second branches are more com- monly its seat. The pain is therefore more frequently suffered over the orbit, in the cheek, mouth, lower jaw, and lower teeth. It will be perceived at once that the dentist must often be called upon to discriminate between this disease and ordinary toothache, and that, unless he be properly informed upon these subjects, he may add to the terrible suffering of his too confi- dent patient, the additional anguish of tooth extraction, and the injury of losing sound and most valuable organs. In most cases the neuralgia of the nerves of the jaw is at first mistaken for toothache, and frequently ignorant dentists have extracted tooth after tooth, and have at last relinquished the patient to his aggravated suffering. The diagnosis of this malady is not difficult. From all acute inflammatory conditions it may be readily distinguished by the absence of all the other symptoms of inflammation except pain, and by the peculiar character and direction of the pain. The fact that it subsides, disappears, and returns, will also serve to distinguish it from the continued pain of inflammation. From toothache depending upon exposed nerves, it may be diagnosed by the evident centralizing of the pain in a certain tooth, by the aggravation of it when the tooth in fault is struck, and by the positive evidence of a cavity in it, with an exqui- sitely sensitive pulp exposed. 142 NEUKALGIA. The treatment of pure neuralgia faciei is palliative and cura- tive. The palliative treatment consists in the use of such means as are calculated to allay the pain of the paroxysm. The cura- tive consists in the employment of such remedies as experience has shown to be most useful in restoring the health of the pa- tient. Of palliative means, warmth is one of the most impor- tant. Cold aggravates the pain intensely, and will almost always excite a paroxysm of pain in a patient subject to neu- ralgia. Warm or even hot applications to the face are there- fore important aids in allaying the suffering. Counter irri- tants, such as mustard plasters, blisters, cupping, &c, are also occasionally useful. But our main reliance for the relief of neuralgic pain, is in the use of narcotics* or anodynes,f and especially of opium, which is vastly superior to all the rest. It is necessary to give this medicine in full doses, if we would benefit the patient under these circumstances. An adult should take two grains of opium, or sixty drops of laudanum, and in some severe cases, or when the patient has become accustomed to the effects of the drug, this dose will require increase or repetition. Aconite, another powerful narcotic, which has a remarkable quality of lessening sensibility, is now much used, both exter- nally and internally, for the relief of neuralgic pain. It must be used with great caution, as it is eminently a dangerous article. The curative treatment of pure neuralgia will be modified by circumstances. If the patient be plethoric, with a red face and active pulse, even general and local bleeding may be pre- mised. Such, however, is rarely the case, and when it is, we have reason to believe that the disease is rather rheumatic than neuralgic. If the digestion be bad, which is often the case, correctives must be directed to the organs involved. But in most cases the restoration of healthy digestion will not be sufficient to procure permanent relief. * Narcotics, from ystg*ca>, I stupify. -j- Anodyne, from u, primitive, oSi/vyj, pain. NEURALGIA. 143 Generally, neuralgia is a disease of debility, and is found in the cold, pale, and feeble, and in persons of evidently broken health. In such cases the tonic medicines offer most advan- tage, and of these none are found to be so useful as the salts of iron. There are several preparations of this medicine. The carbo- nate, if properly prepared, is a good form of administering iron, but by far the most valuable preparation is the sulphate. This has also the advantage of being generally good as found in the shops, and of being always readily procured. It is, I think, much more certain and efficient than the other ferrusri- nous preparations. It may be given in doses of a grain two or three times a day, and must be continued for several weeks. Under its use the patient will generally improve in strength and colour, and with the invigoration of the general system, the neuralgic affection will frequently disappear. If this medicine should disagree with the patient, or it should fail after a fair trial, recourse may be had to other medicines of the tonic class, of which there are many, mineral and vegetable. It is a very common thing for authors and practitioners to confound the pure and intermittent neuralgias, through want of discriminating periodicity, from a tendency to return upon slight provocation. Yet the distinction is plain and very im- portant, for upon proper diagnosis of the form of the disorder depends the rational treatment of it. In pure neuralgia the nerve after the subsidence of a parox- ysm is left in an exceedingly irritable state, so that it will be excited to another by causes of irritation in themselves exceed- ingly slight. But this return is merely accidental and occa- sional, and of course, obeys no law of regular occurrence. In some instances the exciting cause may be so trivial as to escape notice, but after long and painful experience, the patient learns to perceive potent agents for evil in things which previously eluded observation altogether. Periodicity, is the regular return of paroxysms in accord- ance with a law of the disease and independently of provoca- tion. It generally observes fixed periods of return and depar- 144 NEURALGIA. ture, and when irregular as to the common law which governs the type to which it belongs, it obeys some regulation of its own, by which some well-defined proportion of paroxysm to intermission is preserved. It does not follow then, that be- cause the neuralgic pain abates, either of itself or under narco- tics, and recurs in a few hours or days, that consequently it is periodical, and must be treated by quinine. Intermittent Neuralgia. — In order to understand the charac- ter and treatment of this disease, it is necessary to have a cor- rect knowledge of a particular class of fevers, which present very curious phenomena. These fevers belong to the class which we have designated as idiopathic ; and to the family of malarious or marsh fevers. They are commonly known as agues, from the fact that each paroxysm is preceded by a chill. Hence, also, they are known popularly as chills and fevers. The cause of these affections is always malaria ; no other agent or combination of circumstances produces them, and this is so true that the fact of exposure to malaria is most impor- tant in deciding upon the character of the disease in mooted cases. Malarious neuralgia always assumes the intermittent, never, as far as I know, the remittent type. It may appear as a quo- tidian, tertian, or quartan, or it may be irregular in its periods. Its paroxysms are rarely preceded by chill, accompanied by fever, or perceptibly finished by a sweating stage. Though evidently depending upon the same cause as intermittent fever, it has no phenomena in common with the former, except its paroxysmal character, periodicity, and curability by certain specific means. In endeavouring to ascertain the cause of violent intermitting pains in the face, it is all-important to learn whether the pa- tient has previously been exposed to malarious influence. If it shall appear in any instance that he has not been out of the central part of a large city, known to be free, at least in such part of it, from all emanations of a malarious kind, this fact is abundant evidence that the patient has not intermittent neural- NEURALGIA. 145 gia, however strong appearances may be to the contrary of this opinion. On the other hand, if he lives in a marshy or ma- larious country, or if he has visited such a locality during the latter part of the preceding summer or early part of the fall, and especially if the patient has had well-marked ague pre- viously to the facial suffering, then the presumption will be very strong in favour of the malarious origin of the disease. Besides this historical kind of evidence, the attending cir- cumstances will shed much light on the case. If there be no apparent cause in the condition of the teeth of the affected jaw for so much suffering, if no other disease can be detected in the bones or soft parts, if the pain intermits perfectly and returns periodically, or even if not with entire regularity, yet obviously with some obedience to the law of type, and without provoca- tion, all these circumstances taken together will leave little doubt as to the nature of the malady. Cure. — This distressing disease, which, if misunderstood, is one of the severest and most difficult to alleviate or endure, is when properly diagnosed a very manageable affection, and often yields to the very first dose of well-directed medicine. We have previously remarked that the pathological cause of intermittent febrile phenomena is not known ; fortunately for the world, experience has not waited for pathology, but has pointed out the means of relief and the mode of applying it. Certain medicines are known to be positive antidotes to in- termittent malarious fevers of all kinds. These agents, if ex- hibited freely during the intermission, rarely fail to prevent the return of the paroxysm. Owing to the fact that most of these medicines possess tonic or roborant qualities, it has been supposed that they check intermittents, through this quality. Hence, tonics are said to cure ague. I am convinced, however, that the supposition which attri- butes the prevention of intermittent paroxysms to the common roborant quality of tonics is a mistake, and a mistake which probably has led to unfortunate consequences in practice. The medicines which possess in the greatest degree the anti- 13 146 NEURALGIA. dotal power to intermittents, are not those which are the best tonics ; while the best of all roborant medicines have but little? if any, power to check intermittent paroxysms. Cinchona, or Peruvian bark, is by far the best anti-intermit- tent remedy we have, yet as a pure tonic it certainly is vastly inferior to iron, and hardly equal to some of the vegetable bit- ters ; while arsenic, which, next to cinchona, is the most pow- erful anti-paroxysmal medicine of which we have any know- ledge, has no tonic property at all. The anti-intermittent quality is therefore obscure, and the medicines under consideration are prescribed for the cure of these diseases, simply because experience has clearly proved their preventing quality, and not because we perceive any ra- tional relation between the physiological eifect of the medicine and the pathological condition to be removed. In the treatment of intermittent neuralgia, we must rely upon the medicines named, or, if these fail, upon others of the same class. Generally, however, if cinchona and arsenic have failed, we must look to some other quarter for an efficient remedy. The best mode of administering cinchona, is in the form of the sulphate of quinine, because the dose is very much smaller, and sits better upon the stomach, and because, moreover, the cinchona in bulk is uncertain in strength. The best form of administering the quinine, is in solution, although pills of it are often given. In order to dissolve it perfectly in water, it is necessary to add a few drops of sulphuric acid or elix. vit. The dose varies very much with the circumstances of the case. Thus if the intermission be long, a considerable time is afforded between the paroxysms, for the introduction of the antidote, and small doses, frequently given, are preferable ; if, however, but little intermission is afforded, the dose of the me- dicine must be proportionably greater. The dose, also, must vary with the urgency of the case, and the condition of the patient. If he has already suffered long, has been much reduced, and has but little power of resistance left, the dose should be very decided. NEURALGIA. 147 There is also considerable difference of opinion among prac- titioners npon this subject. Some prefer giving large single doses, or at least rarely repeated; others, small doses, fre- quently repeated. Generally speaking, either mode will effect the desired re- sult ; but as it is plain that we should give the least quantity of medicine that will be sufficient, I am in the habit of pre- scribing moderate doses of quinine, and have never found them to fail except when the stomach refused to bear them ; in which cases larger doses would have been yet more objectionable. The prescription of quinine which I generally give, is a so- lution of ten grains, dissolved in an ounce of water. A tea- spoonful, containing a grain and a quarter of quinine, being given as a dose to an adult. This quantity is given every two hours, if there be an inter- mission of considerable duration, or every hour if the time for administering be short. In very serious cases of intermittent, involving great danger to the patient, and when the powers of life were low, I have very much exceeded the quantity above named. Some practi- tioners always give it in doses of ten or twenty grains ; but this quantity is unnecessary, and hardly safe ; for though many patients would bear it without inconvenience, some would suf- fer from its action upon the brain. The dose of quinine to young children, must always be very small, as their nervous system is more excitable, and their brain more easily disturbed, than is the case with adults. Next to quinine, arsenic is our most certain antidote to in- termittent affections. It is given in the form of arsenias po- tassse, or Fowler's mineral solution, in which form it is manageable, and in proper doses entirely safe. The viru- lently poisonous character of arsenic, renders it improper to attempt its administration in any but a diluted form. There are many cases in which the arsenic appears to exer- cise the anti-intermittent power quite as efficiently as cinchona, and the small bulk of the dose, and the readiness with which its flavour may be covered, make it far preferable for admi- nistration to children. 148 NEURALGIA. It may be given very advantageously in alternate doses with quinine. After it has been persevered in for a long time, it is apt to produce oedema, which readily subsides when the medi- cine is withdrawn. The dose of Fowler's solution, to an adult, is eight or ten drops, every one, two, or three hours, or alter- nating every four hours with quinine. Sometimes it produces nausea and irritation of the bowels. In such cases the dose should be lessened. It not unfrequently produces oedematous swelling of the face and hands, which disappears when the medicine is suspended. There are many other remedies, which are more or less effi- cacious in the prevention of intermittent paroxysms, but it is not necessary to mention them here. The quinine and arsenic should be given only during the in- termission ; though if this be very short, the administration of remedies, and especially of the arsenic, may be recommenced before the fever has entirely subsided. In the treatment of intermittent neuralgias, as in other in- termittent affections, the prevention of a paroxysm will be more certain, if a full dose of opium be given an hour before the expected return. In cases of intermittent neuralgia, where the patient has been exposed to malaria for successive years, and has suffered much from the diseases attributed to this cause, the liver and other abdominal viscera are generally deranged, and the neu- ralgia cannot be permanently relieved until these visceral ob- structions are overcome. The purgative preparations of mercury are very useful in such cases. Of course, no permanent cure can be expected, while the patient shall continue to reside in the unhealthy location, as he must, of necessity, be exposed to continual renewal of the dis- ease. Unfortunately, the advice of medical men is rarely of much avail in directing the choice of residence. This is deter- mined, for the most part, by considerations entirely indepen- dent of health ; and there is great difficulty in persuading a man that it is unsafe for him to live where it is most profitable or pleasant, and that his own property is situated where no- body ought to dwell. 149 CHAPTER XIII. MORBID SECRETIONS OF THE MOUTH. Six glands, the parotid, submaxillary, and sublingual of each side, pour their secretions into the cavity of the mouth. The mucous membrane, which lines the organ, also contains upon its surface a great number of crypts, or follicles, which prepare and pour mucus into the mouth. The secretions from the glands and mucous membrane form saliva, which lubricates the facial cavity, and in mastication is thoroughly mixed with the food, the subsequent digestion of which it materially aids. The mucous membrane of the mouth is continuous with that which lines the pharynx, oesophagus, stomach, and intestines, and sympathizes greatly with any diseased condition which affects those organs. Hence the furred tongue in fever, the red tongue of intestinal irritation, &c. The fluids of the mouth are readily changed from their nor- mal condition, when the digestive organs are feeble, and per- form their functions badly. When such is the case, the secre- tion of the stomach and its appendages are so changed as to unfit them for the perfect performance of their work ; they be- come, to a certain extent, foreign substances, and are capable of exciting irritation, and also, by mixing with alimentary matters, of converting them into deleterious agents. Generally the change produced upon the fluids of the stomach, &c, under such circumstances, renders them more acid. Corresponding changes often take place in the fluids of the mouth. They also become acid, and in such cases corrode the dental structures, and cause great devastation of the teeth. They are also liable to be produced in excess, and to be very abundant in salts, which are collected, mixed with viscid mucus 13* 150 MORBID SECRETIONS OF THE MOUTH. about the teeth, especially of the lower jaw, forming the seve- ral varieties of tartar. The saliva of healthy persons is only sufficient for comfort- able lubrication of the mouth, and being passed into the sto- mach as fast as it forms, it does not collect in the mouth, or require to be frequently excreted. When healthy, it is light, frothy, and but little viscid, without odour, floats upon, and mingles readily with water. In this condition it is slightly alkaline. The saliva is acid in dyspepsia, and consequently caries is apt to prey upon the teeth of persons suffering with indigestion. Nor may the dentist expect to arrest the devastation, unless he can remove the cause that is continually decomposing the bony structures of the teeth. That the saliva is acid in certain diseases, is abundantly shown by Mr. Donne*, of Paris, — who was so struck with the changes in the chemical character of the fluids of the mouth, as responding to disordered states of the stomach, that he sug- gested the use of this fact, as the best means of deciding upon doubtful cases of such disorders. MM. Tiedemann and Gmelin had previously found the saliva to be alkaline in man, and all other animals whose secre- tions they had examined. Magendie, with his usual careless- ness of facts, and boldness of theory, taught that the saliva was sometimes strongly alkaline, sometimes neutral, and sometimes acid : when the stomach is empty, the fluids of the mouth, ac- cording to this writer, are acid ; during mastication, alkaline ; the acidity disappearing sometimes at the presence of the first mouthful. The latter part of this opinion, is of course, mere nonsense. According to M. Donne, who seems to have investigated this matter with great carefulness, with the hope to find in it some semeiological fact, which might lead to great practical results, the saliva is constantly alkaline when the stomach is in a healthy condition. This, then, he considers the normal or na- tural quality of the fluids of the mouth, and all deviations from it he considers unhealthy, and indicative of gastric disease. MORBID SECRETIONS OF THE MOUTH. 151 M. Donne* declares that he has never found the saliva acid, when the stomach has performed its functions well. The only testing means used by this gentleman in his many experiments upon the saliva, were slips of litmus paper. The saliva, if acid, will redden the paper. For test of alkalescence the paper should first be reddened by an acid and then sub- jected to the action of the saliva. M. Donne narrates a number of cases of various forms of disease, in all of which the stomach was deranged and the saliva acid. We will quote a few of them. A young woman was admitted into the hospital of La Charite, labouring under severe bronchitis, attended with great tender- ness of the abdomen, excessive irritability of the stomach, diarrhoea, ardent thirst, &c. The saliva was strongly acid. The disease assumed in its progress a marked typhoid charac- ter, the tongue was parched and coated with a brown crust, the abdomen was always very tender ; delirium and coma su- pervened, and the patient died on the tenth day after admis- sion. The saliva was acid during the whole course of the illness. Dissection showed extensive disease of the mucous membrane of the stomach and intestines. A young man was received into La Charite, as a fever pa- tient. All the symptoms of ataxic* fever soon developed them- selves. The saliva during the first days was only slightly acid, but later it became more strongly so ; he died comatose. The saliva remained acid to the end. Dissection showed a fifth part of the mucous membrane of the stomach diseased. A young man was admitted into the hospital as a fever pa- tient. The symptoms were not serious : there was a yellow hue of the skin ; the epigastrium was rather tender on pressure, there were, however, neither vomiting nor diarrhoea present ; the tongue was white, and the saliva was alkaline. During the progress of the case the saliva became acid, continued to be so for three days, then became neutral, and as the patient reco- vered, gradually resumed its alkalinity. In the case of a young man who exhibited the symptoms of gastritis, namely, great tenderness of the epigastrium, thirst, * Ataxic, nervous or typhoid. 152 MORBID SECRETIONS OP THE MOUTH. tongue red and parched, &c, the saliva was found to be deci- dedly acid. By repeated leechings of the abdomen, and the use of demulcent and refrigerant drinks, the symptoms were speedily relieved, and in a few days the saliva was quite neu- tral, having no effect either on the simple litmus paper, or on that which had been previously reddened by an acid. It soon regained its alkalinity. This patient had two relapses of his complaint, and on both occasions the saliva was acid at first, and became neutral, and then alkaline, as the symptoms disappeared. From these and similar facts, M. Donne* inferred that acidity of the saliva was always attendant upon gastric disorders of a febrile character. Professor Harris informs me that repeated experiments have satisfied him that the acidity is confined to the mucous secre- tions of the mouth ; the secretions from the salivary glands never reddening the litmus held to the mouth of their ducts. Schill observes that " carious teeth indicate long-continued irregularities of digestion. The teeth become very sensible (sensitive) in many nervous diseases, and in consequence of the presence of acid in the stomach. They are sometimes covered with a whitish or gray mucus : this occurs chiefly in catarrhs, and inflammations of the digestive and respiratory organs."* When we remember the extreme susceptibility of the teeth to be decomposed by the action of acids (see page 44), we may well understand why caries is general, and hard to arrest. Providence has made the saliva alkaline, in order to protect the important organs it bathes, from injury by acid matters taken into the mouth, and also to moderate the acidity of the gastric fluids. But under many morbid conditions, especially those most common to artificial life, the protecting fluid itself becomes the assailant, and the teeth, exposed at once to the attacks of acid aliments and drinks, and to the more constant action of acidu- lent saliva, soon yield to those corrosive agents. * Schill's Semeiology. DYSPEPSIA. 153 This acid state of the saliva may accompany a vitiated con- dition of the fluids of the stomach, when no gastric suffering has attracted the attention of the patient, and the existence of any disorder in that organ has not been suspected. In such a condition of things, however, the dentist can afford only tem- porary relief, unless, perceiving the evil, he suggests such remedies as may relieve the patient of the disorder upon which the disease of the teeth depends. The practitioner of dentistry should, therefore, be always prepared to test the quality of a patient's saliva, as regards acidity or alkalescence ; and he should also be ready to give such advice as may be necessary, in consequence of any discoveries he may make. When diseases of an acute character exist there will be no demand for the services of the Dental Surgeon, unless his me- chanical assistance be required. It is not necessary, there- fore, for me to treat of such affections. But it often will hap- pen, that a patient will apply for operations upon the mouth, who may be affected with some subacute or chronic disease of his stomach, for which he is not under medical treatment. If the disorder be not very trifling, the dentist ought, in such cases, always to advise application to a judicious physician. But it will often happen, that the patient cannot conveniently procure such attention, or that the dentist may not have such confidence in the skill of the medical practitioner who could be procured, as to authorize him, as a conscientious man, to de- volve the case upon another. He must therefore give the ne- cessary advice himself. In calling, therefore, the attention of the dental student to the consideration of dyspepsia,* as a common name for chronic diseases of the stomach particularly characterized by indigestion, I do not think I am in any degree leading my readers away from the studies proper to them. DYSPEPSIA. Dyspepsia or indigestion, representing any derangement of the function by which the aliment, after having been received * Dyspepsia — At/?, with difficulty, and risTTa, I digest. 154 DYSPEPSIA. into the stomach, is converted into chyle, must necessarily pre- sent a number of appearances, more or less characteristic of the particular trouble they represent, and the degree of its violence. It is therefore impossible to furnish a description sufficiently accurate and comprehensive to cover all the condi- tions of defective digestion which are included under the com- mon name, dyspepsia. Several complicated organs are con- cerned in the process of digestion. These are connected to- gether by the natural dependence of reciprocal necessity, and by powerful sympathies ; and any of them, when diseased, may interrupt the functions of the others. To understand this sub- ject well, it will therefore be necessary to have a complete knowledge of all the morbid conditions of all the organs of di- gestion, and of all the means likely, under any circumstances, to be useful in restoring them to healthy action. Of course, it is not my purpose to discuss this subject in all its fulness of detail. It will be sufficient to impart such prac- tical information, as may be easily remembered, and readily made availing by the dental practitioner. The symptoms of dyspepsia vary much with the duration and nature of the affection, the constitution of the patient, his mode of life, &c. Generally the appetite is capricious, sometimes very feeble. Heartburn, a sense of weight or distension in the stomach after eating, incapacity of digesting certain substances, such as oily matters, pastry, &c, costiveness, abdominal pains, weakness, depression of spirits, &c, are most prominent. From the extensive sympathies existing between the stomach and brain, headache is a very common attendant upon dys- pepsia. This is often very violent, and attended by nausea and vomiting. The patient soon learns by experience that he cannot take certain articles of food or drink with impunity, and every deviation from the diet suitable for him, is attended by renewal of symptoms and aggravated suffering. Dyspepsia may be variously classified for the purpose of description and treatment, but the simple, plain, and practical distinction laid down by Dr. Eberle seems preferable for our DYSPEPSIA. 155 purpose to any of the more accurate, yet more complicated ar- rangements presented by other writers upon this subject. According to Dr. Eberle, dyspepsia may depend upon two distinct morbid conditions of the digestive organs, viz. : 1. On functional debility of the stomach from deficient or vitiated se- cretion of the gastric fluid, and muscular inactivity, indepen- dent of vascular irritation or inflammation. 2dly. On defi- cient or vitiated secretion of the gastric fluid with vascular ir- ritation or chronic inflammation of the mucous membrane of the stomach and duodenum, and morbidly increased peristaltic action of these organs. The characteristic symptoms of the former grade of indiges- tion, are weak appetite ; tongue covered with white fur ; absence of epigastric tenderness, except after a paroxysm of colic from flatulent distension; costiveness; acid and fetid eructations; absence of habitual tension and febrile irritations of the pulse ; and the ability of bearing lean and tender animal food better than vegetable and farinaceous articles of diet. The phenomena which characterize the second or inflamma- tory grade of the disease, are tenderness to pressure of the epi- gastrium, and particularly about the region of the pylorus and duodenum ; a red, chopped, granulated or glossy appearance of the tongue; a firm, tense, small, and somewhat accelerated pulse, with slight manifestations of febrile exacerbations to- wards evening ; emaciation ; irregular action of the bowels, with frequent attacks of mucous, bilious, or watery diarrhoea ; violent protracted pain in the lower part of the epigastrium during the process of digestion ; fulness about the edge of the false ribs on the right side ; an anxious and discontented expression of countenance ; and inability, without great suffering, to endure animal food and stimulants. It appears that the irritative or chronic inflammation of such cases is seated in the mucous membrane of the pyloric extremity of the stomach, and of the duodenum, connected usually with a congested state of the liver, and often with fcecal accumulations in the colon.* * Eberle's Prac. of Medicine. 158 DYSPEPSIA. The causes of dyspepsia are : 1st. Hereditary predisposition. Some families inherit from their parents some peculiarities in the intimate organization of the stomach that inevitably result in dyspepsia of protracted and aggravated character, which makes its appearance about or soon after puberty, and continues with more or less intermission for years. This predisposition, however, is not of very frequent occurrence. 2d. Mental and moral causes, such as exaggerated passions; gloomy habits of thought ; depression of spirits ; over-anxiety of mind. The influence of the feelings over the stomach is well known. Grief destroys the appetite, so do joy and ardent anticipation. Fasting is a natural exponent of sorrow. 3d. Irregular living, especially the artificial life of the fash- ionable world, which turns night into day and day into night ; robbing the body of sleep when most disposed to and best pre- pared for it, and forcing the stomach, at unnatural hours, to eat heartily of the most indigestible and irritating kinds of food, if such ingesta can thus be called without impropriety. 4th. Excessive eating, and drinking, both of water and in- toxicating drinks. 5th. Sedentary living without sufficient exercise. 6th. Unwholesome and insufficient diet. The use of pickles in excess, especially by delicate females. 7th. Want of healthful and sufficiently laborious occupation. It is owing to this, together with the adjuvant action of other causes which we have mentioned, that so many of the young women of our country are feeble, diseased, useless, and short- lived. 8th. The abuse of medicines, especially those of a purgative character. People have a wonderful disposition to be actively purged. Millions of pills, containing irritating and powerful cathartics, such as jalap, scammony, aloes, calomel, gamboge, and croton oil, are annually sold to persons whose only disease is too frequent purgation. The result often is chronic and in- curable dyspepsia. DYSPEPSIA. 157 9th. Eating too fast, so that the gastric juice does not mingle with the food as rapidly as it is taken. Imperfect mastication, generally because of carious teeth. 10th. Extensive disease of the teeth, occasioning frequent and severe toothache, vitiating the secretions of the mouth, and thus furnishing to the stomach saliva of a bad quality. We have just seen that imperfect mastication may cause dys- pepsia. Extensive caries interferes much with mastication. Moreover, pain disturbs digestion, and frequent toothache not only produces the common effects of pain, but from the position of the suffering, interferes with in salivation and regu- lar eating. 11th. To all these causes may be added everything which tends to exhaust the vital energies, as every kind of excess necessarily does. The treatment of dyspepsia consists first, in removing, as far as possible, all the causes of it. It will be useless to make an attempt to cure unless the patient will make persevering and self-denying efforts. The patient must be contented to subsist upon such food as he can readily digest. The diet should be as dry as possible, for all drinks dilute the gastric juice, and when this is vitiated or deficient, dilution renders it still less efficient. As to the character of food, it is exceedingly difficult to lay down a bill of fare which will suit all cases. The stomach, in dyspepsia, is very capricious. Some patients will eat with im- punity what others cannot digest at all. I once had a dys- peptic female patient whose stomach revolted at the most simple and digestible substances, yet retained and digested comfortably, apple-pie and milk. Generally, the patient has learned, by repeated experiments, what food agrees best with him, and to this he should be confined. In general, when the disease is simply one of debility with- out gastric inflammation, animal food answers better than vege- table. In selecting the particular kinds of animal food, we should avoid young meats. Veal, lamb, and young pork are very indigestible by weak stomachs. The mode of preparation 14 158 DYSPEPSIA. also is important. Soups of all kinds are pernicious, as they present the food to the stomach very much diluted and mixed with oily matters. Oils in all forms must be avoided, hence fried food, melted butter, gravies, most kinds of fish, &c, are inadmissible. All acid fruits, and the whole family of nuts, come under similar condemnation. Sugar is very apt to sour upon the stomach, especially if it be dissolved in warm water, as in the form of sweetened tea and coffee. In these cases of debility of the stomach, a little brandy taken at dinner is often very serviceable. The remedy, how- ever, is a dangerous one, and no prospect of advantage from it should induce us to advise it to one who has at some previous time been intemperate in its use. It is better for a man to be a dyspeptic than to be a sot ; and reformed inebriates have seldom a choice between abstinence and excess. Indeed, every patient who may be advised by his physician to use ardent spirits, should be faithfully warned against the danger of ac- quiring an intemperate love of alcoholic excitement. The medicinal treatment of such cases consists in the em- ployment of such occasional purgatives as may be necessary to procure regular alvine evacuations ; in the proper use of mild mercurial means to an extent sufficient to remove torpor of the liver; in the administration of alkalies, if the patient be trou- bled with an excess of acid ; and finally, in the use of suitable tonics. All purgative medicines are not by any means equally well suited for the purpose we have indicated. Those of them which are very harsh and irritating, and those which produce watery and exhausting discharges, would be very injurious to dyspeptics. Indeed, we have enumerated the abuse of these cathartics among the common causes of the disease. Rhubarb, from its aromatic and tonic quality, and its mild- ness, is one of the best medicines for habitual use, under these circumstances. Aloes is somewhat stimulating to the torpid intestine, and generally acts very gently upon the lower bowels. Blue pill mixed with either of the medicines above named, will often prove very advantageous, and calomel given occasionally in a decided dose will be very serviceable when DYSPEPSIA. 159 the liver is indolent, and its secretions deficient either in quan- tity or quality. Of the vegetable tonics, the pure bitters, such as quassia and gentian are the best. But the preparations of iron are more likely to be decidedly advantageous. We must not, however, expect a great deal from medicine in the relief of dyspepsia. At most it is a secondary means of cure. The removal of the causes and the rigid adherence to regimen, will, in most cases, ultimately procure relief. It is very important that the teeth of dyspeptic persons be carefully examined, for often the cause, or at least a cause of the disease may be found in the diseased and defective condi- tion of these organs, and a speedy cure be obtained by their removal. As to the form of dyspepsia attended by sub-inflammatory condition of the lining membrane of the stomach, its cure must be devised upon the principles which govern in the treatment of similar conditions elsewhere. Moderate antiphlogistic means and mild farinaceous diet, will generally be attended with per- manent relief, nevertheless the gastric surfaces, as the mucous membranes elsewhere, after having been inflamed, remain sub- sequently very susceptible to renewal of the disease, and the patient when relieved must be very careful not to presume upon the comfortable feeling of his stomach, and introduce into it stimulating meats, condiments, or liquors. All dyspeptic persons should be advised to eat slowly and chew their food well. If the absence or bad condition of the teeth interfere with mastication, as they will often be found to do, the skill of the dentist must supply the deficiency, or repair the injury of those important organs. Dyspepsia or indigestion expresses only the mal-perform- ance of an act which is the result of the combined effects of various organs. Therefore, as failure of function in any one will interrupt the healthy completion of the great common purpose, dyspepsia must be a general term comprising several disorders. Being immediately connected with the digesting apparatus, and in fact forming an important part of that great 160 SYPHILIS.— RICKETS. — MEASLES. and complicated system by which aliment is received and pre- pared for assimilation, the dental apparatus can hardly escape injury when the other organs of this system are involved in suffering. Indeed, the mucous membrane, which in the sto- mach and intestine is the seat of the digesting process, and in the mouth is continually pouring out important fluids from its surface and glands, is so intimately connected with the dental arch as to unite it in close sympathy with the more important organs of alimentation. A healthy state of the fluids of the mouth is necessary for the safety of the teeth, and the secre- tions of the mouth will not be healthy when the functions of the intestinal canal membrane are disturbed. It is a hopeless task to save the teeth from caries while the patient suffers unmitigated dyspepsia. Syphilis, also, by vitiating the general glandular and secret- ing systems, may produce a state of the buccal fluids very inimical to the structure of the teeth. This will only be the case in those secondary or constitutional forms of lues of which I have already written sufficiently when treating of ulcers. Rickets very much delays dentition, and so impairs the struc- ture of the teeth that when protruded they are very liable to decay. The enamel of teeth formed under the influence of this con- stitutional vice, is often craggy and worm-eaten in appearance, though sufficiently hard. The fang during the progress of the disease has been found somewhat softer than natural. The exanthematous febrile affections, which commonly occur in childhood, interrupt the regular deposit of bony matter in the growing teeth, and cause permanent defects, which are sometimes discernible in the external appearance of the organs. Measles, for instance, often leaves evidences of its visit upon the enamel of the teeth, in the pitted appearance which they present. As fever of all kinds is always attended with vitiation of the secretions of the mouth, we may readily perceive how any pro- tracted disease of this kind may injure the teeth. All serious diseases of the antrum must involve the dental MERCURIAL SALIVATION. 161 arch. Inflammation may be propagated, nutrition impeded, caries communicated, and the arch actually broken up in the course of those often fatal diseases which have their seat in this geographically important cavity. The surgeon dentist should be well acquainted with the va- rious disorders and morbid growths which maybe developed in the antrum. Early detection is often necessary to cure, and none is so likely to have the opportunity of early discovering the hidden mischief, as the dentist. The first symptoms of the disorder are often felt in the teeth, and unless the dentist who may be consulted shall be able to point out the true nature of the evil, delay may be occasioned, and delay may be fatal. Mercurial salivation (ptyalism) has often caused extensive devastation in the dental arch. Mercury, like all other of heaven's boons, has been shamefully abused, and serious and even fatal injuries have resulted from the reckless administra- tion of this most useful medicine. Unhappily, the occurrence of such calamitous accidents has induced such general and unreasonable prejudice against the use of mercurial medicines, that vastly more evil is now suffered by society from the im- properly withholding, than injudiciously using them. The feeling against mercury has been the common hobby-horse of charlatans and unprincipled doctors, and it needs no little firmness to enable a physician to deal honestly with his patient in the use of this drug. From the fact that salivation is inju- rious to the teeth, dentists have been led to comment severely on the use of calomel, and thus have done much to spread abroad terrible notions of the evils inseparable from the em- ployment of this and other mercurial preparations. Some of these censorious gentlemen have seen evidences of mercurial devastation in every form of disorder and variety of decay, and to them calomel is the one thing to be avoided by all who live to eat, or eat to live. Doubtless salivation, especially if profuse, must be destruc- tive to the teeth, and fortunately it is at length understood that ptyalism is not, by any means, necessary to the attainment of all the benefit of mercury. Salivation is an accident always 14* 162 SYPHILIS. — SCROFULA. to be dreaded, and as far as possible to be avoided. Yet even at the risk of it, mercurial remedies are indispensable, inas- much as life is more important than teeth. There is no reason to believe that the use of mercury is in- jurious to the teeth, when salivation is not induced ; yet caries of these organs is very often attributed to it. People are ex- ceedingly apt to confound the post hoc with the propter hoc,* and dentists are as liable as other men to fall into the error. A patient who has escaped a severe attack of fever, finds his teeth rapidly decaying ; in great alarm he applies to the den- tist. The latter glances at the mouth, and with a look of boding sagacity, inquires if the patient has not been taking calomel. The patient replies that he has been taking more or less of it, and then the man of science, as he is presumed to be, launches forth for the hundredth time into a bitter diatribe against mercury as the origin of all the evil. And why might not the lamented caries be as justly charged upon the tartar emetic or magnesia, which the patient may have taken simultaneously with the calomel ? or why does not the dentist seek for the all-sufficient cause of devastation in the fact that the teeth in question had been bathed in the acid saliva of a fevered mouth for weeks consecutively ? Why transfer the blame to the remedy by which the fever was subdued, and cast implied and serious censure upon the physician, whose judicious employment of the vilified drug has, perhaps, saved the pa- tient's life? Until I have other information than I now possess, I cannot believe that the proper employment of mercury is injurious ; and while I reprobate its abuse, and would think the physician unpardonable who would be careless or reckless in the use of a medicine capable of doing so much harm, I cannot but regard that man as the author of greater evil, who by silly declamation against an important remedy, fetters the practitioner in his con- test with the most formidable diseases. Scrofula, to which I have already called attention, interferes with assimilation, and consequently with the completeness of * To consider whatever occurs subsequently, to be consequent upon what has been observed to precede it. PREGNANCY. 163 nutrition and growth. Being often inherited and developing its mischievous nature very early in life, it influences the teeth during the important process of formation, and by preventing their perfect organization renders them feeble to resist the in- fluence of morbific causes. This evil consequence is, however, generally counterbalanced by the thinness and deficiency of mucous and salivary fluid, and the difficulty with which the fluids of the mouth of stru- mous persons become acid. Pregnancy is supposed to be fraught with danger to the teeth. Indeed, this opinion has been sufficiently general to have become condensed into the adage — "for every child a tooth" — meaning that the mother may expect to lose a tooth as the result of each pregnancy. Pregnancy is not disease : it is a physiological condition, and we cannot believe that it is per se, and naturally, a cause of disease anywhere, especially in organs distant and not imme- diately dependent upon the uterus. But in pregnancy, the ner- vous system is irritable, and the sympathies of the body are in more lively play. The vascular action is also greater, and the blood is more highly charged with fibrine. It therefore hap- pens that there is more liability to pain then than at other times, and less patience to endure it. Consequently, if the woman has any diseased teeth, previously neglected, they will be apt to ache, and when aching, the pain to her irritable nerves is intolerable. Besides this, there is occasionally a sympathetic toothache, which, though it cannot be directly traced to the uterus, appears to depend upon its gravid condition, and not upon disease of the tooth itself. The dentist should be aware of this ; it is readily alleviated by an anodyne. It also happens very frequently that the artificial life and the absurd habits of our young females, induce a constitution but little capable of sustaining childbearing, although to the wo- man of good health and vigorous frame, parturition is fraught with no disadvantage to health or shortening of life. These pallid, soft, and delicate girls, when become pregnant, begin rapidly to break down, and the hurried caries which destroys 164 PREGNANCY. their teeth is but the first manifestation of the premature decay of the whole body. This is a subject upon which I could and would willingly write much, but it would be useless. Fashion, custom, inclination, will bear sway over reason and moral obligation ; years of comfort will be sacrificed for hours of mirth ; showy dress and ball-room vigils will continue to feed the insatiable tomb with the loveliest of our race. 165 CHAPTER XIV. MORBID EFFECTS OF CONDITIONS OF THE TEETH AND GUMS, UPON THE GENERAL SYSTEM. Having considered the several forms of disease in other parts, or of the general system, which morbidly affect the teeth, I proceed to inquire what effect these latter organs, in their varied states, whether physiological or pathological, may in- duce in other parts, and what changes they may cause in the more general phenomena of vital action. As the body is a unit, knit by the closest bonds, pervaded by one system of blood-vessels and nerves, directed by one in- telligence, and kept in a continual relation of function and expression by an all-pervading law of reciprocal reaction and sympathy ; as diseases of other parts, and those which in dis- tinction to well-defined and limited affections we call general, are capable of affecting the teeth, it might be apparent, if we had no particular facts in evidence, that the morbid condition of the teeth may produce corresponding evils in other parts, and may even involve the whole system in troubled and morbid action. It might also be evident that severe and long-continued pain, located in the immediate vicinity of the brain, and in parts little accessible to soothing appliances, cannot be less danger- ous to health than pain in other organs situated at greater distance from the nervous centres and more easy of access. It might also be perceived that sensitive organs, in imme- diate contact with the great lining membrane of the thoracic and abdominal cavities, and intimately connected with it by function, cannot be less capable of propagating disorder to it, 166 than parts located far from it, and having no immediate rela- tion to it. Yet natural as these inferences seem to be, they have been, until lately, almost entirely overlooked, and even now the medical profession are by no means awake to the facts and the importance of the morbid relation actually existing between the teeth and other parts. It is exceedingly uncommon to hear that a physician, in searching for obscure causes of protracted ill-health, has paid any attention to the state of the teeth, though often their ter- ribly diseased condition cannot escape involuntary recognition by more of his senses than one. The matter is never alluded to in lectures delivered to medical classes, and, in fact, is hardly recognised at all as a subject for pathological or hy- gienic consideration. Within a few years, however, several writers upon dentistry have urged the medical profession to turn their attention to the diseased conditions of the teeth in connexion with other disorders, and they have supported their appeals with such an array of well-observed and clearly narrated cases as must im- press the mind of all reflecting readers with the fact of the morbid relations in question. Unfortunately, these writings are not read by the general practitioner, and it is to be feared that a long time must elapse before physicians become properly informed upon this subject. In the mean time it is the more important that every dentist be able to perceive these sympathetic conditions, and call the attention of the patient and physician to them. The teeth, while in a physiological condition, are capable of inducing great local distress, and constitutional disorder even of a fatal kind. During their evolution and passage through the gum, the pressure even of a sound tooth upon a sound gum may be attended by irregular phenomena of the most alarming description : it would be strange indeed if the action of a diseased tooth upon the diseased gum should be attended with no evil consequences. That the process of dentition happens in infancy, causes MORBID EFFECTS OF THE TEETH, ETC. 167 certainly a modification of effect in accordance with the pecu- liarities of the infantile constitution ; but, the action of morbid teeth upon the less mobile nerves of the adult may be as cer- tain, though less rapid and ostentatious. The question, however, like other medical questions, is one of fact, not of inference. And I would leave the truth to be deduced from a fair examination of subjected cases. 168 CHAPTER XY. MORBID EFFECTS OF FIRST DENTITION. Dentition is not, in itself, a morbid process, but a healthy physiological act. It would be strange, therefore, if it neces- sarily involved disorder of function and serious consequences to the subject. The truth is, that when naturally performed, under the favour- able circumstances of sound constitution and good health on the part of the child, the cutting of the teeth is effected with- out pain or any collateral evil, these organs appearing in their place without any previous unpleasant sensations to attract at- tention to their progress through the gum. It is thus that the domestic animals perform dentition ; and many children com- plete theirs with no more perceptible inconvenience. More generally, however, the child experiences, at least with some of its teeth, more or less suffering of a local kind, and in many cases the pain is attended by sympathetic irritation of a grave and not unfrequently of a fatal character. It is important to know that, however large may be the pro- portion of painful, in comparison with natural dentitions, the former are nevertheless to be regarded as accidental modifica- tions of the regular and healthy process. Starting with this knowledge, we will, of course, be led to inquire into the causes, so general and so potent, which effect the changes in question, and to devise means and management most proper for escaping or annulling them. Does painful dentition depend upon the pressure exercised by the tooth upon the gums ? If it did, all children would experience suffering and more or less collateral morbid effects. For, although the difference MORBID EFFECTS OF FIRST DENTITION. 169 of natural sensibility in different children would occasion dif- ferences in the degree of trouble arising from this cause, yet this comparative sensitiveness, being merely natural and healthy, could not account for the extreme contrasts exhibited between easy and simple, and complicated and dangerous den- tition. Nor is it at all likely that extreme sensibility would escape morbid manifestation during the rapid evolution of infantile life, until awakened from its passivity by the evolution of or- gans themselves not sensitive (in their healthy state), passing through structures not by any means remarkable for this quality, and performing their eruption so gradually as to make no sudden demands upon the nervous and vascular system, so as to disturb the equilibrium of nervous and vascular distri- bution. Nor is it consistent with the facts observed in the history of dentition that the cause of the suffering is the pressure of the fangs of the teeth upon the periosteum of the alveoli. Those who adopt this explanation have not considered that the shoot- ing of the teeth, characterized by the enlargement of the alve- olar walls, and the distension of the gums occasioned by the formation of the body or of the crown of the teeth, is an epoch often more dangerous than that of the organization of the roots ; which besides would do much more harm in compress- ing and binding the soft and pulpy part of the tooth than the serous membrane, which performs the functions of a peri- osteum and lines the interior of the gum and proper cavity of the teeth.* The truth seems to be, that a great number of children are born into the world so feebly or disproportionably constituted that they are not capable of maturing. Most of these neces- sarily perish during childhood, by some of the many forms of disease common to that period. Many others, though born with sufficient vigour, are reduced by bad diet and defective management to a condition which readily yields to irregular or morbid agents. * Baumes on First Dentition. 15 1T0 MORBID EFFECTS OF FIRST DENTITION. A child may be very feebly organized, and yet may appear for a time plump and healthy, but when the vital powers come to be tested either by accidental or physiological demands upon its energies, the natural feebleness is ascertained by the de- velopment of various morbid phenomena, indicating the parti- cular location and kind of disability. Again, children born healthy are often subjected to privations or to injudicious diet and regimen which rapidly alter their fluids and tissues, and lay the foundation for serious accidents. Dentition demands a certain amount of constitutional energy to accomplish it. The rapid development of any organ does this. The changes which take place at puberty, and the evil consequences, to the feeble, of the developments then com- pleted, are illustrative of this fact. This demand is the se- verest test of functional and organic completeness in the child, and many will not bear it. The development of the teeth determines an unusual flow of blood to the head. This happens at a time when the brain is proportionately large, and undergoing rapid evolution. Inde- pendently of dentition, this period of life is attended by a strong tendency to cerebral affections, and to pulmonary and abdominal complications. The nervous and vascular systems are, in the child of this age, remarkably active. The several organs have to perform not only their functions and the pre- servation of their entireness, but also rapid growth. Animal life is therefore exalted with all its qualities. Among these are sensibility and sympathy ; the capacity to be impressed and to propagate impression. Hence a slight cause may pro- duce great local or constitutional effect, and disease of any kind may induce sympathetic or constitutional disorder appa- rently much out of proportion to its own intensity or import- ance. In the older child the relation of secondary to primary affec- tions is more equable, and the second dentition is performed without the occurrence of those serious constitutional affections which so frequently attend the first. Any unnatural obstacle or impediment to the eruption of the MORBID EFFECTS OF FLRST DENTITION. 171 first teeth, will tend very materially to augment the probability of morbid consequences. A disproportion between the teeth and the jaw, or the unusual hardness and impenetrability of the gum, are of this nature, and sometimes provoke local and sympathetic disturbance. The appearance of several teeth at once may make a larger demand upon the system than it can readily meet, and hence cause embarrassment, or if their dentition be painful, the amount of suffering may be too great for the sensitive and sympathetic nature of the child, especially if it be constitu- tionally feeble. The natural symptoms of healthy dentition, are not remarka- ble. An increased flow of saliva is usually noticed, though this perhaps, is not as certainly the consequence of dentition as is generally supposed. The mouth of infants is generally well supplied with fluids, which, there being no teeth to prevent it, will escape more or less from the mouth. The child also car- ries its fingers to the mouth more frequently, and seems pleased to press a resisting substance between its gums. Gentle fric- tion of the gum also seems to be agreeable. The gums are noticed to be hot, and the child takes the breast frequently. The bowels are generally looser than usual, and the child ordi- narily manifests some little restlessness and sleeps less pro- foundly than previously. These symptoms precede the eruption of the teeth by several weeks, and seem to depend upon the rapid ossification and growth of thft teeth. After a few days, they often subside, to be renewed when the teeth are pressing forward and about to penetrate the gum. It is common to alleviate these little inconveniences, by giv- ing the child a coral, crust of bread, or other hard substance, to press upon with its gums. Nature is generally a very correct guide as to her own wants, and as it is natural thus to allay the sensation of the gums at this period, it must be right. A priori, however, we might have feared that the continual pressure would condense and harden the gum, and make it more impenetrable. 172 MORBID EFFECTS OF FIRST DENTITION. Inasmuch, as nature has not indicated the precise degree of assistance proper for the purpose, it would be well to use sub- strnces which do not possess this quality in an unnecessary degree. The French use a stick of marsh mallows, or liquorice root dipped in honey, or a sweetened decoction of barley — the Ger- mans, a small bag filled with sugar and spices. It is doubtful, however, whether the success of this invention for quieting the child may not induce the nurse or mother to neglect it, and withhold the breast which it would take eagerly and frequently. Nothing so soothes the infant as the frequent lubrication of the mouth with the mother's milk, and where nothing in the state of the mother's health or the condition of her breast for- bids this indulgence, it is cruel and unnatural to deny it. It may be, too, that the constant use of sweet and condimental substances would disorder the stomach of the child ; an accident to be studiously avoided during teething. The bowels are generally loose during dentition, and even when the purging is very frequent we must not consider it ex- cessive while the child nurses freely, and especially while it does not emaciate. Costiveness is much more to be feared under such circum- stances than purging. It is unnatural, and unless overcome by proper treatment will result in irritations, local, and per- haps sympathetic, which may not easily be remedied. It is always important to restrict a teething child to proper aliment. The bowels may very readily be irritated, and the system is so liable to violent excitement at this time that all irritation should be dreaded, especially irritation of the abdo- men, for this is the most important part of a child, being the centre of the very active processes of nutrition and augmenta- tion everywhere going on. This is no time to try experiments upon the stomach. Nutritious and easily digested food, and that which is free from acidity, is to be given, and in such quantities as the child is willing to take. Unless, indeed, it has been habitually over-crammed and taught to eat an unna- tural quantity. MORBID EFFECTS OF FIRST DENTITION. 173 When the mother has milk, this is, of course, the best food for the infant, but it will generally happen that the child will require more nourishment than it can obtain from this source. In selecting food for it, regard must be had to the condition of the child. If delicate and thin, animal food will often be indispensable. Beef, mutton, and occasionally a little salt meat may be given with advantage. Young meats are gelati- nous and less digestible, and should be avoided. If the child, on the contrary, be too fat, if it has been over- crammecl with milk until it presents an appearance similar to that of the show calves, stuffed and swollen for exhibition at a fair, it should have diet of a far less nutritious kind. Farina- ceous articles well diluted with water will be more suitable. Milk, if fresh and sweet, generally agrees well with children ; but the milk of the cow is more nutritious than that of the mo- ther, and should be diluted. Cream freely diluted with water generally agrees better than milk. It is common among the rich to thicken the child's milk with arrow-root, tons les mois, or other concentrated farinaceous food. The consequence generally is that the parents are en- abled to rejoice over fat babies, and soon to sorrow over sick ones. Instead of making the milk of the cow more nutritious, it should be rendered less so than natural. It is rarely that articles of this kind, even when they are what they are repre- sented to be, are fit for children. But this is rarely the case. Most of the arrow-root, &c, of the shops is potato starch.* Some parents are in the habit of refusing children flesh of all kinds, and indulging them freely in milk and potatoes. The result generally is to fatten the children excessively, without providing them with a proportionate amount of muscular fibre. The child should have as much exercise in the open air as the circumstances of the parent will admit. All kinds of ex- ercise seem to do it good. It is seldom fatigued even by very long rides, and rarely fails to acknowledge, in its altered ap- * If the milk require the addition of any farinaceous substance, I prefer rice flour. 15* 174 MORBID EFFECTS OF FIRST DENTITION. pearance, the good effect of even an hour's exercise in the fields. Frequent bathing is of great use to children of all ages, but even this means requires to be administered with judgment. The cold bath is a powerful remedy, and cannot be used with equal safety and advantage upon all children. Those who are ruddy and robust will bear it well ; while others who are pallid and of cold skins may suffer serious injury from it. If after the bath the child shivers for a considerable time, and remains cool, and if it contracts a dread of the water, the temperature should be elevated to meet the condition of its sensibilities. Of course, in cold weather, the water should always be warmed in proportion to the necessities of the case. When dentition becomes complicated with morbid conditions, directly or indirectly connected with it, the management of it requires far more care and skill. The local symptoms are to be allayed, serious symptomatic affections are to be relieved, and the strength of the child to be supported through a tedious process, in which the powers of the system are taxed to their utmost capacity. A single mistake here will often prove fatal, and it is easy under such circumstances to make mistakes. The diseases of dentition are local, those which affect the teeth, gums and mouth — or sympathetic, those which manifest themselves in other organs. The local diseases of dentition are, first, inflammation of the gums. These are swollen, hot, redder than common and very sensitive. The child will not permit them to be touched, and incessantly craves the breast, or cold liquids. The condition of the gum is almost always attended with more or less fever and irritation of the intestinal canal. There is also an evident determination of blood to the head. The face is flushed, the head hot, the eyes red and watery, the flow of saliva profuse, and sometimes the salivary glands are swollen and tender. Aphthous exudations are often noticed, and it is said, though this must be very uncommon, that abscesses sometimes occur at the root of the tongue. The fever is generally ardent, and increases and subsides MORBID EFFECTS OF FIRST DENTITION. 175 with remarkable suddenness. The thirst attending it is very great, and a strong tendency to irregular muscular contrac- tions or convulsion is generally observed. The sleep of the child is uneasy and frequently interrupted. It often starts and screams, and when awake is usually fretful and stupid by turns. These symptoms are often very suddenly and effectually allayed by freely incising the gum and capsule down to the tooth or teeth, and liberating them from their investments. This expedient is generally resorted to whenever the gum is elevated and distended ; sometimes, however, it is of no avail, either because it is not effectually done, or because the symp- toms to be relieved do not in fact depend upon the mere me- chanical pressure. The French writers make a formidable matter of this little operation ; and indeed, as practised by some of them, it is no trifle, for they make a crucial incision upon the tooth and dis- sect up the flaps of the gum, or else, with a bistoury, completely cut off the top of it. There is no necessity for such painful and protracted opera- tions ; a free incision, until the lancet grates upon the tooth, is all that is necessary for the incisors ; and when the double teeth are in question, a cross incision may be added. The lancet should be carried down to the tooth, or else no good will be done. The bleeding which results is trifling and salutary ; tending to relieve the inflamed and swollen gum. It has been objected to this operation, that unless the tooth should be very near the surface, the incision would heal and the cicatrix would offer more resistance than the original struc- ture of the gum. The fact is, however, that if such a cicatrix should occur, and the symptoms return, it would be very easy to divide the gum again ; moreover, a cicatrix is always a feeble tissue, which is far less resistant than the natural part whose loss it represents. Conjointly with the use of the gum-lancet, attention must be paid to the bowels of the child. If it be costive, the torpor of 176 MORBID EFFECTS OF FIRST DENTITION. the bowels must be relieved by the administration of proper purgatives. Of these, calomel is for several reasons by far the most useful, and is equally safe, for occasional administration, with the most innocent of the class. In these conditions the abdominal secretions are always vicious, and we have no means so powerful as calomel for the restoration of impeded or altered secerning function. To a child of a year old, four, and to one of two years, eight grains should be given at a single dose ; and, if necessary, its cathartic effect insured by the subsequent administration of castor oil or magnesia. Small doses of calomel are ineffectual, and, if frequently repeated, are dangerous. Should the bowels be too loose, and the passages thin and white, the same medicine, similarly administered, or joined to a little rhubarb or chalk, will generally check the diarrhoea. In these cases, as where constipation exists, the fault seems to be in the defective or altered secretion of the liver, which calomel restores. The fever will generally abate in proportion as the bowels are put right. Should it continue ardent, however, and especially if the cerebral plethora should increase or remain unabated, a few leeches behind the ears will often prove ser- viceable. The cold bath, or sponging with cold water, will also allay the fever and restlessness. The warm bath may sometimes be preferable, and will be equally serviceable. Above all, country air, and exercise out of doors, are the best means of combating the disorders of dentition. "Very different," says Mr. Jay,* "was the practice of our forefathers, who, misled by the fanciful doctrine of signatures, were in the habit of applying to the gums specific ointments made of the brains of hares, or of the combs of cocks, which as old Hartman would have us believe, ' cause the production of teeth without difficulty, and free from accidents.'" * Cyclop, of Prac. Med., Art. Dentition. MORBID EFFECTS OF FIRST DENTITION. 177 It is questionable whether we have much right to laugh at the metaphysical medicine of our ancestors : certainly our posterity will find abundant occasion to ridicule our own. We have yet to learn that any ancient theory or practice of cure was more utterly absurd than Homoeopathy or the cold water treatment. The doctrine of signatures is quite as philo- sophical as Mesmerism, and the combs of cocks and brains of hares are certainly as efficacious as Hahnemann's dilutions. Among the local diseases of complicated dentition we must enumerate caries of the tooth and abscess of the gam. When from any cause, local or constitutional, caries of the tooth takes place, it engenders inflammation of the periosteum, which soon extends to the gum. This becomes painful, swollen, and ten- der ; an effusion of fluid takes place between the fang and its investing membrane, which thus becomes a sort of cyst or sac ; finally pus is formed, an abscess appears, and the matter is voided, either by a spontaneous or artificial opening. The continuance of the carious tooth as an irritant will, of course, prevent the proper healing of the ulcer, and the fungus, so common in carious ulcers, will shoot up. " In other cases the pressure of the abscess having produced absorption of a portion of the alveolar process at its lower part, it effuses its contents through the aperture thus formed, and the matter insinuates itself along the surface of the lower jaw, and forms an internal tumour near its base. This tumour is at first hard and discoloured, but in the course of time it ulti- mately inflames, and bursting or being opened, leaves a pucker- ing in the integument, which, adhering to the bone, remains a permanent blemish. "When the diseased tooth, which is the cause of the mischief, is removed before external redness takes place, the tumour ultimately retires, and leaves the skin unblemished."* A spongy condition of the gums, in which they bleed freely at the slightest touch, is sometimes observed in dentition. Ulceration sometimes attends this condition. Weakened * Coleys' Diseases of Children. 178 MORBID EFFECTS OF FIRST DENTITION. digestion, and consequent imperfect preparation of chyle and insufficient nutrition, may be considered the cause of this affection. Treatment. — Inflammation of the gum may be very much abated by the application of a leech to it. In order to do this with facility, a thread may be passed by a needle through the extremity of the animal, and it then may be enclosed in a glass tube. When the inflammation has subsided, the carious tooth should be extracted. Should an abscess occur from a similar cause, extraction must also be resorted to. Sponginess and ulceration of the gums, depending upon a depraved digestion, must be met by such means as will restore the alimentary canal to the regular and complete performance of its functions. Mild astringent lotions, such as myrrhine and aluminous solutions, may be simultaneously employed. 179 CHAPTER XVI. SYMPATHETIC DISEASES OF DENTITION. A vast number of diseases have been described by different authors, as the results of dentition. The recapitulation of them would show a crowded list of formidable complaints, from which it would seem that no child could escape. Dentition appears in this exhibition as the Pandora's box from which all manner of evils are successively let loose to worry and destroy the devoted infant. Without pretending to enumerate the forms of disorder attributed to teething, I offer the following as a specimen : Vomiting, anorexia, diarrhoea, cholera, costive- ness, increased or diminished urine, urethral or vaginal dis- charge, with painful micturition ; dry cough, dyspnoea, catarrh, pneumonia, spasmodic affections of the face, limbs, glottis, &c, insomnia, agitation, and fright on awaking ; epilepsy, somno- lence, stertor, coma, transient palsy of the arms and legs, ophthalmia, hydrocephalus, marasmus, eruptions, especially about the head and face, swelling of the hands and feet, en- largement of the cervical, femoral, and mesenteric glands, and other scrofulous affections. Although any of these disorders may, and all of them do occasionally occur during dentition, it does not by any means follow that teething is the cause of them. The mucous mem- branes of children are very liable to inflammatory affections, and their brain is very liable to sympathize with these and other disorders. Moreover, the process of dentition would certainly afford an awkward complication to any of these forms of disorder occurring simultaneously with it, or provoked by accident during the progress of teething. No doubt, also, den- tition itself, especially if obstructed, or otherwise irregular or 180 SYMPATHETIC DISEASES OF DENTITION. morbid, may become the exciting cause of any disorder to which the child may at the time happen to be most prone. Should inflammatory affections of mucous membranes occur during dentition, the treatment should be regulated by the na- ture of the particular case, and the judgment of the physician. It would always be well, however, to examine the gums care- fully, and to incise them freely if they be at all swollen. This can do no harm, and sometimes will result very happily. Very often, perhaps most frequently, the mucous affections are not inflammatory, but consist in a kind of morbidly in- creased sensibility, which we call irritation. The irritability of the stomach, the vomiting and purging are frequently of this kind, and would only be aggravated by antiphlogistic treatment. Proper purgatives, especially calomel, proper food, and suf- ficient exercise, will be found to accomplish all or nearly all that art can do for the relief of such conditions. The cough which accompanies dentition is also due to the irritability of the mucous membrane, and needs no special treat- ment. The inexperienced practitioner must be careful, however, not to confound this condition with proper catarrh or pneumonia. Children are liable to severe pulmonary disorders, which re- quire the most prompt and vigorous treatment, and which it would always be serious and often fatal to neglect. The febrile disturbance, the quick, short respiration, the distended nostril, and the indescribable, yet intelligible ap- pearance of the little patient, will render mistake entirely unnecessary. The most serious complication of dentition is undoubtedly a gastro-intestinal disorder, which has acquired the name of Cholera Infantum. This disease occurs only in hot weather, and is almost pecu- liar to cities. Occasional cases of it, however, occurring in warm, unsheltered places in the country, are sufficient to show that its urban character is dependent simply upon the heat of cities, which especially at night is very much greater than is SYMPATHETIC DISEASES OF DENTITION. 181 experienced in rsral situations, unless very unfavourably cir- cumstanced. This disease seems closely connected with dentition, for although very young infants may be attacked by it, they are by no means so liable as those who have completed their first year. Hence the familiar danger of the child's "second summer." The disorder usually commences by purging ; frequently as the immediate consequence of some indigestible substance taken into the stomach, but often without any known exciting cause. The matters passed at first are light green — presenting some- what the appearance of chopped grass, and gradually becoming paler until they are of an extremely pale yellow or absolutely white. Vomiting, especially after swallowing liquids, gene- rally attends the diarrhoea, and commonly fever of a fickle fluctuating character also occurs. The child emaciates very rapidly, and in a few weeks or days will be reduced to a mere skeleton, and be too feeble to stand alone. The brain and nervous system become torpid, the muscles relaxed, the child somnolent and stupid, and death, from cerebral congestion or convulsions, closes the scene. The disease is sometimes acute and rapid in its development and progress, at other times chronic. The only medicinal agent which is uniformly beneficial in this disease is calomel. The nature of the alvine discharges evinces a deficiency or entire absence of bilious matter. A full purgative dose of calomel rarely fails to restore this secretion, and all the symp- toms are alleviated by it. From the fact that this medicine can be given in small bulk, that it is almost tasteless, and that it will remain in the sto- mach which rejects all other drugs, it is peculiarly adapted to the condition in question. As this adaptation makes it the most available, it is exceedingly fortunate that its medical qualities make it by far the most efficient of remedies in this disease. Some writers recommend it to be given in small doses, fre- quently repeated, but while there is no advantage to be gained 16 182 SYMPATHETIC DISEASES OF DENTITION. by this procedure, there is risk incurred of mercurializing the child ; which would generally be fatal to it. It is true that this rarely occurs ; but some children have a peculiar constitu- tional susceptibility to mercurial action, and it is better to risk nothing unnecessarily in this respect. The dose which experience leads me to employ, is from five to ten grains, according to the age of the child and the condi- tion of its sensibility. It may be repeated several times within a week or less, if necessary. Alkaline medicines, soda, potassa, magnesia, and chalk, are also useful in neutralizing acid, and, perhaps, also in correcting the disordered condition of the mucous membranes. A cautious yet bold use of opium, will often render service which no other treatment will afford. It quiets the stomach, soothes irritation, checks the diarrhoea, and gives refreshing sleep. The great difficulty in the treatment of this disease arises from the fact that it is the result of causes which continue to act ; so that the disorder is constantly reproduced. These causes are heat and dentition ; and it is often impos- sible to cure the child while the causes continue to act. In large, well-ventilated rooms, it is often possible, even in cities, to procure for the child a temperature which is salutary; but even under these circumstances it is not always possible to do so. When, therefore, the little patient is the child of poverty, imprisoned in the small room of a small house, shut up in a court or alley, it is almost impossible to rescue it from death. The most certain of all remedies is to take the child to the country. There proper medical treatment will rarely, or never, fail to cure the disease. Children in apparently the last de- gree of prostration are sometimes revived as by miracle, by the cool air of the country. But when we say country, we do not mean a hot room near the roof of an unshaded tavern fronting on a turnpike road, where numbers of sick children are shut up together, in a tem- perature perhaps higher than that of the spacious city man- SYMPATHETIC DISEASES OF DENTITION. 183 sions from which they have been hastily removed. Shade and green grass are essential. There must be no bare surface to reflect the heat, and there must be shade where the child may be exercised, and where it may be conveyed in the middle of the day, when country houses are as warm, and often, from their size and construction, warmer than city dwellings. Convulsions very frequently occur during dentition. They are of an epileptic character. The symptoms are a fixed stare and often distortion of the eyes, insensibility and frequent irregular contraction and expansion of the muscles, generally of the limbs and face. The jaws are firmly clenched, and the saliva is ejected in froth from the lips. This is a very frightful and generally very alarming affection, though not very often fatal. Convulsions during dentition may be excited by several causes. The first and the most common is the eating of crude and indigestible matters ; secondly, fever ; and thirdly, the irritation of the teeth themselves : often two, and sometimes all three of these causes act together. The convulsion generally passes off in a few minutes, but another will occur unless the cause be removed. Sometimes it will continue with little or no mitigation for hours, and some- times it continues until the death of the patient. In order to relieve the spasms, it is generally sufficient to put the extremi- ties in warm water and pour cold water on the head : if this do not speedily accomplish the end, more active means must be used, and such, as look to the removal of the cause. If spontaneously, or by use of the bath, the convulsion sub- sides, we should carefully inquire into the cause of it. If the child has recently eaten anything, it should be immediately vomited, and indeed this can rarely be amiss, for it is often impossible to elicit the necessary information, until the pre- sence of the ejected matters exhibits the cause of irritation. If the child have fever, it should be bled, in order to relieve the brain, which is suffering from the rapid circulation of blood through it. This may be done either by the lancet or by leeches. If the gum be swollen and tense, and the child seems to be 184 SYMPATHETIC DISEASES OF DENTITION. suffering from this cause, a free incision will often relieve the tendency to spasm, by allaying the local, and with it the cere- bral irritation. Finally, if the child be costive, its bowels should be imme- diately opened by injection, and subsequently by a purgative dose of calomel. Dr. Underwood describes a peculiar swelling of the hands and feet as a casual attendant upon dentition. He considered it, however, as rather beneficial than otherwise, as it ceased spontaneously with the appearance of the teeth. Cutaneous eruptions frequently occur during dentition, but they are of little consequence, as they spontaneously disappear, and, in some instances, may be considered as a salutary diver- sion made by nature for the relief of the brain. Sometimes, however, they are so disagreeable, that some efforts are de- manded for their relief. Most, or perhaps all of them, occur independently of dentition, and as a description of them would be tedious, and without plates, unsatisfactory, and as they are all fully described in works specially upon this subject, it will only be necessary to do little more than name them here. The curious student may seek further information from writers upon cutaneous disease. The principal varieties are, an erythematous efflorescence behind the ears, called, in medical language, intertrigo ; crusta lactea ; the several varieties of strophulus ; small phlyctense, or blisters, and evanescent red spots. Although these eruptions occur frequently during dentition, they are by no means peculiar to this period, and it is difficult to show that they are necessarily connected with the cutting of the teeth. INTERTRIGO. This is a kind of erythemic or superficial inflammation of the skin, generally attended with some exudation of a semi- purulent matter, occurring behind the ears. When the two excoriated surfaces rub upon each other, the result is fre- quently a very ugly superficial ulcer. The disease can be readily cured by the use of absorbent or "drying" powders. SYMPATHETIC DISEASES OF DENTITION. 185 All moist applications do harm. A most valuable prescription for this and similar conditions of the skin is a powder composed of two parts of lapis calaminaris, and one part of calomel, rubbed together in a mortar. This is to be freely dusted upon the sore by means of a little raw cotton, several times a day. It will rarely fail of success. There is an opinion very prevalent that it is hazardous to dry up these eruptions, but, according to my observation, there is no ground for this supposition. CRUSTA LACTEA, OR MILK CRUST (PORRIGO LARVALIS). This eruption appears with white vesicles, speedily passing into dark-coloured scabs, itching and ichorous, and frequently covering a large part of the face, head, and sometimes other parts. The eruption is very ugly and unpleasant, but is rarely in- jurious to the child. The little patient is generally plump and hearty. Indeed, the disease seems rather to depend upon a plethoric state, than upon any morbid condition of an impor- tant nature. The teething is not impeded by it. Crusta Lactea is often obstinate and of some months' dura- tion. The only serious attendant upon the disease is the itch- ing, which is sometimes so annoying to the child as to cause it to fall away, and become sallow, &c. "No treatment is required, or, rather, none does it much good. The bowels should be kept free, and the itching allayed by warm bathing, lotions of weak spirit and water, and solutions of Sul. Zinc. Where there is much discharge from beneath the scabs, the drying powder already mentioned is a good application. As a general rule, the less we do to cure this affection the better. Time will certainly restore to the child its natural skin ; medicine might, and if persevered in, would destroy its appetite, tease its stomach, enfeeble its health, and, after all, produce no effect upon the eruption, except, perhaps, to make it worse. STROPHULUS, TOOTH RASH, RED GUM. omr 16* This is an eruption very common to nursing children. It 186 SYMPATHETIC DISEASES OF DENTITION. consists of red or white and itchy papulae evolved upon the face and lower limbs, disappearing and returning, and ending generally in the throwing off of a kind of powdery desquama- tion. The papules present differences in size and appearance, which have given origin to different designations. When vividly red, prominent, scattered over the cheeks, face, arms, and dorsal aspect of the hands, and intermingled with erythematous patches of varying extent, it is called Strophulus Intertinctus (Bayer.) When the papulae are white, large, and without surrounding redness of the base, the affection is called Strophulus Candidus (Willan.) When the papulae are very thick, smaller, and confluent, Willan calls it Strophulus Confertus ; and finally, S. Volati- cus, when it occurs in circular patches, or clusters, here and there, on the surface. All those forms of strophulus may affect the child at the same time. It is not by any means a serious affection, though it some- times torments the child by the itching it causes. To allay this, we may use the cold or warm bath, purgatives, and cool dressing ; for the sufferings of the child may be very unneces- sarily aggravated by warm clothing, especially at night. The disease spontaneously declines, in a few days or weeks, leaving behind it no traces of its previous existence. Phlyctence, are vesications or blisters of different sizes, re- sembling scalds or burns. They soon disappear, and require no special treatment. There are a number of rashes seen during dentition, which it is not necessary for us to describe particularly. Scrofulous children are subject, during dentition, to the lymphatic disor- ders peculiar to their constitution, such as is manifested by the swelling of the cervical, inguinal, and mesenteric glands. The treatment of these, and kindred affections, must turn upon the means of invigoration previously referred to when considering the constitutional vice upon which they depend. Proper nutriment, exercise, clothing, &c, will do all that can be expected from external agents. SYMPATHETIC DISEASES OF DENTITION. 187 SECOND DENTITION. The cutting of the second set of teeth is commonly accom- plished without inconvenience, either of a local or constitutional character, with the exception of the wisdom teeth, which being often crowded, not unfrequently occasion a great deal of suffer- ing, such as acute local pain, inflammation of the gums and adjacent tissues, fever, violent headache, ophthalmia, &c. This suffering has often been mistaken for that accompanying other affections, such as neuralgia, intermittent fever, and rheuma- tism. Abscesses near the angle of the jaw may occur under these circumstances. Of course the treatment would be to liberate the impeded tooth by a free incision, or even, under certain conditions, to extract it. The inflammation of the soft parts must be combated, if necessary, by antiphlogistic means. THIRD DENTITION. A number of well-authenticated cases of partial and even complete dentition, occurring in very old persons, are recorded in the books. In one instance recorded in the Edinburgh Medical Com., vol. iii., the subject of this late teething suffered very severely. The patient, in this instance, was sixty years old, and en- tirely toothless. At this time he experienced very severe pain in his gums and jaws, which at length amounted to excruciat- ing torture ; but at the end of twenty-one days from the be- ginning of his sufferings, he was compensated by the appear- ance of a complete new set of teeth. With regard to the constitutional effects of this abnormal dentition, Prof. Harris, who relates two cases of this kind as having occurred under his own observation, remarks : " It would seem that the efforts made by nature for the production of a third complete set of teeth, are usually so great, that they exhaust the remaining energies of the system ; for occurrences of this kind are generally soon followed by death." 188 CHAPTER XVII. EFFECTS OF DISEASED TEETH AND GUMS UPON ADJACENT PAETS AND THE GENERAL SYSTEM. That diseased conditions of the teeth and the structures adjacent to them, do exert a most pernicious influence upon the general health, is a fact as well established as any other medical observation ; yet the medical profession are, apparently with very few exceptions, entirely unaware of it. I am not apprised that the subject is ever alluded to by lec- turers on the practice of physic, when recapitulating to their classes the causes of functional disturbance and constitutional suffering ; it is not noticed in the many text-books on practice ; and, certainly, however frequently the physician may look into the mouths of his patients, it is very rarely that his compre- hensive glance perceives anything worthy of note in the de- caying organs of mastication. It is full time that practitioners of medicine should perceive the importance of the teeth and of their diseases ; but, until they do so, it is the more important that the dentist should be able to point out the causes of obscure disease, which the phy- sician has in vain endeavoured to discover, simply because he has sought for it everywhere but in the right place. It might be granted, a priori, that if physiological conditions of the teeth, owing to their peculiar position, association, and history, may exercise powerful influence upon the. health of other organs, pathological conditions of these same teeth can- not be entirely harmless. Again, if we would examine the structure of a tooth, and perceive how completely its sensitive part is enclosed in an unyielding bony case, we might readily infer from the conse- EFFECTS OF DISEASED TEETH AND GUMS. J by quences of compression in other parts, that the swollen and inflamed pulp, &c, would be exceedingly painful. If, too, we would regard the close connexion existing between the teeth, the rapidity with which the flash of sympathetic pain darts along the nervous cords that vitalize them, and the intolerable and protracted suffering which ensues, upon even trifling irrita- tion of these sensitive filaments, and remember that pain itself is fully capable of deranging the whole economy, and inducing serious and fatal disorder, we might, without the aid of much reflection, adopt the very rational conclusion that the diseases of the teeth must be of considerable consequence to the entire organization. We might, also, with similar propriety, conclude that the teeth were not made merely for ornament, and that mastication and insalivation are something more than mere forms of introduction to the stomach ; that they are important to digestion, which is important to the entireness of organs and the performance of function, and that if mastication, and the insalivation accompanying it, be imperfectly performed, some corresponding imperfection of digestion must result. "We might also infer, from the known consequences of long-con- tinued morbid influences, however unimportant in their imme- diate action, that disturbance of digestion, constantly repeated, must, in time, develope evils of a serious character. The old pathological maxim, " ubi irritatio ibi fluxus,"* is fraught with a valuable lesson to the medical practitioner. It is true that the nervous, and to a certain degree, even the vas- cular forces hurry to the part which throws out the signal of distress, and all the floating energies of the system are directed to the relief of the suffering. If it can be readily accomplished, the equilibrium of the body is soon restored, and no perceptible inconvenience results. But if from the impracticable nature of the tissue or organ affected, but little relief can be given, and if the efforts of nature to accomplish cure or removal of the part, end only in accumulating about it an uncommon amount of sensibility, increasing the irritation and demanding * " Where there is irritation, to that part •will be the flow," 190 EFFECTS OF DISEASED TEETH AND GUMS. yet more of constitutional effort to combat it, the consequence must be such a diversion of nervous influences from other parts as to weaken their force of action, and to embarrass their functions. In short, it is easy to understand that when the first move- ment towards constitutional derangement has been made, if the cause continue to act, each accession of morbid condition must aggravate and extend the evil, and hence it is that causes in themselves very slight may, if long continued, from the influ- ence of sympathy and the accident of relations, induce morbid conditions of the most serious character. The remarks of Mr. Koecker upon this point are so sensible and so well expressed, that no apology will be necessary for introducing them here at some length. Mr. Koecker observes that, "to form a more distinct con- ception of the very powerful morbific influence which the dis- eases of the teeth and their contiguous parts must unavoidably produce upon the general constitution, it is necessary to con- sider the peculiarity of the structure and functions of these parts. " The extremely hard and dense structure of the bony parts of the teeth, and the great arterial activity and nervous irrita- bility of their lining membranes, which can so powerfully, and for so long a time, defend the teeth against general local and morbid influences, are also causes of their producing very ex- tensive morbid effects upon the whole system. The functions of the teeth as well as of the gums, when in a healthy state, act as powerful stimuli towards their preservation, but when these parts are diseased or affected with disorder of any kind, they become constant causes of irritation upon them as well as upon the general health. The bony structure of the teeth, however, having in itself but little self-restoring power, and their peculiar functions being much less favourable to this na- tural process than those of any other part of the body, and the teeth and their gums, periostea and sockets, being altogether dependent upon each other, this power is much more constantly and in a much higher degree required, and seems to be much EFFECTS OF DISEASED TEETH AND GUMS. 191 more exerted by these than by any other structures ; and the more these powerful efforts are incapable of curing the dental diseases, and resisted in their efforts to remove their causes, the more active is the constitution in its attempts to resist the progress of such diseases, whilst at the same time a conside- rable portion of general health and strength is consumed in the struggle. " Diseases in the bony structure, and indeed of the teeth and gums generally, when yet in their incipient stage and without being influenced by any other causes than the local disorder itself, produce no greater constitutional effects than other local maladies ; but with this difference, that their self-curative ac- tion is exerted in a proportion corresponding to the peculiar structure, functions, and relations of these parts, and therefore comparatively much greater and longer continued than that produced by diseases of other parts or bones. In this state they proceed very slowly, and their morbid effects can only be detected by the most minute attention. " The general system, however, in the mean time being often disturbed, the caries will be found to proceed much faster to- wards the cavity of the teeth, and the inflammation of the gums to increase. In that event, any constitutional disorder is competent to aggravate the local one, whilst the latter, also, in its turn, greatly excites and augments the former. At this period it may be still taken as a general rule, that the morbid influences of general disease upon the dental maladies are more powerful than + hose of the teeth upon the general system. " The teeth having been deprived of their vitality by the destruction of their lining membranes, are not only rendered useless, but are converted into lifeless incumbrances upon the system, which produce, by their mechanical and chemical irri- tation, an action similar to that effected by gangrene or morti- fication in other bones, by meaus of which, nature attempts to throw off the dead part. " The parts surrounding such dead teeth, viz. : gums, perios- tea, sockets and maxillary bones, are thus involved in serious disease, inflammation gradually extends over the whole of these 192 EFFECTS OF DISEASED TEETH AND GUMS. parts, and a strong effort appears to be made to effect the ex- pulsion of the decayed teeth, now become dead and offending bodies. But although nature might succeed in thus removing almost any other soft or hard part of the body of equal dimen- sions, in a few weeks or months, a space of from five to ten years, and sometimes a much longer period is required for the removal, by the same natural power, of a dead tooth. " As long as the primary diseases are principally confined to the teeth themselves, and in these instances where they are the proximate local causes of diseases of the mouth without sup- posing the existence of many dead stumps of teeth, so long may we look for those acute symptoms and effects which have been stated, and see them change alternately from one form of disease into another, but after that period, or when the local maladies having originally commenced in the gums, periostea, alveoli, and maxillary bones, shall have extended to a certain degree, a total transition into a permanent chronic state of the disease takes place. " In such a state of disease nature seems exclusively and actively engaged by producing inflammation and suppuration in extricating the mouth from all the morbid causes affecting the diseased parts, such as dead roots and stumps, tartar, and teeth which are loose or irregularly situated. The sanative power of nature being, however, very rarely competent to effect such a cure, the various diseases of the gums, periostea, alveoli, and maxillary bones are exasperated, and for the most part terminate in a state of suppuration and mortification."* When the chronic condition here described has been fairly reached in the progress of disease, the sensibility of the parts is much diminished ; the gums and periostea are thickened and callous, and the continual discharge sufficiently depletes the vessels, to relieve them of the suffering incident to inflamma- tory engorgement. All resistance to devastation of the dental arch seems to cease, and the parts are abandoned to rapid de- struction. In the mean time the patient congratulates himself * Koecker, Princ. Dental Surgery. EFFECTS OF DISEASED TEETH AND GUMS. 193 that his teeth have ceased to ache, and consequently gives himself no trouble about them. Inflammation, suppuration and caries now spread along the dental arch until every tooth is broken down and every root has become a permanent irri- tant, provoking a constant purulent discharge from the soft parts about it. The food is no longer chewed, and everything which passes through the mouth is mixed with a vitiated compound of saliva, mucus, pus, and blood, which descends to the stomach to mingle with the gastric juice, and deteriorate the quality of that most important fluid. The absorbents, too, are constantly at work, and the dis- solved fragments of carious bone, &c, are continually thrown into the current of the blood. The alveoli cannot escape the general ruin. Involved in the all-pervading inflammation, they also suppurate and break down, and not unfrequently the maxillary bones and the an- trum are also involved in disease. Dyspeptic symptoms, marasmus, cough and other pectoral symptoms, violent neuralgic affections of the face, great nervous depression, hysterics and hypochondriasis, may be expected to attend such conditions of the teeth. The dyspepsia is easily accounted for. In the first place, the food is badly prepared for the stomach ; 2d, the fluids of the mouth, constantly trickling into the stomach, impair its tone and vitiate its solvent secretion; and 3d, the continual demand made upon the system by the vain efforts which nature makes to cure the diseases of the teeth, and also by the fre- quent and severe pain, diminishes the nervous influence which the stomach receives, and impairs its powers. Every one is aware that when the stomach is full, there takes place in that organ such a concentration of nervous energy as is sensibly felt by its loss in other parts of the body. Hence the drowsiness and the indisposition to mental and physical effort experienced after a hearty meal. It is also well known that anything which attracts from the 17 194 EFFECTS OF DISEASED TEETH AND GUMS. stomach this accumulated nervous power, impairs appetite and digestion. Extraordinary emotions, powerful intellectual efforts, vene- real excesses, &c, all act in this way upon the digestive appa- ratus. Pain, also, wherever located, produces a similar effect, and the impairment from this cause will be important in pro- portion to the frequency and continuance of the suffering. In these several facts we have sufficient reasons for the indi- gestion which so frequently attends extensive diseases of the teeth. Marasmus, or gradual emaciation, is but a consequence of the insufficient nutrition attending dyspepsia. Cough and other pectoral symptoms, may result as the con- sequence of any prolonged irritation, especially if digestion be impaired. The mucous membrane of the larynx, trachea, and lungs sympathizing with similar structures, and participating in the common defect of nutrition. Neuralgic affections of the face, head, and neck, are occa- sioned by the continual irritation of the extremities of the dental nerve, and the propagation of it to the trunk and branches of the great fifth pair, or trifacial nerve. Depression of spirits, hysterics, and hypochondriasis, result from continual nervous irritation, and the debility of nerve which results from long-continued over-action. Indigestion also is a powerful cause of the melancholy or hysterical condi- tion so often observed in these cases. Epilepsy, and other affections not enumerated above, some- times occur as the result of dental irritation, as will be shown by the following cases narrated by Dr. Rush [Med. Bepos. vol. vi. 285.) Case 1. "Some time in the month of October, 1801," says Dr. Rush, "I attended Miss 0. 0. with a rheumatism in her hip joint, which yielded for a while to the several remedies for that disease. In the month of November it returned with great violence, accompanied with a severe toothache. Sus- pecting the rheumatic affection was excited by the pain in her tooth, I directed it to be extracted. The rheumatism imme- EFFECTS OF DISEASED TEETH AND GUMS. 195 cliately left her hip, and she recovered in a few days. She has continued ever since to be free from it. " Soon after this I was consulted by Mrs. T. R., who had been affected for several weeks with dyspepsia and toothache. Her tooth, though no mark of decay appeared in it, was drawn, by my advice. The next day she was relieved from her dis- tressing stomach complaints, and has continued ever since to enjoy good health. From the soundness of the external part of the tooth, and the adjoining gums, there was no reason to suspect a discharge of matter from it had produced the disease in the stomach." (Doubtless it was due to the irritation, and the consequent deviation of nervous influence to the suffering parts.) Case 2. (Dr. Rush.) " Some time in the year 1801, I was consulted by the father of a young gentlemaji in Baltimore, who had been affected with epilepsy. I inquired into the state of his teeth [an inquiry which is even yet very unusual in such cases, but which serves to show the superiority of Dr. R. in judgment and comprehensiveness of thought], and was informed that several of them in his upper jaw were very much decayed. I directed them to be extracted, and advised him afterwards to lose a few ounces of blood at any time when he felt the pre- monitory symptoms of a recurrence of his fits. He followed my advice ; in consequence of which I had lately the pleasure of hearing from his brother that he was perfectly cured.". In commenting upon these cases, Dr. Rush remarks : "I have been made happy by discovering that I have only added to the observations of other physicians in pointing out a connexion between the extraction of decayed and diseased teeth, and the cure of general disease. Several cases of the efficiency of that remedy in relieving headache and vertigo, are mentioned by Dr. Darwin. Dr. Grater relates that M. Petit, a celebrated French surgeon, had often cured intermittent fevers, which had resisted the bark for months and even years, by this prescription." (These cases must have been merely irritative fever, appearing, as it generally does, with exacerbations de- pending upon constantly recurring circumstances, such as the stimulus of light, food, exercise, &c. They were not true in- 196 EFFECTS OF DISEASED TEETH AND GUMS. termittents.) He also quotes from the work of Petit, two cases; the one of consumption (apparently), the other of ver- tigo, both of long continuance, which were suddenly cured by the extraction of two decayed teeth in the former, and of two supernumerary teeth in the latter case. "In the second number of a late work, entitled 'Bibliotheque Germanique Medico-Chirurgicale,' there is an account, by Dr. Seibold, of a young woman who had been affected for several months with, great inflammation, pain, and ulcers in her right upper and lower jaws, at the usual time of the appearance of the catamenia, which were always deficient in quantity. Upon in- specting the seats of these morbid affections, the doctor dis- covered several of the molars in both jaws to be decayed. He directed them to be drawn, in consequence of which the woman was relieved of the monthly disease in her mouth, and after- wards had a regular discharge of her catamenia. "These facts," continues Dr. Rush, "though but little at- tended to, should not surprise us, when we recollect how often the most distressing general diseases are brought on by very inconsiderable inlets of morbid excitement into the system. A small tumour concealed in the fleshy part of the leg, has been known to bring on epilepsy. A trifling wound with a splinter, or a nail, even after it has healed, has often induced a fatal teta- nus. Worms in the bowels have" produced internal dropsy of the brain, and a stone in the kidney has excited the most vio- lent commotions in every part of the system. Many hundred facts of a similar nature are to be met with in the records of medicine.* * I met with a remarkable case of this kind a year ago. A wagoner, be- tween 40 and 50 years of age, a very athletic man, had been engaged on the day previous in lifting some logs of wood, and perceived a little blood upon his finger, though no wound could be seen. Early the next morning he drove his team to the city, nine miles distant. On the road he suffered with intense pain in the finger, and when he reached the city, he was chilly, pale, and evidently labouring under great constitutional irritation. The finger showed no wound. The pain increasing, he with considerable difficulty reached home. Erysipelas appeared, and he died in a few days. The season of the year, being winter, precludes the possibility of his having been bitten by a serpent. He was not intemperate in his habits. EFFECTS OF DISEASED TEETH AND GUMS. 197 u When we consider how often the teeth, when decayed, are exposed to irritation from hot and cold drinks and aliments, from pressure, by mortification, and from the cold air, and how intimate the connexion of the mouth is with the whole system, I am disposed to believe they are often unsuspected causes of general, and particularly of nervous, diseases. When we add to the list of these diseases the morbid effects of the acrid and putrid matters which are sometimes discharged from carious teeth, or from ulcers in the gums, created by them; also the influence which both have in preventing perfect mastication, and the connexion of that animal function with good health, I cannot help thinking that our success in the treatment of all chronic diseases would be very much promoted by directing our inquiries into the state of the teeth in sick people, and by ad- vising their extraction in every case in which they are decayed. It is not necessary that they should be attended with pain, in order to produce disease ; for splinters, tumours, and other irri- tants before mentioned, often bring on disease and death, when they give no pain, and are unsuspected as causes of them. This translation of sensation and motion to parts remote from the place where impressions are made, appears in many in- stances, and seems to depend upon an original law of the ani- mal economy." Tissot, who wrote nearly a century ago, had become aware, from observation, of the great importance of diseases of the teeth to the general health. He describes toothache as result- ing from gou 1 - and rheumatism, as connected with disordered stomach, and as the result of the presence of noxious matters in the blood, which, according to the pathology of his day, was the mode of expressing what we mean by constitutional vices or disorders. He also mentions intermittent toothache, which he cured with Peruvian bark ; and neuralgic toothache, which was arrested by generous diet and wine. Modern medicine, or rather, medical writers, have retrogra- ded in some respects, however much they may congratulate themselves upon their progress in others. Microscopic soma- tology but poorly compensates for that close observation of 17* 198 EFFECTS OF DISEASED TEETH AND GUMS. living disease, upon which our fathers deservedly laid so much stress. In the Dublin Medical Free Press, I find the following case recorded: — Case 3. Painful affection of the eye cured by extracting a tooth.— Dr. Emmeuch relates a case of this kind. A man con- sulted him on account of a painful affection of one of his eyes, which had lasted fourteen years, and occasioned great suffer- ing. There was considerable vascularity of the conjunctiva and sclerotica, especially around the cornea, which structure itself was somewhat opaque and spotted. There was a con- tinual flow of tears, with pain, and intolerance of light. All these symptoms were greatly aggravated by any indiscretion in diet and the use of the slightest stimulus, such as a single glass of wine. All kinds of remedies had been tried in vain, at different times, and the affection seemed incurable. On examination of the upper jaw, Dr. E. found a carious tooth in the side corresponding to that of the affected eye. The portion of the jaw around the tooth was painful, and very sen- sitive to the touch. The patient thought the affection of the tooth had begun simultaneously with that of the eye. The tooth was drawn, and almost immediately afterwards the symp- toms relating to the eye began to subside, and soon entirely disappeared. The affection of the eye was evidently the result of sympathy between the second and third branches of the fifth pair of nerves. Dr. Kush (Med. Inq. and Observations on the Diseases of the Mind, p. 33,) observes that "Irritation, from certain foreign matters retained in irritable parts of the body, is among the causes of insanity." He adds, " I once knew some small shot which were lodged in the foot of a schoolboy, induce madness, several years after he became a man. It (insanity) has been brought on, in one instance, by decayed teeth, which were not accompanied with pain." Mr. Koecker has published a number of cases, forcibly illus- trating the effect of diseases of the teeth upon the general health. From these I select the following: — EFFECTS OF DISEASED TEETH AND GUMS. 199 Case 4. "Mrs. P., a lady of great respectability, under the medical care of Dr. Jule Rucco, of Leicester Square, had, some years since, continually suffered from dyspepsia, as "well as from various kinds of nervous attacks of a very annoying and alarming nature. This judicious physician had for a long time suspected the cause, and frequently proposed to consult me. By the wish of the lady, however, the dentist of the family was at last sent for, and three or four teeth and roots were removed, which, according to the assertion of the dental at- tendant, were all that could be extracted. The disease, how- ever, was only aggravated by this interference, and the suf- ferings of the patient increased more and more. " About six months after, the doctor again urged a meeting with me on the subject, and at last I was sent for. I found the lady labouring under a complete salivation, from an extraor- dinary sympathy of all the glands in any way connected with the teeth. On the previous night, and, indeed, for many nights preceding, she had been suffering such violent fits of convul- sion as to alarm the whole family. The face was affected with an acute erysipelatous inflammation, accompanied with head- ache, as also with considerable derangement of the digestive functions, such as sickness, vomiting, loss of appetite, &c. By examining the mouth, I found that the previous dental treatment had been very partial, and I proposed the removal of every tooth and root which produced irritation. " The lady consented immediately to my proposal, and the necessary operations were performed on the 8th of October, 1824, when nine decayed teeth, some of them mere roots, were extracted. The patient was requested to rinse her mouth frequently with a diluted astringent lotion. By this simple local treatment, and by the further medical care of Dr. Rucco, she was perfectly cured in about a week after the operation. " Very soon after her recovery, the lady was enabled to fulfil a promise of marriage which for some time had been pre- vented by her protracted and distressing disease. Since that period, she has enjoyed perfectly good health. " The farther treatment of the case has, however, been de- 200 EFFECTS OF DISEASED TEETH AND GUMS. layed, on the accomplishment of which, of course, the perma- nency of the cure will depend." Case 5. A literary gentleman in the neighbourhood of Lon- don had been for some years under the medical care of Mr. J. Derbyshire, of Greek Street, Soho, on account of a constant state of derangement of his digestion. Much sedentary occupation, and some excessive grief, had of late greatly augmented the distressing symptoms generally accompanying this cruel disorder. His disease had assumed the character of hypochondriasis. His spirits were so dejected, and the state of his bodily health was so low, that he was no longer capable of attending to his ordinary business. Having had some conversations with Mr. Derbyshire on the influence of disease of the teeth upon the general health, that gentleman was induced, at his next visit, to inquire into the state of his patient's teeth, and learning that they were in a very deplorable condition, he proposed a consultation with me on the subject. After a particular examination, I found every tooth in the patient's mouth more or less carious, or dead, and all the gums and sockets in a very diseased state. On the 27th of May, 1824, twenty-one teeth and roots were extracted, all of which were more or less in a state of putrefac- tion — three large grinders only excepted, which were either suffering from complicated caries, or producing morbid irrita- tion upon the other parts, from some other causes. The mouth was restored to perfect health in the course of about six weeks. During the progress of treatment of the dis- eases of the mouth, the general health improved very surpris- ingly; and after the restoration of perfect health to all the re- maining teeth, and their relative parts, the patient enjoyed uninterrupted good health, and returned to his ordinary pro- fessional avocations. Case 6. The following is a letter which was handed to me (Mr. Koecker) by Miss B., Manchester Street, London, in the beginning of the month of May, 1825. The history it gives is, perhaps, one of the most distressing cases of its kind, concern- ing a lady of great respectability and rank in Scotland, of EFFECTS OF DISEASED TEETH AND GUMS. 201 about thirty-eight years of age. Its contents, indeed, are not less remarkable for the manner in which they display the un- common fortitude of the unhappy sufferer, than for the strik- ing confirmation which they give of the facts which I have de- tailed, as well as the description I have given, respecting the present state of dental surgery. Considering this evidence as most useful and important, I beg to submit to the reader the whole of the fair sufferer's most interesting and affecting com- munication. "My Dear , I have been so ill since I wrote you last, that I have not been able to answer your kind letter. As I can express myself to you easier than to a stranger, I shall endeavour to give you some idea of my present state, and you can give my letter to Mr. Koecker. Constant faint gnawing pains in my gums, membrane of my mouth and cheeks, ac- companied with considerable swelling of the latter, which are always blotched, inflamed, and irritated, just in the way some people's faces are affected when suffering toothache; my very nose is swelled and inflamed, and the muscles of the under part of my face so contracted and drawn upwards, that I cannot swallow anything but liquids. My mouth is contracted and full of slimy saliva. In bed I have constant twitches in my gums, like what I could figure electricity. Sometimes my gums and face burn like fire, and sometimes feel as if every nerve and blood-vessel were filled with ice, and the sheets near my mouth are wet with saliva. All these sensations often run down behind my ears, to my neck and arms; and at these times I have a great hurry and agitation of spirits, and aching across the breast and heart. To me, one of my greatest tor- tures is the extraordinary inflation of gums, particularly to- wards the roof of my mouth. They feel as if they absolutely tore from the bone, hove up, as it were, with the wind, and my jaws feel twice too large for my mouth, the pressure against my face is such. The same sensation often proceeds to my cheek bones, which increases the swelling of the muscles and the dragging up of the under jaw. 202 EFFECTS OF DISEASED TEETH AND GUMS. " I must now go back in my history, that Mr. Koecker may know the progress of the last five years of my continued misery. But, unluckily, I fear it is impossible to make any one under- stand my sufferings, they are so various and complicated. You know I always blamed my teeth as the cause of all my suffer- ings ; but I am now convinced that the disease is in my gums and remains of the alveolar processes ; and as I was told that was a part of his profession Mr. Koecker was supposed to be very skilful in, it makes me very anxious to have his opinion. You will remember how long (many months) the sockets of my large molar teeth stood open, and even when they did heal up, the gums were full of morbid sensibility. When I last saw you, I had only about five front teeth remaining, and eight below. About 1818 they began to ache a little, and, as usual, to irritate and inflame my cheeks. The five upper ones began to spoil; but I fought on with them until the winter of 1819, when the inflammation, and the various sensations I have men- tioned before as now suffering, increasing, and the teeth them- selves aching, I had them pulled. The gums swelled and inflamed most dreadfully, the horrid sensations in the roof of my mouth increased, and my face was as bad as ever. In about a month the wounds healed, but the gums remained swelled and became a hard white gristle. After suffering for many months, I had the gums opened. They were so hard and thick, the dentist said they were like bone. The sockets were not the least absorbed ; of course, rough, and in some parts exfoliated. " The gums were kept open near a month, and caustic ap- plied to excite absorption. In the course of this process the point of a tooth was discovered in one of the sockets, and ex- tracted. It w T as a full-grown eye-tooth, which, for want of room, had never made its way down. I was easier as long as the gums were open ; but just where I was, when they healed up and resumed their state. " Some months after this, my under jaw became affected ; the teeth were not spoiled, but became- so painful to the touch, that I could bear nothing in my mouth to touch them. My EFFECTS OF DISEASED TEETH AND GUMS. 203 lips became very tremulous, and my hands trembled so that I could neither feed nor dress myself. "When warm in bed they ceased; but from the moment I rose and began to speak, or let the air into my mouth, I never ceased trembling, and the dry retchings (which you remember how tortured I used to be with) increased so as to bring on vomiting. I suffered in this way for eleven weeks, when, in despair, I had all my remaining teeth pulled. The tremblings and retchings quickly abated, and in a few weeks completely left me, and I have never had them since. My under gums, even before the teeth were pulled, were a hard gristle, and almost as white as the teeth. My gums have been often opened to give me relief, but as nothing will induce them to suppurate, I get no advantage, the wound- ing only increasing the hardness. "These gums seem to me to act as levers, pressing on the nerves and blood-vessels, and keeping up a constant irritation and inflammation in my mouth and face. " Under an idea that my complaint proceeded from neural- gia, I was advised to have the mental nerves divided at the chin, which did no good, and has created such hard tumours on these places, that I think their pressure on the side of the jaw is the cause of the twitching pain of my under lip, and the contraction of the muscles. "I would take it as a great favour if Mr. Koecker would say whether he thinks he could be of any use to me here, until I am able (which, alas ! I fear I am not) to come to London ; or if he could give me any advice which I might desire to be done here ; and if he will be so very good as to mention what are the different kinds of diseases he has ever met with in the gums or alveolar processes, and his mode of treatment. There seems to be an idea here that if the sockets are not carious, there can be no disease there ; but I think Fox mentions other- wise. "My upper gums had not been touched for four years, until a week ago, when a part was opened that was very trouble- some, and much swelled. The bone was full of points and inequalities, and rough ; sounding gritty, like sand. There 204 EFFECTS OF DISEASED TEETH AND GUMS. was a great deal of thick slime, like the white of egg, mixed with blood. Some nitrous acid was put upon the wound, to try to keep it open a little, but in vain. It is already covered with a new gum, and the old thick parts gaping open. I am sure if these old swelled gums could be got away, I should suffer less. " I should think there is about the eighth of an inch of the socket remaining. The ridge of the under jaw is as sharp as a knife, and so painful to the touch, when I press it, that it makes my face, ears, and neck burn. My lips are painful, and are drawn in. I was advised to try false teeth, but they in- creased my sufferings ten-fold, which is very hard, as the clinching of my jaws adds much to my sufferings. My eyes are beginning to be much affected, which must plead my apology to Mr. Koecker for this sad scrawl, which I think you will need to help him to decipher. "There are various opinions about my complaint. One says it is a nervous complaint at the origin of the nerves, affecting the extremities of these nerves ; others say it is a nervous affection of the dental nerves and their ramifications on the face ; and others are of opinion it is an affection of the cover- ing of the bone. I am satisfied it is some disease of the an- trum. Could it injure me to have the antrum opened to ease my mind ? There is one place where I think there is part of a fang of a tooth, which I am certain was broken, as the den- tist burnt the tooth without letting me see it ; perhaps that may torment me." Mr. Koecker gives no opinion upon this case ; but the lady seems to me to have had more discernment than her profes- sional advisers. The disease was probably seated in the an- trum, and very likely the fragment of fang was the irritating cause. The following cases are reported by Dr. C. A. Harris : — Case 7. " In September, 1830, I was consulted by Mr. — , at that time a resident of New York. Before I examined his teeth, he informed me that his general health had been EFFECTS OF DISEASED TEETH AXD GUMS. 205 very bad for four or five years past, and that he had applied to some of the most eminent physicians of New York, Troy, and Albany, but had not obtained any permanent relief from his sufferings. "The character of the symptoms that prevailed at this time was very peculiar. His digestive organs were so much de- ranged, that he was obliged to observe the strictest regimen, and confine himself to the simplest kind of vegetable food. Besides the dyspeptic affection with which he was troubled, he had severe paroxysms of headache and vomiting, that recurred at regular intervals of from four to five weeks. These were always preceded by numbness, which commenced in his tongue and extended thence throughout the whole system. This sen- sation continued usually for about two hours, when it was suc- ceeded by a violent pain in the head and partial vertigo, from which, in about ten hours, he was relieved by vomiting. The effects of these paroxysms lasted about ten days, and the other symptoms had continued, without much mitigation, for three years. "On examining his mouth, I gave it as my opinion that the diseased state of his teeth was the cause of his affliction. This idea, though entirely novel to him, he was disposed to believe correct, and therefore readily consented to the treatment I prescribed. Many of his teeth were much decayed, and nearly all of them covered with tartar. The roots of some were de- nuded of the gums, the alveolar processes more or less absorbed, the gums turge^cent, fungoid, bleeding on the slightest touch, and of a dark red colour. The secretions of the mouth were viscid, and their exhalations exceedingly offensive. " Such of his teeth as could not be perfectly restored were extracted, and as much tartar was taken away as could be con- veniently removed at one time, and the rest at subsequent sit- tings. His gums were freely scarified, and a tonic astringent and detergent wash was directed to be used three or four times every day. Under this treatment the local affection of the mouth rapidly disappeared, and in about four or five weeks his teeth and gums became perfectly healthy. His general health 18 206 EFFECTS OF DISEASED TEETH AND GUMS. also began to improve, and in about two months it was perfectly restored, and has so continued." Case 8, communicated hy Dr. Harris. " In February, 1851, W. S., of Virginia, aged about 45, called on me for advice in relation to a tumour in the roof of his mouth, which had been first perceived fifteen months previously, during which time there had been an occasional dripping of purulent matter be- hind the velum palati. On inquiring into the history of the case, I learned, that about two or three weeks previous to the occurrence of the tumour, he had an attack of toothache. The pain was felt in the first nght superior molar, but had subsided before the formation of the tumour, leaving the tooth somewhat sensitive and sore to the touch and slightly elongated. As it caused him but little inconvenience, having some years before lost the tooth in the lower jaw with which the diseased upper molar antagonized, it was not suspected to have any connexion with the disease of the palate, although the swelling had fre- quently extended down the side of the alveolar border opposite the palatine root. " Having ascertained these facts, I had but little difficulty in tracing the origin of the disease to the alveolus of the palatine root of the tooth in question : the tooth being necrosed. " The extraction of the tooth confirmed the correctness of my suspicions. In three clays the tumour of the palate disappeared, and the trickling of pus ceased." It might be curious to inquire, what would have been the opinion given of this case, and the treatment pursued, by some able sur- geons to whom the effects of diseased teeth upon the adjacent structures had never been a subject of inquiry or observation. As the tooth did not ache, and had not ached for some time before the appearance of the tumour, it probably would have never been suspected of any agency in the matter. Had its necrosed and elongated condition been observed, it would natu- rally have been attributed to the pressure of the tumour upon the alveolus. The probabilities are very small, that any but a dentist or a surgeon more than commonly attentive to the teeth, would have perceived the patient's condition, or relieved EFFECTS OF DISEASED TEETH AND GUMS. 207 it. Very probably lie would have been subjected to painful and worse than useless attempts at cure, until the disease, so simple and so manageable, might have become far more serious and intractable. As a general rule, in all local inflammations, tumours, &c, of the parts adjacent to the teeth, the latter are to be suspected as the cause ; and, until thorough observation and careful consideration have determined the contrary, we should not look elsewhere for the origin of the evil. Proba- bly, in nine cases out of ten, our first suspicions will prove to be correct. Dr. S , a distinguished surgeon and physician of Virginia, reports the two cases following : Case 9. "Mrs. S — — , a lady of thirty or thirty-five years of age, with several children, in easy circumstances, rather delicate and of sedentary habits, complained of derangement in the functions of the digestive organs, with much nervous disorder, and a painful sensation about the head, as if there were a pound weight on the top of it, with an occasional tight- ening of the scalp. This last sensation, she compared to that which might be expected from having the scalp forcibly drawn together on the vertex by the clawing of some animal with talons, as a hawk. Her friends, at first, thought but little of her complaints, and from their eccentricity were inclined to believe them, for the most part, imaginary. The affection of the head, however, and the sensitiveness of the nervous system, evidently increased, until they became so harassing and acute, that they deprived her of rest, and made manifest inroads upon her healthful appearance. " Medical advice having been now obtained, a regular and carefully- directed course of purgatives was prescribed, but with little or no advantage. The cathartics having been discon- tinued, the Rub. Ferri, Bark, Valerian, Mineral Acids, Zinc, Assafcetida, &c, were next tried, to which were added frictions and tepid salt baths, but still without any material amendment. " She now began to have evident exacerbations of fever towards evening, which passed off with copious and debilitating sweats, that much reduced her, and caused her countenance to 208 EFFECTS OF DISEASED TEETH AND GUMS. assume a sickly aspect. She visited the watering-places in Virginia, but though her strength was somewhat recruited, the distressing symptoms, with some slight modifications, still con- tinued. She was occasionally confined to the house, but gene- rally was able to take some slight exercise in the open air. " This state of things had continued for eighteen months, when the attention of her physician was called to an abscess formed near the root of one of her incisor teeth. This brought about an inquiry into the general state of the teeth, of which the following is the result : " Mrs. S , at an early period had bad teeth, which, since her marriage, had been gradually growing worse. A few years before the time of which I speak, two of the incisors of the upper jaw were clipped off close to the sockets, and artificial teeth were inserted on the fangs. Much pain, irritation, and swelling of the gums and lips followed the operation, and similar symptoms occasionally occurred for a year or two afterwards, and were frequently attended with alveolar abscesses. The remaining incisors of the upper jaw, and several of the inferior and superior molar teeth, were found to be in a dilapidated state. The alveolar processes of several of the inferior molars were partially destroyed, and one or two of their roots were turned on one side, and clung to the alveoli by the remaining integuments. " The situation of the mouth rendered it quite probable that the ill health of the patient arose from the irritation produced by the bad state of her teeth ; the more so, as her nervous system was exceedingly sensitive. She was persuaded to have the carious incisors and the worst of the molars removed ; and, a short time after this was done, her health began to improve. The affection of the head and scalp soon ceased, the nervous symptoms vanished, and she is now in good health, and has a set of teeth decidedly more ornamental than those given her by nature ever were. The speedy restoration of her health after the removal of her diseased teeth, justifies the conclusion that her bad health depended on the bad state in which these organs were found." EFFECTS OF DISEASED TEETH AND GUMS. 209 The following case, related by the same gentleman, is parti- cularly worthy of attention, as showing the terrible conse- quences which may result from ignorance of the effects which disease of the teeth, or even of a single tooth, is capable of producing in subjects of certain constitutions : Case 10. " Miss W , a maiden lady of about fifty years of age, in comfortable circumstances, and for the most part sedentary of habit, had suffered much from pain in the right cheek. For some time it was not considered of much moment, but, on its continuance, a physician was consulted. " He found but a single tooth, one of the second molars, in the superior maxillary of the affected side, and that was in a semi-decayed state. The gums above the teeth, and for half an inch on each side of it, were much swollen and of a livid redness. The tumour seemed spongoid and puffy to the touch, but there was neither fluctuation nor abscess. The patient's health had not sensibly deteriorated. She said the tumour on the gums had existed for many weeks, but had not been at- tended with any remarkable pain, until the occurrence of that of which she complained. She described it as being deep in the cheek, and generally dull, but now and then, for an instant, sharp and lancinating. She said the tooth, for several years past, had been accustomed to ache occasionally, but that, not- withstanding its decayed state, it was very useful, and she had therefore declined having it extracted. " The immediate extraction of the tooth was, however, thought advisable, and with her consent, it was effected. A week afterwards the spongy tumour of the gum continued, with- out any abatement of the pain in the cheek. The tumour was now laid open with a lancet. It contained no matter, but was filled with those shaggy or shreddy fungi, which are often seen to occupy tumours or diseased bones. An abscess, or some other affection of the antrum, was suspected. A perforation was therefore made in its cavity, and about a table-spoonful of very dark brown matter discharged, which gave the silver spoon into which it was received a thin coat of the blackest pigment, and, on account of its offensive smell, was almost insupportable. 18* 210 EFFECTS OF DISEASED TEETH AND GUMS. There was a difficulty in reaching the disease with remedies, and it was thought advisable to enlarge the communication with the antrum. The crown of a small trephine was accord- ingly applied to the alveolar portion of the superior maxillary, the soft parts having been first dissected up, and a correspond- ing portion of the bone was removed. The end of the little finger could now be introduced into the antrum, the inner sur- face of which, it was easy to perceive, had, at several points, been denuded of the pituitary membrane and of the periosteum. " The disease was now fairly exposed, and nothing could ex- ceed the offensiveness of its fetor when not corrected by suitable dressings. The usual antiseptics and detergents were locally applied, while ionics and a generous diet were prescribed to sustain the patient's general health, and every effort was made to substitute a healthy purulent secretion for the ill-conditioned and offensive discharge from the antrum, but without any effect. "An irremediable necrosis seemed to have taken possession of the superior maxillary of the affected side, which soon began to come away by piecemeal. In the mean time the soft parts about it were laid waste by the phagedenic character of the ulceration, and the eye of the same side became seriously af- fected. The disease now progressed rapidly. The perforation of the antrum was made on the 11th of March, 1821, and on the 26th of May following, the patient was found in a perfect state of apoplexy, the disease having penetrated the basis of the cranium and seized upon the brain itself. On the 30th of the same month she expired, and was thus released, by death, from the most horrible disease that can be conceived, but which had its origin in nothing more extraordinary than a neglected carious tooth." PHTHISIS PULMONALIS INDUCED BY DENTAL IRRITATION. Dr. M , an eminent practitioner of this State, reports the following extraordinary case : Case 11. " In the summer of 1834, 1 was called to visit Mr. D. M , who had come into this neighbourhood to obtain EFFECTS OF DISEASED TEETH AND GUMS. 211 the benefit of the country air, having resided in Baltimore from his earliest youth. When I saw him he was in the last stage of phthisis pulmonalis. He gave me the following history of his case : "About eight years previous he felt a soreness and tumefac- tion in his gum at the posterior part of his mouth, and as he had never cut the dentes sapientise, he thought the disquietude was occasioned by the progress of one of these teeth, and in consequence gave it no attention until the soreness and inflam- mation had extended themselves over the whole surface of his mouth and fauces. The tooth not having protruded through the gum, he consulted his family physician, who advised imme- diate extraction. " In conformity with this advice, he called on an eminent dentist of Baltimore, but the tooth not having presented itself and the cause of his suffering being doubted, the operation was deferred. His sufferings, however, having become intole- rable, and the irritation having extended itself to the lungs, producing considerable uneasiness, he determined, if it were at all possible, to have the tooth removed. A few days after, he stated his determination to the dentist. The gum was freely split, and after considerable pain and difficulty, the tooth ex- tracted. The inflammation in his mouth and fauces immedi- ately subsided, his appetite returned, and his general health soon became as good as formerly. Ci About three years subsequent to this, his mouth and fau- ces, under similar circumstances, and from the same cause, became very sore and painful. The inflammation soon reached the lungs, and established a confirmed phthisis pulmonalis. He died a few weeks after my first visit." The subject of this case was doubtless the victim of tubercu- lar disease of the lungs. The tubercles were latent until the dental irritation was propagated to them, when inflammation and softening rapidly ensued. The teeth, though they did not, strictly speaking, cause the consumption, evidently precipitated it, and perhaps anticipated the fatal development by many years. The same physician, to whom we are indebted for the 212 EFFECTS OF DISEASED TEETH AND GUMS. preceding case, has recorded another, in which the fatal result was more directly attributable to dental suffering. He says : Case 12. "My friend, Dr. L , of Frederick, Md., was called to visit a young gentleman who laboured under violent pain of the face and inferior maxillary, with very great tume- faction of the gums. His sufferings were traced to the roots of one of his molar teeth, which had been broken in an attempt to extract it. His gums and the glands of his throat became so much enlarged, that it was impossible to remove the offend- ing portion of the tooth. The inflammation, notwithstanding the skilful exertions of the physician, rapidly increased, high and intractable fever supervened, deglutition became totally obstructed, and, in a few days, he died." Case 13. A case very similar to the last, though more for- tunate in its results, came within my knowledge lately. A dentist was applied to to extract a molar tooth, which he did. He told the patient that the tooth had come out entire; and dismissed him. Violent inflammation ensued, a large abscess formed, and the life of the man was brought into imminent jeopardy. His physician called in a surgeon, and both being baffled, an eminent dentist was consulted. He suspected that a fragment of the root had been left, and after great difficulty, owing to the swelling of the parts, he succeeded in extracting it, and saving the life of the patient. Dr. Fitch, in his "System of Dental Surgery," narrates a number of cases of constitutional disease, evidently caused by the protracted irritation incident to diseased conditions of the teeth and gums, from which I select the following : — Case 14. "In February, 1827, Dr. SamuelJackson called and requested me to see Mrs. R , living in Tenth above Walnut Street, who, he said, was labouring under every symp- tom of confirmed phthisis pulmonalis, and also appeared to suffer greatly from a diseased state of. her mouth. I, accord- ingly, called on Mrs. R . The following were her symp- toms : great emaciation, hectic fever, almost constant cough, nearly a total loss of voice, articulation being extremely diffi- cult, the voice as if speaking through a trumpet. Dr. Jackson EFFECTS OF DISEASED TEETH AND GUMS. 213 said that in the practice of seven years in the hospital, alms- house, and private practice, he had never seen a person re- cover from the symptoms under which Mrs. R laboured. " The following was the condition of Mrs. R 's mouth. About two years before she had the upper wisdom-tooth of the left side plugged, and the ping was pounded in by a mallet and punch. The fangs of the tooth converged together so as to form a fang of a conical shape. In hammering in the plug the socket was much injured. A chronic inflammation took place, which passed back over the palate, half arches, and some distance down the oesophagus, also over the glottis, epi- glottis, and larynx. It then travelled forwards on the right side of the under jaw, and caused to inflame and slough away all the sockets and teeth of the lower jaw but one, which was the left dens sapientias. When I first saw Mrs. R , the process of inflammation, sloughing, and gangrene was at its height. Extensive exfoliations of the jaw were taking place. Dr. Jackson and myself concluded that the patient could not live more than four weeks. " Treatment. I at once removed all the teeth that were loose, and whose sockets were in a state of gangrene and ex- foliation. I likewise, as fast as possible, removed all the dead bone, and directed the patient to wash her mouth constantly with a strong infusion of powdered galls. In about eighteen days her mouth was perfectly well. The amendment of her general health was surprisingly rapid. In five weeks she was able to take lo:ig walks in the street, and in six months she was restored to perfect health. Nearly six years have passed away, and she still continues perfectly well." As a corollary to this case, Dr. Fitch very properly ob- serves: "I think we may safely infer, although diseased teeth do not, in every instance, excite general diseases of the sys- tem and of the lungs, yet, like an insidious enemy, they are ever ready to unite with or exasperate other causes, so as finally to undermine the powers of the system. I would ear- nestly solicit the attention of the medical faculty in general to a critical inquiry into the state of the teeth in all cases of pul- 214 EFFECTS OF DISEASED TEETH AND GUMS. monary affection ; and there is hardly a doubt that their in- quiries would result in the general conclusion that a diseased state of the teeth and gums does very frequently excite pulmo- nary affections, especially in persons predisposed to them, and always aggravates these complaints, let them be excited by whatever cause they may." Professor Chapman, of the University of Pennsylvania, in his lectures related the following case : — • Case 15. " Some years since a lady came from a distant part of the country to this city, in pursuit of medical aid, and placed herself under the care of Dr. Chapman. He found her labouring under every symptom of obstinate dyspepsia, by which her health and strength were greatly impaired. His correct and well-known acumen in the pathology of disease immedi- ately led him to inquire into the state of her gums and teeth. He found her gums in a high state of inflammation, and many of her teeth loose and diseased. By the direction of Dr. Chapman she applied to one of our most respectable dentists, and had her mouth and teeth placed in a healthy condition, and with the return of health in her teeth, gums, &c, every dyspeptic symptom left her, and she became quite well. " After some time had elapsed, and the lady's health seemed confirmed, she had a few artificial teeth placed in her mouth to supply some which she had lost, which, either from not being well adapted and properly inserted in her mouth, or from some peculiarity in the lady's constitution, proved a source of irrita- tion, and brought on a return of the distressing dyspeptic symp- toms, which compelled her to dispense entirely with the artifi- cial teeth, when her health was again completely restored." The celebrated Baglivi observes, that " Persons whose teeth are in an unclean and viscid state, though daily washed, have universally a weak stomach, bad digestion, and offensive breath, headache after meals, generally bad health and low spirits. If engaged in business or study they are irritable and impatient, and are often seized with dizziness. From weakness of the stomach they are naturally somnolent, scarcely wakeful in the morning, and never satisfied with sleep." EFFECTS OE DISEASED TEETH AND GUMS. 215 Hufeland enumerates sound teeth among the signs of long life. "For good digestion," he says, " good teeth are ex- tremely necessary, and one, therefore, may consider them among the essential properties requisite for long life : and in two points of view — First, good and strong teeth are always a sign of a sound, strong constitution, and good juices. Those who lose their teeth early, have, in a certain measure, taken possession of the other world, with a part of their bodies. Secondly, the teeth are a great help to digestion, and, conse- quently, to restoration." Mr. Liston observes:* "From the presence of carious teeth, or decayed portions of teeth, many evils, both local and general, ensue, besides inflammation and abscess. They are frequently the cause, and the sole cause, of violent and con- tinued headaches ; of glandular swellings in the neck, terminat- ing in, or combined with, abscess ; of enlargement and inflam- mation of the tonsils, either chronic or acute; of ulcerations of the tongue and lips, often assuming a malignant action from continued irritation; of painful feelings in the face, tic-doulou- reux, pains in the tongue, jaws, &c; of disordered stomach from affection of the nerves, or from imperfect mastication ; of continued constitutional irritation, which may give rise to seri- ous diseases." Case 16. (Dr. Fitch.) "Mrs. S , aged about 38 years, was sent to me, by one of our most eminent physicians, with a request that I would examine her teeth, and perform such ope- rations upon them as I judged proper, to render them and the gums healthy. The state of this lady's health was miserable ; she was harrassed by the most distressing symptoms of dys- pepsia. Her digestion was very imperfect, the stomach irri- tated, loss of appetite, and a most melancholy depression of spirits. When she first called it was necessary for her to re- pose herself for some time, before she could have her mouth examined. " Upon examining her teeth and gums, I found nearly all the former in a state of disease, and the latter were in a state of * Liston's Surgery. 216 EFFECTS OF DISEASED TEETH AND GUMS. suppuration, much inflamed and swollen. A considerable de- posit of tartar was formed around the necks of the teeth ; in several instances their fangs were denuded of the gum by the deposit of tartar, and, in fine, her mouth was in a general state of disease. I need not detail the several operations by which her mouth and teeth were rendered healthy. Suffice it to say, that in about four weeks her mouth was perfectly well. The amendment of the general health, after the first operations were performed on her teeth, was also surprising, and would have been entirely so to any person not acquainted with the immense sympathy between the mouth, gums, &c, and the stomach. " Within five weeks after I saw her, every vestige of disease in her digestive organs left her, and she was apparently in per- fect health." Case IT. Neuralgia from diseased teeth. — (Prof. Harris.) "The following is one of the many cases of tic-douloureux or neuralgia faciei, produced by disordered teeth, that have come under my own observation. " The subject of it was a lady about forty years, of sedentary habits, and naturally of rather a nervous temperament. For several years she had been afflicted at times with a most dis- tressing and painful affection of her face, which was pronounced by her physician to be tic-douloureux. The pain was some- times so acute and lancinating that it almost deprived her of reason. It generally commenced near or a little anterior to the angle of the superior maxillary bone, thence it darted across the face to the alee of the nose, and then to the temple, forehead, and angle of the eye, accompanied with frequent and sudden transitions from one side to the other, twitching and tremors of the muscles of the affected parts, and with a preter- natural flow of saliva. Her face, and sometimes the whole of her head, were rendered so sore by these paroxysms, that the slightest touch would produce pain. "These paroxysms, although they were generally of short duration, frequently recurred as often as ten or fifteen times in twenty-four hours, and sometimes lasted ten, sixteen, and even EFFECTS OF DISEASED TEETH AND GUMS. 217 twenty clays, after which they would gradually subside, having subjected her during their continuance to the greatest misery, and leaving after their subsidence a dull, heavy pain in one or faoth jaws. A sensation similar to this was always (especially in the right side of the upper jaw) experienced several days before one of these attacks, which often enabled her physician to ward them off, and finally led to- the detection of their cause. These spasms were more severe and occurred more frequently in cold, damp, and wet than in warm and dry wea- ther. "Bark, quinine, carb. ferri, stramonium, belladonna, and various other tonics and antispasmodics were prescribed, but without any apparent beneficial effect. Leeching, sinapisms, and epispastics were also of no avail. As a last resort, it was determined to divide the affected nerve ; but before the opera- tion the physician was induced by the pain in the jaws, always preceding these paroxysms, to examine the condition of the patient's teeth. The examination showed them to be in a very unhealthy state. The molares generally, and especially those on the right side, were involved in complicated caries. The gums were much tumefied and inflamed, and very sensitive. "Her teeth and gums, from the diseased condition in which they were found, were immediately supposed to have some agency in producing the affection of the face. A consultation with me was therefore proposed, and I was requested to. visit her. " On examining her teeth, I found that eleven were so much decayed as to render their restoration impracticable. It was therefore determined to remove them immediately, but it was not thought proper, owing to her extreme debility and the state of her nervous system, that more than two or three should be extracted at one time. "So great was her agitation at the mere thought of the ope- ration, that notwithstanding the agony she suffered, she could not, on my first visit, be persuaded to have even a single tooth extracted, but requested me to call on the next day, when she 19 218 EFFECTS OF DISEASED TEETH AND GUMS. promised she would submit to the removal of as many as she possibly could. " I accordingly called on the following day, and to the as- tonishment of her friends, she allowed all her jaw teeth that were carious, eleven in number, to be at once extracted. The operation at once revealed the cause of her disease. The roots of three of these teeth were very much enlarged by bony depo- sitions. One of the fangs, was, at its extremity, about the size of a pea. Those of the other two were not quite so large, but a disposition to exostosis was manifested by all. With the re- moval of these teeth, all symptoms of pain entirely vanished, nor have they, to my knowledge, returned since." Case 18. Death caused by the extraction of a tooth. — (Jour- dain.) "A citizen having submitted to the extraction of a tooth, the gums became gangrenous; the gangrene reached the brain and caused death." The same author reports a case of Case 19. " Convulsions and death caused by the shortening of a tooth longer than the others. A nun of Padua having had a tooth shortened in order to get rid of the deformity, died im- mediately in an epileptic convulsion. A small fragment of nerve was discovered in the section of the tooth." This case and others, which fortunately have not terminated so seriously, should be a warning to all operators upon the teeth, not to inflict sudden and violent pangs. Experience shows us that a great amount of pain can be endured, if slowly and gradually inflicted, while instinct teaches us all to dread sudden pangs, even of more moderate intensity. Even in ex- tracting a tooth, it is better to operate gradually rather than wrench it out with a sudden and violent effort. If pain be gradually inflicted, the nervous system, conscious of the coming trial, summons up all its powers of endurance ; but when taken by surprise, the shock is severely felt and the consequences may even be fatal, as in the case just quoted. Pain is a great evil. It should never be inflicted unneces- sarily, and when necessity occurs, the inflictor should use all possible means to render the suffering as tolerable as possible. Moreover, there is great difference in individuals as to the EFFECTS OF DISEASED TEETH AND GUMS. 219 tolerance of pain ; even as to the perception of it. Many per- sons will suffer terribly from -operations which would not cause serious pain to others. The same persons will suffer much more at one time than another. All these considerations are well worthy the attention of the dentist. Very severe headache of the neuralgic kind, is frequently caused by diseases of the teeth and the irritation produced by the pressure of dead roots in the jaw. In illustration of this, I will quote a few from many cases : Case 20. " Inveterate headache cured by the extraction of many roots of carious teeth. — (Fabricius Hildanus.) A lady was afflicted with a very severe continued pain in the left side of her head. The violence of the pain was chiefly experienced in cold, damp weather. By the advice of her physicians, she had tried a great many remedies, internal and external, but without suc- cess. Finally, I was called to see her. I carefully examined all the causes of her malady. I learned from her that for six months she was afflicted with an agonizing pain in the teeth of the left jaw. After this, the pain somewhat abated, but left a similar one in the corresponding side of the head. I conjec- tured from that the headache was caused by the roots of dead teeth. Upon examining the upper jaw, I found four carious teeth whose roots were deeply planted. I advised her to have them extracted, to which she cheerfully consented. I then purged her freely and applied cups to her neck and shoulders, and directed an aposeme to be taken during four days in the morning. On the fifth, while fasting, I extirpated the roots." After other treatment of a kind then in vogue, but of no utility, the lady recovered. Case 21, Headache dependent upon the teeth. — (M. Petit.) "The late Princess of Conde* recommended to her physicians one of her protegees, to be cured of a headache of five years' duration. She had been bled twenty times, and finally M. Petit was requested to bleed her in the throat. This surgeon having examined the patient, was led from her complaint of a pain and weight in the lower jaw, to look into her mouth. He found some irregularity in the teeth, and upon close inspection 220 EFFECTS OF DISEASED TEETH AND GUMS. ascertained that the patient had an unnatural number of them, there being eighteen in the lower' jaw. The second molar on each side appearing to be most crowded, he took them out, and in twenty-four hours the lady was cured of a headache of five years' continuance." Case 22. Ophthalmia and loss of an eye by abscess upon the teeth. — (Fab. Hil.) "A lady of Cologne was for a long time tormented with inflammation upon the last molar of the left side, which was carious. By the advice of physicians, she was frequently purged, and cupped between the shoulders, but as she refused to have the tooth extracted, the continued irrita- tion of the gums occasioned inflammation of the eye on the same side, which finally destroyed the sight." Case 23. Ear-ache cured by extracting a tooth. — (Jour- dain.) " A lady had long suffered with severe pain in the right ear. All the ordinary remedies were used without effect At length she was asked if she had any carious teeth. She replied that she had not : that all her teeth were good and never gave her any inconvenience. Nevertheless, her mouth was carefully examined. At first sight all seemed right, but a close inspection showed external caries of the dens sapientiae. As the pain of the ear extended to the angle of the jaw, and even a little along its base, I persuaded the lady to permit me to extract this tooth, which I suspected to be the real cause of the mischief. Three days afterwards, the lady was perfectly and permanently relieved." A similar case is reported by Mr. Koecker. Dr. Darwin relates several cases of serious disorder produced in adjacent parts and in the general system by diseased teeth. The following are very remarkable : Case 24. "Mrs. , about thirty years of age, was seized with great pain about the middle of the right parietal bone, which had continued a whole day before I saw her, and was so violent as to threaten convulsions. Not being able to detect a decaying tooth or tender one, by examination with my eye or by striking them with a teaspoon, and fearing bad con- sequences from her tendency to convulsions, I advised her to EFFECTS OF DISEASED TEETH AND GUMS. 221 permit the extraction of the last tooth of the under jaw on the affected side, which was done without any good effect. She was then directed to lose blood and to take a brisk cathartic, and after that had operated, about sixty drops of laudanum were given her, with large doses of bark, by which the pain was removed. "In about a fortnight she took a cathartic by ill advice, and the pain returned with greater violence in the same place, and before I could arrive, she suffered a paralytic stroke, which affected her limbs and her face on one side, and relieved the pain of her head. "About a year afterwards I was again called to see her on account of a pain as violent as before, exactly on the same part of the other parietal bone. On examining the mouth, I found the second molaris of the under jaw, on the side before affected, was now decayed, and concluded that this tooth had occasioned the stroke of the palsy, by the pain and consequent irritation it had caused. On this account I earnestly entreated her to allow the sound molaris of the same jaw, opposite to the decayed one, to be extracted ; which was forthwith done, and the pain of her head immediately ceased." Case 25. (Darwin.) Since the above was first published, I have seen two case which were very similar, and seemed much to confirm the above theory of sympathetic hemicrania, being, perhaps, always owing to the sympathy of the mem- branes about the cranium with those about diseased teeth. "Lord M. snd Mr. B., of Edinburgh, both of them about the middle of life, were afflicted with violent hemicrania for about two years ; in the beginning of which time, they both assured me that their teeth were perfectly sound, but on in- specting their mouths I found all the molares were now so de- cayed as to have lost their crowns. After having suffered pain for sixteen or eighteen months, almost incessantly, in different parts of their heads, they had each a hemiplegia, from which they gradually recovered as much as paralytic affections gene- rally do recover. All the stumps of their teeth, which were useless, were directed to be extracted, as the swallowing so 19* 222 EFFECTS OF DISEASED TEETH AND GUMS. much putrid matter from decaying bones, seemed to injure their digestion." Sir Henry Halford, in a paper on tic-douloureux, read before the College of Physicians, related the following cases which came under his own observation : — Case 26. " A lady, forty years of age, suffered under the violent form of tic-douloureux, at Brighton, notwithstanding the careful attention and skill of a very judicious physician there. On returning to town, it was observed that the rending spasms, by which the disease is marked, were frequently preceded by an uneasiness in one particular tooth, which exhibited, how- ever, no signs of unsoundness ; but the constancy of this symp- tom was enough to justify the extraction of the tooth in this instance ; and on its being drawn, a large exostosis was ob- served at the root of the tooth, and the lady never suffered more than very slight attacks, and these very seldom, after- wards." Case 27. (Sir Henry Halford.) "The late Earl of C. un- derwent martyrdom by this disease, and excited the warmest sympathy of his friends by the agonies he sustained for many years. He submitted to the operation for the division of seve- ral branches of the fifth pair of nerves repeatedly, by Sir Everard Home and Mr. Charles Bell, without obtaining more than temporary relief. At length he was seized with apoplexy, and lay insensible for some days, and in great peril, from the attack, but finally recovered. After the apoplexy the parox- ysms of tic-douloureux became less frequent and less severe, and were administered to satisfactorily by an ingenious physi- cian, who wrote his inaugural exercise on the disease. For the last year or two of his life, his lordship ceased to suffer from the tic-douloureux, and died at an advanced age, without any marked malady. While I attended him he underwent repeated exfoliations of the alveolar process of the teeth, which I thought occasioned his torment." Doubtless, the exfoliations being completed, and the disease of those parts removed, the irritation ceased, and the patient recovered. It is melancholy to think of the protracted suffer- EFFECTS OF DISEASED TEETH AND GUMS. 223 ing which rendered the life of this unfortunate nobleman wretched and comparatively useless, and which might probably have been cured with little difficulty, if such men as Sir Eve- rard Home and Mr. Charles Bell had been aware of the sym- pathetic disorder which may be, and often is, produced by diseased teeth. These eminent gentlemen not only did no good, but they inflicted great additional pain on their unhappy patient ; but, doubtless, he would have fared little better in other hands, for the profession, while searching with powerful microscopes for causes of disease, entirely overlook the teeth, though reason and experience, the demonstrations of the ana- tomist, and the voices of the most discerning of the masters in medicine, are continually pointing them to the important sympathies of these organs. From its relation to the teeth of the upper jaw, the fangs of which frequently perforate its floor, the antrum is often the seat of disease of a serious and sometimes fatal character, resulting from irritation produced by diseased conditions of these highly sensitive organs. Indeed, the teeth are directly or indirectly concerned in most of the diseases of the antrum. Boyer, Deschamps, Harris, and most others who have written upon this subject, give united testimony to this fact. Dr. Harris, in the second edition of his valuable work on Dental Surgery, records several cases in evidence of the facility with which diseased teeth may propagate disorder to the antrum, and the formidable diseases which may result therefrom. I select the following : — Case 28. (Dr. Harris.) "Mrs. L., at twenty-seven or twenty-eight years, of a scrofulous habit, had been at times affected, for more than two years, with a deep-seated pain in the right side of her face, midway between the orbit and the alveolar ridge, and on closing the left nostril, and making a violent expiration through the right, discharged a slightly, yet perceptibly fetid mucous matter, which occasionally excoriated the mucous membrane lining this cavity of the nose. The pain, from the fact that it was most severe in cold and damp weather, was thought to be rheumatic. General and local 224 EFFECTS OF DISEASED TEETH AND GUMS. bleeding, fomentations, mustard plasters, purgatives, anodynes, tonics, and many other remedies, had been employed in vain. "A severe paroxysm of toothache, about this time, more than two years since she first felt the deep-seated pain in her cheek, induced her to apply to me. "On examining her mouth, the crowns of the second molar, dens sapientise, and first bicuspis of the affected side, were found to be destroyed by caries ; the gums, covering the sockets of their roots, were inflamed and very sensitive. It was the roots of the wisdom or third molar tooth that ached. Extrac- tion being the only remedy that held out the least prospect of relief, I at once proposed the operation, and, at the same time, urged upon her the importance of having the roots of the second molar and first bicuspid removed. A great deal of per- suasion was necessary to obtain her consent, she being of an exceedingly nervous and timid disposition; but, having made up her mind to submit, she determined to have the operation performed immediately. She had no cause to regret it ; for not only was she freed from the annoyance which the roots had occasioned to her tongue, gums, &c, but the operation was also followed by a speedy subsidence of the pain in the cheek, and a cessation of the fetid discharge from the nose." Case 29. (Dr. Harris.) "In December, 1841, I was con- sulted by Mr. S. M. J , twenty-three years of age. He had been affected for several months with a dull heavy pain, which, as he said, seemed to be seated deep in his right cheek ; and as in the case last described, a fetid mucous matter was dis- charged from the nostril of the affected side, on making a violent expiration, though it, with the other nasal cavity, closed. His teeth, to all appearance, were perfectly sound ; but his gums, around the first and second bicuspides and first molar, were inflamed, spongy, and slightly ulcerated between their edges and the necks of the teeth, from which they had separated, to the edge of the alveoli. This condition he at- tributed to a blow which he had received by a fall, upon these teeth, about two years before. It was immediately followed by pain, inflammation, and, in about two months, the exfolia- EFFECTS OF DISEASED TEETH AND GUMS. 225 tion of several small portions of the alveolar processes, which came out through the gum. These were the only unpleasant effects which he experienced at the time, but afterwards there was always a slight soreness in the teeth that had received the injury. This gradually extended higher and higher into the substance of the jaw, until about four months previously to his calling upon me, when its place seemed to be taken by the kind of pain first described, and soon after, the fetid discharge from the nostril was discovered. " That the deep-seated pain in the right superior maxillary was occasioned by inflammation of the mucous membrane which lined the sinus, I could not doubt ; and that this had resulted from the alveolar irritation caused by the violence that had been inflicted upon the bicuspides and first molaris, to me, was equally evident. I therefore proposed the extraction of the teeth, to which he consented. Three weeks afterwards the pain in his jaw had entirely disappeared." Case 30. (Dr. Shepherd.) Neuralgia vs. Toothache. — " Neuralgia has become a very fashionable disease now-a-days, and many persons suffer long and severely, and ransack the whole materia medica in search of remedies ; and finally an examination of the teeth is thought of, the very first thing that should have been done. In nine cases out of ten of supposed neuralgia, the extraction of some badly-decayed tooth, which the suffering individual knows ought to have been out more than a year ago, perhaps, would cause a subsidence of all symptoms of neuralgia. " As a prominent example of the above, I am induced to re- port the following case :— Miss C. W., a resident of this town, of delicate constitution, was attacked with severe pain in the right side of the head, neck and shoulder, about twelve months ago; and from the severity of the pain, and other circum- stances attending it, she came to the conclusion that it was neu- ralgia; and by concurrence with her medical adviser, her opinion was confirmed. She used, therefore, all possible remedies for that disease, without success. In the mean time her attacks were growing more frequent and more severe ; and for the last 226 EFFECTS OF DISEASED TEETH AND GUMS. two or three months, they occurred daily at precisely five o'clock in the afternoon, and continued with the most intense severity until midnight ; when the pain would begin gradually to subside, growing less and less until she was perfectly easy. These daily attacks came on with such perfect regularity that, to use her own words, 'five o'clock was a terror to her before it came.' At this stage of the disease she was in Baltimore, whether in search of medical advice or not, I do not know; but while there she consulted Dr. B., an eminent physician of that city ; and he advised her to have her teeth examined, in- timating that they might be involved; he gave her, at the same time, a prescription for neuralgia, to be used in case the teeth were not at fault. With this advice she returned home, and sent for me, and related to me substantially what I have stated above. I examined her teeth, and found the inferior wisdom- tooth of the right side decayed to the nerve, and I gave it as my opinion that all her i neuralgia' originated there ; I there- fore advised its immediate extraction, to which she assented. The first day after the tooth was extracted she had very little pain, the next still less, and the third none at all. " Thus a perfect cure was effected, of what perhaps nine- teen out of twenty of our very best physicians would have pro- nounced neuralgia, without once thinking of the teeth, by the simple extraction of a bad tooth. "I do not offer the above as a case of rare occurrence; I have often met with such in the course of my dental practice, as doubtless dentists in general have ; and I cannot account for the fact, that physicians so generally prescribe for neural- gia, without once thinking of the teeth, when there is so strik- ing a similarity to true neuralgia in many cases of toothache. In the case above, there were some striking peculiarities, which would have been, perhaps, sufficient to screen the most vigilant from the charge of superficiality in . the examination of his patients, though he might have forgotten the teeth. The dura- tion, the regular increase of pain, the extent to which the sys- tem was affected, and when the attacks became daily, the per- fect uniformity as to the time of commencement, together with EFFECTS OF DISEASED TEETH AND GUMS. 227 the nervous temperament of the subject, were all circumstances well calculated to mislead the judgment ; and yet this proved to be a case of toothache, a fact which might have been proved just as easily in its very commencement, if an examination of the teeth had been once thought of as a matter of any consequence." The cases above mentioned are but a few of a great number that might be collected, showing the importance of the teeth, in their healthy and unhealthy conditions, to the well-being of the whole economy. Surely those here presented will be suf- ficient to arouse the physician to the necessity of regarding the agency of these organs in the production and continuance of diseases, and to impress the dentist with the importance of pursuing his vocation, not as a mere mechanical craft to be ex- ercised upon isolated excrescences of the body, but as a part of curative science, embracing in its relations, the knowledge of diseased life as manifested by many organs, or by them all. The general surgeon must be more than a mere cutter of flesh or setter of bones; the obstetrician more than a man midwife; and the dentist is unworthy of the confidence or respect of the community who is not well-informed upon the nature and his- tory of disease, and the part which the organs upon which he operates perform in its causation, or modification. It is strange that physicians have paid so little attention to this subject. It would be less so, if so many of the ablest writers among them had not so earnestly and repeatedly pro- claimed the importance of giving to the teeth their due con- sideration in the diagnosis of disease. But when Hunter, Rush, Darwin, Halford, Chapman, and other such men, have taken special pains to direct the attention of the profession to the subject, it is unaccountable that their voices have been alto- gether unheeded. Unfortunately, it has now become the fashion to study patho- logy in the corpse-house, rather than by the bed-side ; to make microscopical inquisitions of disease upon the dead, rather than to observe its phenomena in the living. From the very neces- sity of the case this necrological research falls into the hands 228 EFFECTS OF DISEASED TEETH AND GUMS. of the young and inexperienced, and these become writers and teachers before they have been to the only sure school of medi- cine, the chamber of the sick. As the teeth may be seen by the naked eye, they are not likely to be considered of much importance. Had they been discernible only by the micro- scope, they doubtless would have received due consideration. It is said that the celebrated Pennant, by use of the micro- scope, lost the use of his eyes. I fear that this is too com- monly the fate of his successors. I fully coincide with Dr. Fitch, who well remarks: "We are not to contemn the diseases of the teeth because they seem insignificant. Many persons are formed of a fibre so fragile, as to be broken by the slightest shock ; of a stamina so deli- cate, as to be affected by the slightest impression. Disease in its steps at first is, as it were, soft and hesitating, weak in its powers, and slow in its progress. But every instance of in- dulgence, and each succeeding advantage gained, confirms its step, increases its powers, and hastens its progress, and what but a moment ago seemed a thing too insignificant to mention, now rises a monster that derides human effort, and whose sting is the arrow of death. "Almost inappreciable are the beginnings of many fatal dis- eases ; and could the grave reveal its secrets, I have not a doubt, when I consider the number of diseases produced by diseased teeth, that it would be found that thousands are there, in whom the first fatal impulse was given by a diseased state of these organs ; and could I raise my voice so as to be heard by every medical man in America, I would say to them, attend to your patients' teeth, and if they are diseased, direct such remedies as shall restore them to health ; and if in health, such means as will keep them so." 229 CHAPTER XVIII. WOUNDS OF THE MOUTH AND FACE. The face, with, all the organs which enter into its structure, is exposed to the several forms of injury which are known by the common name of wound. Surrounded as the human body is by a great number of sub- stances denser and more resistant than itself, it is liable to have its tissues separated, penetrated, torn, violently compressed, or broken asunder. Consisting, also, of a number of ele- ments constituting organized parts, and held in union by the mysterious force of vitality, it is also liable to have this union dissolved by the action of forces more powerful than life, and to be chemically disintegrated. As the face from the necessity of the case must be uncovered, and as from its position it is most liable to be injured by falls or reached by malicious blows, it is more frequently wounded than any other part of the body; and owing to the deformity which attends scarring of the countenance as well as the im- portance of the organs connected with it, facial wounds require more nicety in their management than any others. The mouth is very frequently involved in these injuries, and the teeth are often displaced or fractured by them. The mani- pulations required for the reparation of these wounds require a dexterity only to be acquired by daily observation of the teeth in their natural positions, and the habit of handling and operating upon them. The dentist, if believed skilful, is there- fore often called upon, even by the general surgeon, to aid in the management of such cases. In medical language, a wound is a recent lesion or interrup- 20 230 WOUNDS OF THE MOUTH AND FACE. tion of the continuity of parts from an external cause ; but the term is made to include all hurts received from agents acting mechanically or chemically upon the surface of the body. Wounds differ materially from one another, in kind, extent, position, and character of the parts wounded. When the parts are merely divided by a clean, sharp instru- ment, with as little injury to the separated tissues as possible, the wound is called a Simple Incision — {simple incised wound). If the parts be rudely torn asunder, the injury is called a Laceration — (lacerated wound). If the part be violently and suddenly compressed, so as to rupture some of the small ves- sels and break or otherwise injure the muscular fibre, skin, &c, the injury is called a Contusion, or Bruise — (contused wound). If a pointed instrument be forced into the body, penetrating tissues, it causes a Puncture — (punctured wound). If a bone be broken, the wound is called a Fracture. Injuries from bodies propelled by gunpowder are called Gfun-shot ivounds, and from fire, Burns. To these may be added Poisoned ivounds, or those in which a slight puncture or trivial laceration becomes the means of introducing venomous matter into the system; such wounds are inflicted by certain insects, serpents, and rabid animals. Simple Incised wounds are, per se, the least serious of all injuries, though from the flow of blood which attends them, they are generally the most alarming. In these cases the parts are simply separated, of course not without injury at the immediate line of division, but without any which suspends the vital action of the separated surfaces, or breaks up their relation, so as to render readaptation diffi- cult. Of course these wounds may be of the most serious nature, or immediately fatal, if large vessels be divided or vital func- tions interrupted by them. In these cases the danger is not from the nature of the wound, but from the accident of its seat. Commonly the most alarming and most dangerous complica- tion of incised wounds, is the bleeding or hemorrhage which WOUNDS OF THE MOUTH AND FACE. 231 attends them. This will be greater or less, according to the size and character 'of blood-vessels divided, the form of the in- cision, and the vascular activity, &c, of the patient. A wound of this character may be attended by venous or arterial hemorrhage. A slight incision will commonly be attended by a gush of dark- coloured blood from the superficial veins. This flows freely for some minutes, but if the wounded part be not officiously bathed, and especially if it be bound up, the hemorrhage soon ceases, and does not again return. Sometimes the gush is so considerable as to cause the pa- tient to faint, or, in medical language, to induce syncope.* In this condition the patient has temporarily lost his conscious- ness, his skin has become cold, and his pulse ceased to be per- ceptible. This state, though apparently very dangerous, is by no means so, unless the patient has previously been much exhausted. On the contrary, it is salutary ; for it checks the hemorrhage, and affords time for the permanent closure of the wound in the way to be described presently. As the syncope depends upon the want of circulation through the brain, the patient should be placed in a recumbent position with his head low. If fainting be feared in any case, this is the best position and the best means to prevent it. The arrest of venous hemorrhage depends upon the singular and most important quality possessed by the blood to solidify or coagulate when exposed to the air. Without such a provi- sion, the slightest wounds would be very troublesome, and often fatal. As soon as a coagulum forms about the orifice of the wounded vessel, the bleeding ceases, and the current of blood, finding no longer an artificial egress, pursues its natural course. It is evident that if the flow of blood be very great, or if the wound be very large, the coagulum will be longer in forming a sufficient barrier to the hemorrhage. For the blood must be * Syncope, ivyHmris — I fall down. 232 WOUNDS OF THE MOUTH AND FACE. at rest before it can coagulate, and the amount which, under these circumstances, will be arrested by the edges of the wound, etc., and detained until coagulation, will bear but a small proportion to the current, and will be constantly washed away by it. It is in such cases that fainting is sure to occur, and by this means the flow being stopped, the blood at the moment filling the wound is arrested and coagulates before the action of the heart is recovered. Sometimes, however, it happens that small veins will bleed obstinately and profusely ; owing to the peculiar irritation of the wounded part or the indisposition of the blood to coagulate. It is evident that compression of the lips of a wounded vessel so as to obstruct its channel, is the readiest way to stop the hemorrhage, and that as the flow of blood in the veins is to- wards the heart, the pressure should, when these vessels are wounded, be especially upon the distal extremity of the wound. Inasmuch, however, as the veins anastomose* freely, pressure must be exerted upon both sides of the wound. As soon as the flow of blood through the vessel is arrested, the blood begins to coagulate at the point where it is impeded, and in a little while a plug of coagulum effectually stops each end of the divided vein. It is never necessary to tie a vein, unless it be of the largest size, and the operation is always very dangerous. Arteries may be tied with impunity ; but the veins, when thus treated, are very apt to develope an inflammation of their lining mem- brane (phlebitisf) which is rapidly propagated to the heart, and is generally fatal. Styptics,J of many kinds, have been employed more or less for ages, for the stay of hemorrhage. These are astringent substances which corrugate the animal fibre, thus contracting the orifice of the wound, or articles of a * Anastomose — communicate by a number of mouths ; from Ava, and ^2, a stench. DISEASES OF THE ANTRUM OR MAXILLARY SIXUS. 327 fetor to caries of the bones. They are, therefore, more com- mon in syphilitic and scrofulous subjects. The breath of persons afflicted with ozsena is often so offen- sive as to render them almost intolerable to others, and the consciousness of the disgust which their presence occasions, is naturally a source of continual mortification and distress. Where the ulcer can be perceived and reached, it should be touched with the nitrate of silver, and the application repeated until cure is effected. When no direct application can be made through the natural openings, as must be the case when the sore is seated in the antrum, an opening must be made as be- fore directed, and a solution of nitrate of silver injected, if the caustic cannot be immediately applied to the part. If the patient be tainted with syphilitic disease, no local re- medy can be effectual. He must be placed at once under proper constitutional treatment, and this must be persevered in until the vice is eradicated. In case of scrofula, the same remark applies. Local remedies, however, are not by any means to be neglected. They may very much hasten the cure, and per- haps may render effectual constitutional means which other- wise may be impotent. Every expedient should be tried before leaving the patient to suffer the distress and serious inconveniences attendant upon such a disgusting disease. POLYPI AHS OTHER TUMOURS. Polypi are tumours of various consistencies and rapid growth, which appear in several cavities of the body which are lined by mucous membranes, but are most common in the nose, uterus, and maxillary sinus. They also occur, occasionally, in the rectum and vagina. They occur much more frequently in the nose than elsewhere, and next to the nose, in the uterus. The tumour growing into all the irregular cavities of the nasal fossa, &c, has sometimes an irregular form, which from a fancied resemblance to the animal of the same name, has ori- ginated its designation. Several varieties of polypoid tumours are described by wri- 328 DISEASES OP THE ANTRUM OR MAXILLARY SINUS. ters. ' Mr. Pott thought one class of them always malignant, and another benign. The one like carcinoma being painful, causing constitutional irritation through morbid processes de- veloped within itself, and tending to convert adjacent tissues into its own morbid structure, the other not painful, not caus- ing any suffering, local or constitutional, except indirectly by producing pressure upon other parts or filling up cavities which are necessary to be kept open. In short, he considered that one class of polypi, the benign, are inconvenient or even fatal, merely by mechanical action ; while the other, or malignant class, though equally troublesome by their pressure and ob- struction which they cause, are per se pathologically dangerous to the health and life. Deschamps describes four varieties, which he calls vascular fungus, mucous lymphatic, scirrhous, and sarcomatous. Dr. Warren classifies polypi as membranous, fibrous, and vas- cular. The latter, he says, is rare. Jourdain recognised three kinds — one loose, pale, indolent, and benign, also called vesi- cular polypus ; another, hard, unyielding, livid, and painful, marked with veins, and often hideous ; and a third, fleshy, elongated, and easily stretched. Samuel Cooper observes, " Some polyi are red, soft, and sen- sitive, but free from pain, and exactly like a piece of healthy flesh. When this kind of polypus is of a softer consistence, semi-transparent, and of a pale, yellowish colour, in conse- quence of being less vascular, it is called the gelatinous poly- pus, and usually arises from the mucous membrane of the side of the antrum, or the middle of the cavity of the nostril be- tween the upper and lower turbinated bone. No doubt car- cinomatous tumours in the antrum have occasionally been con- founded with polypi, but there is no good reason for believing, as some have asserted, that true polypi never originate in that cavity. Many eminent surgeons have testified to having met with true antral polypi. When a polypus of the benign kind occurs in the antrum, it may escape detection until it has completely filled the cavity DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 329 and begun to push its way into the nose and distend the walls of the sinus. A tumour of the malignant kind might be suspected from the ' pain seated in it, and when enlarged sufficiently to press upon the bones, the twofold suffering produced by pressing and be- ing pressed must cause greatly aggravated distress. The me- chanical consequences of the continued pressure soon show themselves. The cheek swells, or rather is pushed out, the palate and alveolar ridge are depressed ; the molar teeth are loosened, the gums become inflamed and spongy, the floor of the orbit is elevated ; fistulous openings are often formed through which sanious pus percolates, or the matter finds its way through the opening into the nose, and at length the tumour, pushing through the floor of the antrum, appears in the mouth, or forc- ing its way through one or both of the distended nasal open- ings is seen in one or both of the nostrils. Of course, the parts subjected to this pressure and disrup- tion, become diseased, and inflammation, suppuration, ulcera- tion, caries, and necrosis, may all be added to the list of secon- dary diseases incident to polypus. The causes of polypus are not satisfactorily ascertained. Probably they require some constitutional predisposition to render the parts where they ap- pear capable of producing them, and when the susceptibility exists, any irritation may be the exciting cause of the morbid growth. It is certain that diseased teeth and fangs must be regarded as the most common of the existing causes of polypus in the antrum. The following cases from Jourdain are in point : "In 1772, I had occasion to visit a shoemaker, living in the Faubourg St. Marcel, who had for some years had a kind of ex- ostosis of the right superior maxillary. The tumour was as large as a medium sized apple, displaced the nose, deranged the palate, and threw the eye upward against the superciliary ridge, permitting the lids to open but slightly. The sinus had three fistulous openings : one below the malar process, a second near the bicuspids, and a third near the inner canthus of the 28* 330 DISEASES OF THE ANTEUM OR MAXILLARY SINUS. eye. In none was there any discoloration of the skin, and al- ternately, from the two first, there was discharged an acrid reddish humour. Most of the teeth of the affected side were lost ; those which remained were sound, but much displaced by the tumour. The right nostril was obstructed by a polypus of a scirrhous hardness. In sounding the sinus through the fistu- lous openings, the instrument came in contact with fleshy masses in that cavity, some hard, some soft, giving out, when wounded, a bloody discharge, resembling wine lees. The na- sal wall of the sinus was destroyed, but the maxillary bone was not softened. " The disease seems to have had its origin in repeated attacks of alveolar abscess, the consequence of bad teeth, which usu- ally terminated in fistula. Gradually the bone began to swell, and the nostril to become obstructed, till his appearance was much as I have described. Had I been suffered to operate, I would have removed all the teeth, good and bad, involved in the tumour, and then making a crucial incision through the cheek, would have exposed the bone, which, from its extreme thinness in this case, I might hope readily to remove. I would then have removed the exposed tumours from the antrum, by knife, cautery, or both combined, as occasion might suggest ; looking carefully to the condition of the bone, and seeking, after the operation, to establish a healthy suppuration in the part. Case II. — Polypus in the Right Sinus. — In 1773, a lady, whose right cheek had been swollen and singularly hard for nearly two years, applied to me. " The tumour was the result of successive inflammatory at- tacks of the first bicuspis and three molars of that side, only the fangs of which remained, and these were covered by a poly- pous tumour that had distended and softened the outer plate of the maxillary bone. " I first made an incision down to the alveolar sockets, and after the arrest of the hemorrhage, removed the roots, twelve in number, each having at their extremity a morbid growth, showing that here was the chief cause of the disease. Their DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 331 removal caused considerable hemorrhage. I examined the wound on the next day, and found that the bulk of the tumour lay between the plate of the maxillary bone, diminishing up- wards, and terminating at the orbit. "Between the cheek and gums were two fistulous openings, which discharged a dark, fetid humour. The diseased state of the bones decided me to remove the tumour by two vertical in- cisions through them. This space permitted me to introduce my finger into the sinus. Its membrane was swollen, and there was yet a portion of the tumour attached to the orbital plate. This, from its propinquity to the eye, I feared to cauterize with the hot iron, and therefore used spirit of vitriol, with a small quantity of corrosive sublimate dissolved in it [nitrate of silver would be much better], being careful to employ dry dress- ings, that the escharotic might not, by spreading, cause injury to the surrounding parts. " After eighteen clays' use of the same, a healthy appearance of the membrane was induced, suppuration established, and at the close of the fourth month, after some slight exfoliation of bone, the patient was restored." With regard to the treatment of antral polypi, it resolves itself simply into making an opening into the sinus, and re- moving the tumour. Unfortunately, many of these morbid growths recur after re- moval, and grow with more rapidity than at first, and therefore it is necessary to destroy the mucous membrane upon which they are seated, so as perfectly to eradicate the disease. For this purpose, the old surgeons used the actual cautery freely. Probably the free application of lunar caustic would accomplish all that could be expected from the heated iron. It is often impossible to apply either so completely as to remove every particle of the diseased product ; and if the tumour be a result of constitutional pravity, we, for the most part, gain little by the operation. Dr. C. A. Harris thinks that in cases of malignant tumours seated in the antrum, the application of the white hot iron is indispensable to safety. 332 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. In remarking upon the bold practice of the French surgeons in the treatment of these affections, Mr. Thomas Bell com- mends their mode of procedure as worthy of praise and imita- tion, and expresses himself very severely against the timidity of English surgeons who have shrunk from the use of the actual cautery, and have left the patient to die with a linger- ing and painful disease, without any attempt at relief. Certainly, as life is rendered intolerable, and death inevita- ble, by these tumours, 'we are justified in using any means which may promise relief. I have already (chap, xxii.), de- scribed a malignant fungous tumour which occasionally makes its appearance in the antrum. When the disease is of the ma- lignant character, a cure cannot be expected. The mode of amputating the superior maxillary, as described by Mr. Liston, has also been given in chap. xxii. INSECTS IN THE CAVITY. The human body has many parasites inhabiting its various tissues. More than a score of these have been described. Some infest the intestinal canal, others are found in the heart and large arteries ; some dwell in the muscular, others in the cellu- lar tissue ; some prefer the liver, others the kidneys, and some the sinuses of the head. The mode by which these creatures are produced, has long been a subject of curious inquiry, but it is not necessary for me to discuss the subject. It is enough to know that they exist within the body, and often prove troublesome inmates. That the larvae of insects do find their way into the maxillary sinus, is proved by abundant evidence. In the Memoirs of the Academy of Surgery, vol. v. p. 233, as quoted by Deschamps, it is recorded, that in the course of a disease of the maxillary sinus, there issued, from day to day, a considerable number of whitish worms, two or three lines long, some of which were living. The same author relates two instances in which long round worms were found in the maxil- lary sinus. The most singular case of the kind is reported by Mr. Hey- DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 333 sham, a medical practitioner of Carlisle, and may be found in Cooper's Surgical Dictionary. In this case, the patient was a strong woman of sixty, who was for many years subject to acute pain in the antrum, extending over one side of the head. These pains never entirely ceased, but were more severe in winter than in summer, and were always subject to frequent periodical exacerbations. The patient had tried anodynes without advantage, and had submitted to a mercurial course, by which her sufferings were aggravated. All her teeth on the affected side had been drawn. At length it was determined to open the antrum, though there was nothing to indicate abscess or any other disease in this cavity. In four days no benefit had resulted from the operation. Bark injections and the elixir of aloes were thrown into the sinus. On the fifth day a dead insect was extracted by means of forceps. It was more than an inch long, and thicker than a common quill. The patient now experienced relief for several hours ; but the pains afterwards returned with the former severity. Oil was then injected, and two other insects similar to the former were extracted. No others appeared, and the wound closed. She was much relieved for several months, when the pains returned worse than ever, and were particularly com- plained of in the frontal sinus. We are not informed of further treatment. Should worms be found in the cavity, they must be destroyed by the injection of oil, or other liquids likely to effect the pur- pose. 334 CHAPTER XXIV. DISEASES OF THE PALATE. The palate is often incomplete through congenital defect. It is frequently the seat of disease, which destroys its soft parts, and even its bones. As the palate forms the vault or roof of the mouth, separat- ing it from the nasal cavities, and furnishing a most important part of the organ of voice and mastication, its diseases and de- ficiencies are of great consequence, exceedingly impairing the comfort and usefulness of the subject of them. Congenital defects of the palate may differ very much in ex- tent. Generally the deficiency is found along the median line, sometimes involving only the soft, sometimes also the bony structures. At times the fissure extends from the lips entirely along the median line of the roof of the mouth, presenting the appearance of the two lateral halves of the body not being united at this point. Congenital defects, however, are not always so regular. Er- rors of formation may occasion an increase of the concavity of the arch, forcing the alveolar ridges too far apart, and produc- ing deformity in the dental range. Sometimes, from an oppo- site condition "of things, the alveolar borders may be brought more than usually close together. The teeth may be imper- fectly developed, and their texture less dense than usual. Mr. Stearns makes three classes of congenital fissure of the palate. The first class embraces all the cases in which the fis- sure extends through the velum, palate, and maxillary bones, to the alveolar border, 'and sometimes through the whole extent of the median symphysis. This is usually complicated with hare-lip. DISEASES OF THE PALATE. 335 In the second class, the bones of the palate are apparently entire, though the cavity of the arch may be somewhat greater than usual, and the fissure extend a short distance into their posterior margins. In this case, the lesion is almost wholly confined to the velum palati. The third class embraces those cases in which the fissure is confined to the soft parts, extending, perhaps, only a short way up into the uvula. This form of fissure is, probably, less fre- quently met with than either of the preceding.* When the palate is defective, the voice is impaired, and the impairment is in proportion to the extent of the lesion. Some- times it is almost entirely destroyed by the inability of the pa- tient to utter distinct sounds. Nothing can be more distress- ing than this calamitous injury to the organs of speech, which combines the distress arising from the consciousness of ludi- crous appearance with the inconvenience of difficult and imper- fect articulation. Interference with the voice is not the only evil attending de- fects of the palate. Mastication and deglutition are also im- peded. Food, notwithstanding the patient's careful or instinc- tive efforts, will find its way into the nose, causing great unpleasantness, and depriving the unfortunate subject of the deformity of much of the pleasure of eating, which, after all that has been said and written in its disparagement, is unques- tionably the most universally prized of all sensual gratifications. When the deficiency is congenital, the young infant finds difficulty in nursing, but generally, with that preservative in- stinct which is given to the little helpless creatures, in such perfection as to supply abundantly all lack of experience in such matters, the child generally contrives to manage its de- fective organs so w T ell as to obviate much of the inconvenience naturally attending the deformity. Instead of taking the nip- ple between the upper surface of the tongue and superior gum, &c, the infant places the tongue on the nipple, and presses it against the lower gum, closing the palatine fissure with the tongue, as with an obturator.f * Harris's Dictionary of Dental Science. f Delabarre. 336 DISEASES OF THE PALATE. The mechanism of nursing is perfected as the child advances in life ; dexterity of course increasing with the constant use of the parts, until such a proficiency is acquired that solids are masticated, and speech is as far as possible performed. The mechanism of mastication as performed in such cases is thus described by Delabarre. When the food is chewed, the aliment is conveyed between the tongue and movable floor, which serves for a point d'appui to it, and then it is brought back between the teeth. Thus it is that the complicated operation of masti- cation and deglutition is performed without the alimentary mor- sel getting into the nose, or if this does sometimes happen, it is the result of accident. When perforations of the palatine arch occur in mature life through the agency of disease, the patient is in a much more unfortunate case than the subject of congenital deformity. The latter, gradually habituated to the performance of mastica- tion and deglutition, with his imperfect organs, accomplishes these functions, if not well, yet with comparative comfort, while the former having been habituated to use the tongue differently, is not capable of adopting the mode of procedure applicable to his new condition, and consequently is continually passing his food and drink into the nose. If the teeth be not properly coapted, another source of difficulty and vexation is added, as the introduction of the food is thus rendered very troublesome. If the velum and uvula be defective or wanting, deglutition is exceedingly difficult, as the alimentary matters, instead of passing comfortably along the pharynx, are, to a greater or less degree, forced into the posterior nares. This is the case whether the lesion be congenital or accidental. Sometimes deglutition can only be effected by throwing back the head as far as possible and casting the food into the pharynx. The inconvenience of imperfect speech is as serious as that of incomplete or difficult mastication and deglutition. Mr. Stearns says, that perforation or fissure of the palate may render the articulation of some of the letters impossible, and at the same time vitiate the character of all the others. The indistinctness of utterance is usually proportioned to the DISEASES OF THE PALATE. 337 extent of the lesion. Thus, when the fissure extends as far as the alveolar processes, the patient loses several of the letters, which another, with only a portion of the soft palate involved, is able to produce with considerable distinctness. In cases of fissure, particularly those of the more extensive kind, the move- ments of the tongue are comparatively limited, as the patient is instinctively aware that the very effort he should make in order to give letters their appropriate articulation, often serves to render the impediment more painful. So far, indeed, is this inactivity of the organs sometimes persisted in, that speech be- comes little else than the emission of a succession of vowel sounds, which, in lieu of receiving proper consonant adjuncts, are only made intelligible by the accompanying inflection, key, gesticulation, and expression of countenance, all of which are, more or less, the vehicles of thought.* With the limited action of the tongue, nearly all the muscles concerned in the forma- tion of articulate sounds, in a greater or less degree, participate, while the muscles about the nose, as the compressor nasi and depressor nasi are violently contracted, for the purpose of clos- ing the nostrils and preventing the escape of the sound. This gives a particularly disagreeable aspect to the features. The most common cause of lesions of the palate is syphilis. This terrible disorder, when once it becomes constitutional, pro- duces a number of strange local affections, differing very much from one another, all of them distressing, and some of them dangerous, and not unfrequently fatal. Beginning as a local affection, usually a primary sore, syphilis may gradually poison the whole circulating fluids, and cause defects of nutrition and alterations of tissue in various parts of the body. The manner of effects produced by secondary syphilis, differs very much in different persons, as it is influenced by a variety of determining or modelling circumstances. Eruptions upon * Observations on Congenital Fissure of the Palate, with some remarks on Articulation and Impediments of Speech, by Charles TV. Stearns, Esq,. Sur- geon, London. 29 338 DISEASES OF THE PALATE. the surface, local inflammations, ulcers, augmentation and loss of parts, may all be occasioned by the penetrating and potent virus. The soft parts about the throat are particularly apt to be the seat of constitutional syphilitic ulcers, and the bones of the palate are very frequently perforated or wasted by venereal caries. It is very necessary, however, to be aware that palatine ul- cerations, caries, and necrosis may occur from other than a venereal cause. It would be terrible indeed to add the cruel suspicion of such a malady to the sufferings of a patient whose disease, having no affinity to lues, should claim sym- pathy instead of begetting contempt and disgust. We must, therefore, be very careful to make no mistakes in matters of such delicacy. Moreover, the treatment of these affections must depend upon the accuracy of the diagnosis, and that which would be judicious in the case of syphilitic affection might be very improper under other circumstances. When the true history of the case can be obtained, the facts will give much assistance in forming an opinion, but this can not always be procured ; we are, therefore, often obliged to form our opinion from the appearances before us. The only constitutional vice, other than the venereal, which may cause a similar palatine devastation, is scrofula, and when scrofula is the cause of the affection, the prevalent vice will display itself elsewhere, in derangements of the lymphatic sys- tem, and the other affections which usually attend upon this general pravity. Syphilis is more rapid than scrofula ; and the local affections produced by it are more painful. According to Mr. Hunter, venereal disease generally makes its appearance, in these parts, at once, in the form of an ulcer, without much previous tumefaction. He describes the ulcer as a fair loss of substance, part being dug out as it were from the body of the tonsil (if seated upon it). It has a determinate edge, and is commonly very foul, having a thick white matter, like a slough, adhering to it, and not admitting of being washed away. All authors, how- DISEASES OF THE PALATE. 339 ever, admit the extreme difficulty of distinguishing venereal affections in these parts, with absolute certainty, by merely local observation, and no appearance of sores about the palate warrant us in declaring the disease syphilitic, without corre- sponding symptoms justify the suspicion. While this is the case, however, any suspicious sore will authorize us to try such remedies as are known to be efficacious in syphilis, it being much more dangerous to neglect a syphilitic sore than tem- porarily to maltreat a scrofulous one. No purity on the part of a married female can always be satisfactory of her freedom from syphilitic taint, as, disgraceful as it is to human nature to make the confession, we are frequently compelled to recognise the ravages of the disease in these victims to the matrimonial tie, who are perfectly innocent of any impropriety. I need not say, that when the dentist discovers such a condition to exist, though humanity will demand that in some way or other the cure be provided, benevolence, no less imperious, requires, that the unfortunate subject of the odious inoculation shall be kept in blissful ignorance of the nature of the malady. Of course, where venereal or scrofulous disease is at work upon the parts, proper constitutional remedies must precede all mere mechanical attempts to repair existing damage. The devastation of the palatine tissues, soft or bony, may sometimes result from the local irritation produced by dead teeth, &c. This, of course, can only occur in those enfeebled constitutions in which nature is not able to resist even a trivial morbid impression, but seems barely capable of maintaining a nutrition equal to the ordinary wear and tear of tissues. That such cases do occur, is stated by Jourdain, Harris, and many others. Harris says,* " The local irritants occasioning the palatine diseases are dead and loose teeth, roots of teeth, salivary cal- culus, mechanical injuries, acrid humours, &c. The case of a lady of irreproachable character is related by Jourdain, in whom a scratch on the palate with a fish-bone, caused a tumour, * Dictionary of Dental Science, art. Palate. 840 DISEASES OF THE PALATE. which suppurated and degenerated into an ulcer with hard ele- vated edges and a fungus in the middle." Dr. Cone mentions a similar case. The following are reported by Jourdain : Case I. — " Mr. Noel had a tumour of the palate, which, on pressure, discharged pus through one fistulous opening, on the outer side of the right alveolus, between the canine and incisor, and another in the socket of the second molar, which had been removed some time since. The patient would not consent to proper measures in the first instance. The canine incisors and first molar became loose and were extracted; the alveolus around the site of the second molar sloughed away. The tu- mour still continued to enlarge, and some embarrassment was felt in the nostril: the patient then put himself under my care. The tumour, when lanced, discharged a very fetid pus, and I found, on introducing my probe, that a portion of the palate and maxillary bones were necrosed and almost completely de- tached. I removed them with ease : the one from the palate was the size of the nail of the index finger, that from the maxilla, larger. The removal of these sequestra, exposed the pituitary membrane of the floor of the nostril, as was proved by the sneezing excited by touching it on the lingual side. I dressed the wound for some days with dry lint, and then used gargles, &c. In twelve days the cicatrix was complete. " I have treated many similar cases, arising from simple ab- scess, the sequel of dental disease. I have always, when the opening was of sufficient size, either awaited the natural separa- tion of the sequestrum, or when assured that it was no longer adherent to the sound bone, gently withdrawn it. Simple causes may often be productive of extensive injury, as the fol- lowing case will show : Case II. — " A bailiff, named Broch, had a tumour of the palate as large as a pigeon's egg, with swelling of the nose and upper lip, consequent upon a decayed condition of the teeth. Pus escaped from the nose, and there was a fistulous canal from the second incisor to the first molar of the left side. " As the case seemed an urgent one, I removed the decayed DISEASES OF THE PALATE. 341 teeth and stumps, thus destroying the fistula. I then excised the palatine tumour, and found the bone carious and the nasal membrane covering it perforated, which accounted for the dis- charge of pus from the nostril. I first employed dressings of dry lint, emollient and detergent gargles, and after the subsi- dence of local inflammation, touched the bone with mercurial water twice in eight days. In this time the sequestrum sepa- rated, leaving an opening into the nostril about the size of a quill, which was closed by a prolongation of the mucous mem- brane. I made use of dressings of dry lint, gently applied, and occasional styptics to suppress exuberant granulations. The entire cure occupied six weeks." For a great number of similar cases, the reader may consult Jourdain's work. When local irritants cause or seem to be connected with the disease, they should be promptly and completely removed. The after treatment will be conducted upon general surgical principles. When a fissure has been permanently formed and its limits ultimately defined, whether it has been congenital or accidental, the indication is to remove the deformity by producing a clo- sure of the fissure, or, if this cannot be done, to supply the defi- ciency of the parts by such mechanical appliances as may be deemed most suitable. When the soft palate or some portion of it has been lost, the lesion has been substituted by means of an operation, which has been termed staphyloplasty.* The operation can be successful only when the perforation is small. It consists in detaching a portion of mucous mem- brane from the surrounding parts, and so adjusting them with reference to the perforation, as to procure a permanent cover- ing of the cavity, when adhesive inflammation has been effected. The operation is difficult, and requires great dexterity in exe- cution as well as ingenuity in contrivance. Dr. Pancoast, in his Operative Surgery, describes an operation of this kind, * 2r*<}>yA», the uvula, and 7r\A, I form. 29* 342 DISEASES OF THE PALATE. successfully performed by himself, to close a hole near the cen- tre of the hard palate, which formed a communication between the nose and mouth. The operation for closing a cleft palate is called staphylo- raphy.* It consists in paring away the edges of the fissure and closing them so perfectly as to produce union by adhesion. The operation has been successfully performed by a great number of surgeons, European and American, and several methods of performing it have been adopted and suggested ; each having its advocates. Dr. S. P. Hullihen, surgeon dentist of Wheeling, Va., of whose surgical skill I have already made mention, had per- formed this operation successfully eleven times, up to the year 1849. This ingenious surgeon has invented a bistoury for par- ing the edges of the fissure, which possesses decided advantages over the ordinary double-edged knife. It is composed of two parts, which open like scissors, but when closed, form a double- edged knife or bistoury. The manner of using it is as follows : After first seizing the cleft edge of the velum, at the base of the uvula, with a pair of curved forceps, and putting it on the stretch, the bistoury, with its back towards and against the pa- late bone, should be pushed through the velum near its edge ; then, by opening it, the edges will be pared off in the most even and perfect manner possible. Further procedure should be suspended until the hemorrhage, although seldom very great, shall have partially subsided. A needle, armed with a well-waxed ligature, and held in a pair of suitable forceps, should be passed from before backwards, through the most dependent part of the left margin, about three lines from the edge. As soon as it is seen on the opposite side, it should be grasped by the assistant, with a pair of long- handled forceps, and as soon as the hold of the port-aiguille is relaxed, drawn through, replaced in the latter, and passed through from behind forwards, the right margin of the velum opposite to the left. After the patient has rested a few mi- nutes, a second, third, or fourth ligature should be introduced.f * ireKpvxn, and Pa», a suture. f Die. Dental Science, DISEASES OF THE PALATE, 343 Dr. J. C. Warren, and his son, Dr. John Mason Warren, have each performed this operation repeatedly, and with great success. In most of these cases the fissure has extended through both soft and hard palate, and in one case through the jaw and Kp. Dr. J. M. Warren's method has been to dissect off the mu- cous membrane from the hard palate, on either side, and stretch this across the fissure, and then unite the edges by sutures. Although it is generally asserted by surgical writers, that when the fissure of the hard palate exceeds an inch, no union can be expected, Dr. Warren has proved by his success in such cases, that the opinion is erroneous.* Dieffenbach recommends that a longitudinal incision be made at a short distance from the edges of the fissure, in order to permit the closure to be accomplished in the way before men- tioned. A great variety of instruments have been invented by different surgeons, and recommended to be used in this operation. I have already mentioned the cutting scissors of Dr. Hullihen. A variety of needles and needle-holders have been proposed. Dr. J. C. Warren uses a needle with a movable point. Dr. N. R. Smith prefers a simple lance-shaped instrument, mounted on a handle, and having a slit near its point, which opens at its posterior end. The needle is broader in front of the eye than behind it, which renders the passage of the back part easier. Armed with a ligature, the curved portion of the needle is car- ried beyond the fissure, and its point introduced behind the middle of the uvula, and as soon as it has come out far enough to expose the ligature in the slit, the ligature is taken hold of with a tenaculum, disengaged from the slit or eye in the needle, and the needle is withdrawn. A second ligature is introduced, half an inch higher up, and, if necessary, a third, at an equal distance from the second. With the ends of the ligature passed through the uvula, this part is drawn forwards, until the fissure in the soft palate shall assume a nearly horizontal position. * Reese's Cooper's Surgical Dictionary. 344 DISEASES OF THE PALATE. Its edges are then cut off with scissors or bistoury. The liga- tures are then tied, and the ends cut off. Dr. Hullihen has invented an instrument for passing the needle, which he calls an acutenaculum, and which he thinks better adapted to the purpose than any other. It is composed of a staff and a slide. The staff is a small steel bar, six inches in length, a fourth of an inch in breadth, and an eighth of an inch thick, with an arm at the upper end, rising at a curve from the staff, and half an inch long. On the external or superior side of this arm a duplicate arm is retained by a steel spring attachment, which brings the two arms in close contact, forming the jaws of the instrument. Between these two arms, and on the duplicature, is a small groove, formed to receive the ligature ; and when the ligature is pressed between the jaws of the instru- ment, they open, and it slides to the point designed for its reception, immediately below which, the jaws are perforated with a hole for the introduction of the needle. Two inches from the inferior end of the staff, a pair of rings are affixed, to receive the thumb and index finger, the rings standing parallel with the staff, and sideways to the direction of the arms of the instrument. A slide formed of steel, equal in length, thickness, and breadth to the staff, is made to fit the upper surface of the staff, and to move with ease up and down, upon guides on the same. From the superior end of the slide is a short, straight, spear-shaped needle, constructed with an eye just back of its point, with a small notch opening to it from the upper surface. When the ligature has been fitted in its place in the jaws of the instrument, and the slide adjusted to the staff, the slide is forced upwards, the needle and jaws, approach each other, and the needle passes through the hole in the latter, just under the ligature, which is caught in the notch of the needle, and as the slide is drawn backwards the eye of the needle is threaded, and the ligature drawn through the velum. This instrument is cer- tainly an ingenious one, and the preference given it by the inventor, who has operated so often and so well, is sufficient commendation. DISEASES OF THE PALATE. 345 For a more particular description of this instrument, made intelligible by an accompanying plate, the reader is referred to an excellent article on cleft palate, by Dr. Hullihen, published in vol. v., page 166, of the American Journal of Dental Science. Concise and admirable directions will also be found in that paper, for conducting every step of the operation. When the loss of parts is so great as to forbid an attempt to close the fissure by an operation, nothing remains to be done but to cover it by a gold plate or obturator, such as the circum- stances of the case will admit. The skilful dentist will often be able to remedy these serious lesions to a very great extent, by well-devised and artistically-executed substitutes. For a description of these mechanical means, and the mode of adjusting them, I refer the reader to the works on mechanical dentistry. 346 CHAPTER XXV. ANESTHETICS — CHLOROFORM ; SULPHURIC ETHER. The term Anaesthetic has been recently introduced into the Materia Medica to designate a class of substances which obtund and, if sufficiently administered, suspend the consciousness, and sensibility to pain. They are narcotics, rapid and fleeting in their action, and producing profound stupor, without the danger to life which attends the production of such a condition by other medicines of the class. The introduction of these agents into medical practice is of very recent date, and though their effects upon the human body, and their applicability to the purposes for which they are ad- ministered, have been very carefully studied for several years, the important question of the extent of their availability has not yet been conclusively determined. The application of Anaesthetics to Dentistry is a subject about which the utmost difference of opinion exists among those whose opinions are most entitled to consideration, and, as upon a question involving such serious issues, all dentists should be better informed than they are likely to be without a much wider range of reading than the common scope of their studies requires, it may not be without advantage to devote a chapter to the examination of this subject. To devise some means of deadening the sensibilities to such an extent as to permit the performance of surgical operations, without the infliction of agonizing pain, and thus at once to prevent the actual suffering and the preceding dread, which invest these frequently necessary processes of cure with so much of the horrible, has long been a desideratum with the ANESTHETICS. 347 medical profession, but until an American dentist actually accomplished it by administering ether by inhalation, no pro- gress towards the desired result seemed to have been made. Sir Humphry Davy had reported a successful experiment upon himself "with nitrous oxide, and Mr. Horace Wells made some trials, not altogether without success, with the same agent, as early as 1814. Berzelius had called the attention of che- mists to the fact that a mixture of hydrogen with oxygen when inhaled would produce sleep,* but none of these facts led to any practical application of an anesthetic agent. In the year 1846, Mr. Morton, now Dr. Morton, a dentist of Boston, after experimenting upon himself and several of his patients, prevailed upon Dr. J. C. Warren to use the ether inhala- tion, in an operation at the Massachusetts General Hospital. The experiment was only partially successful, but being repeated with more favourable results, the use of Sulphuric Ether as an anesthetic became frequent, both in this country and Europe. Public opinion was from the first very much divided as to the advantages of the administration. In many of the first expe- riments ether decidedly failed, and although accounts of success- ful inhalations were multiplied from various quarters, surgeons found so much of uncertainty and inconvenience in the use of the agent, that it would probably have never come into general use. Dr. Simpson, of Edinburgh, having attempted the administra- tion of ether in parturition, was led to seek another agent, more certain and less objectionable, and after experimenting with various substances, announced the discovery of the extra- ordinary powers of Chloroform. Dr. Simpson's high standing in the profession, and the num- ber of successful experiments made by him, produced the most enthusiastic excitement with regard to the new agent, not only among surgeons and obstetricians, but the public generally. Chloroform was administered freely in an immense number of cases, and of course often very imprudently, yet there was a con- siderable time before a fatal accident occurred. At last, how- ever, several deaths under the use of this agent were announced, * Beck's Materia xWedica, article Anaesthetics, by Dr. Gilman. 348 ANESTHETICS. in frightful succession, and the profession and the public were taught that every good partakes of the imperfect condition to which human affairs are subject, and may by imprudence and ignorance be made an evil. Since the dangerous nature of chloroform and ether have been discovered, we have reason to wonder that a far greater number had not fallen victims to the recklessness with which the new medicines were administered and inhaled. These powerful agents were not only prescribed by surgeons who had yet to learn the extent of their control over the human system, but were inhaled by thousands for amusement, and to satisfy curiosity. COMPARATIVE ADVANTAGES OF CHLOROFORM AND ETHER. With regard to the preference which should be given to one or the other of these agents, there has been much controversy, and there yet is much difference of opinion. Those whose name and fame were identified with the success of ether felt naturally reluctant to permit it to be superseded by another anaesthetic, and their prominent position to be occupied by others ; while the discoverer of chloroform, and those who were the first to proclaim its powers, may be sup- posed to have been excited by a similar feeling, to exaggerate the importance of their own agent, and deny the value of ether. The surgical profession, however, having no personal interest in the matter, set themselves carefully to investigate the several propositions submitted on the one side and the other, and the decided judgment is upon the whole favourable to chloroform. The comparison made by Dr. Simpson, who first introduced the anaesthetic use of chloroform, between this agent and ether, is thus set forth in his pamphlet : 1. A greatly less quantity of chloroform than of ether is requisite to produce the anaesthetic effect, usually from a hun- dred to a hundred and twenty drops of chloroform being suffi- cient, and with some patients much less. I have seen a strong ANESTHETICS. 349 person, rendered completely insensible by six or seven inspira- tions of thirty drops of the liquid. 2. Its action is much more rapid and complete, and generally more persistent. I have almost always seen from ten to twenty full inspirations suffice. Hence the time of the surgeon is saved, and the preliminary stage of excitement which pertains to all narcotizing agents being curtailed, or indeed practically abo- lished, the patient has not the same degree of tendency to exhi- laration and talking. 3. Most of those who know from previous experience the sensation produced by ether inhalation, and who have subse- quently breathed the chloroform, have strongly declared the inhalation and influence of chloroform to be far more agreeable and pleasant than those of ether. 4. I believe that considering the small quantity requisite as compared with ether, the use of chloroform will be less expen- sive than that of ether. 5. Its perfume is not unpleasant but the reverse, and the odour of it does not remain, for any length of time, obstinately attached to the clothes of the attendant or exhaling, in a dis- agreeable form from the lungs of the patient, as so generally happens with sulphuric ether. 6. Being required in much less quantity it is much more por- table and transmissible than sulphuric ether. 7. No inhaler or instrument is necessary for its exhibition. A little of the liquid diffused upon the interior of a hollow shaped sponge or a pocket handkerchief, or a piece of linen or paper, and held over the mouth and nostrils, so as to be fully inhaled, generally suffices in about a minute or two, to produce the desired effect. Dr. Henry J. Bigelow, in an admirable paper upon anaesthetic agents, appended to the report of the committee on surgery, published in the first volume of the transactions of the Ameri- can Medical Association, testifies that there is no difference of importance in the general character of the insensibility or other symptoms resulting from the inhalation of ether, and chloro- 30 350 ANESTHETICS. form. The latter is much more potent than ether, more pala- table, and less irritating to the lungs. Dr. Gilman, in the report of the Committee on Obstetrics, Vol. II. of Transactions of American Medical Association says : There are to ether some very strong objections. It sometimes irritates the respiratory apparatus to such a degree, that its continued use and the production of anaesthesia by it are im- possible. It is sometimes impossible to get the patient beyond the state of excitement, and this state is always longer and more violent than when chloroform is used. Ether is more often followed by unpleasant effects, as headache, soreness of the chest, &c. In some persons it produces a very free flow of saliva, which entering the posterior fauces may embarrass respi- ration. The advantages of chloroform are, a smaller quantity is required, fewer persons resist its influence, and it produces no cough, choking, salivation, or other evidences of irritation of the mucous membrane. The state of excitement is avoided, or is so short as to amount to nothing. In short, chloroform has every advantage except safety. The Doctor then proceeds to show that the danger of administering chloroform is rather due to the inexperience or carelessness of administrators than to any necessary quality of the agent itself. In the report on Surgery published in the same volume, Dr. N. R. Smith gives his voice decidedly in favour of chloroform over ether, as by far the most powerful anaesthetic, and least annoying in the act of respiration. Dr. Smith is not satisfied, that in point of safety, there is much real advantage in the use of ether. In the first two instances of the employment of ether in his practice, though the administration was effected by an expe- rienced gentleman from Boston, the result was very unfortunate. In neither instance was the anaesthetic influence complete, and in both there resulted great perturbation of the vascular and nervous systems, characterized by delirium and a pulse of 140 per minute. Both patients remained in a doubtful state in regard to recovery, for forty-eight hours. In another instance, in which the same surgeon employed ether in the amputation of the female breast, an unusual degree of irritative fever fol- ANESTHETICS. 351 lowed the operation, resulting, after some twenty clays, in fatal consecutive abscess of the right pleura. The reporter proceeds : "We believe that the deleterious effects of ether are less clearly chargeable to this agent, because they are more remote, and therefore likely to be referred to other causes. The fatal effects of chloroform, being almost instan- taneous, are referable to nothing else. The post hoc, propter hoc here strikes the mind with irresistible force. It must also be borne in mind, in comparing the safety of chloroform with that of ether, that the former agent has been employed much more extensively than ether, though of more recent discovery and application. The use of ether had scarcely become general when it was superseded by the discovery of Mr. Simpson, and at this time the reported cases of its employment are twenty fold more numerous than those of the employment of ether. " He who fixes his attention exclusively on the fatal cases from chloroform, without adverting to the vast number in which it has been employed, is very naturally filled with alarm. But when we consider that this agent has probably been adminis- tered to millions of subjects, and that only fifteen cases of death from its use can be adduced, the individual who subjects him- self to its influence ought to feel no more apprehension than he who takes his seat in a railroad car, and much less than one who essays a voyage across the Atlantic. The conclusions of the Committee upon this subject are thus summarily expressed : "Contemplating all the facts which, in relation to the use of anaesthetic agents, have been contributed during the past year, your Committee congratulate the Association on the great pro- gress which has been made in establishing professional and public confidence in these extraordinary agents, and on the vast benefit which is likely to result to mankind, from this achievement of science and humanity. To them the recorded experience of surgeons, at home and abroad, appears abun- dantly to justify the following conclusions. " 1. The means of generally rendering patients insensible to the pain of surgical operations, so long a desideratum, have at 352 ANESTHETICS. length been furnished in the anaesthetic agents, sulphuric ether, chloroform, and chloric ether. " 2. The employment of these agents for obviating pain in most severe surgical operations is now not only justifiable, but the imperative duty of Surgeons, and indeed we may almost adopt the language of Professor Miller, before the Medico- chirurgical Society of Edinburgh, that ' no one among his surgi- cal friends would deem himself justified, morally or profession- ally, in now operating upon a patient in a waking and sensi- tive state.' " 3. Of the ansesthetic agents, chloroform is decidedly the most efficient and facile of respiration ; but being most powerful, is at the same time most dangerous, when incautiously employed. " 4. In formidable and painful operations, chloroform not only obviates pain, but contributes to the safety of the patient, by preventing shock, and the irritation which is the antecedent, and, to a certain extent, the cause of inflammation. " 5. The use of chloroform is inadvisable in trivial cases, be- cause the danger from its use is greater than that from the ope- ration. All must admit that of the two objects to be held in view in a surgical operation, safety and immunity from pain, the former is the more important. " 6. In regard to circumstances under which chloroform should be employed, we adopt the conclusions of the French Academy : 'It should not be used when there exists any disease of the heart, any aneurism near the heart, any threatening dyspnoea, any tendency to engorgement of the lungs or brain. Care must be taken, that during the inhalation, atmospheric air be suffi- ciently mixed with the vapour of chloroform, and that respira- tion be carried on freely. The inhalation should be suspended as soon as insensibility is obtained.' "7. The best vehicle for the administration of chloroform or ether is a handkerchief or sponge of loose texture, through which the atmosphere may be copiously inhaled." However similar may be the ultimate effects of ether and chloroform as to the production of insensibility, the result does AN2ESTHETICS. 353 not seem to be attained by the same mode of action upon the nervous system. Ether is decidedly stimulating in the first instance, and the degree of excitement or intoxication it produces is sometimes so great as seriously to embarrass or even prevent the operation it is intended to facilitate. Like all other excitements, this is followed by corresponding depression, and the secondary effects of the agent are therefore to be seriously considered, when the administration of ether is proposed. Chloroform seems to be directly depressing or sedative in its action, lessening the sen- sibility of the nervous system, without any preceding stage of excitement, or exhilaration. I have administered chloroform in a number of instances, but have never seen it produce a con- dition which might be termed intoxication. EFFECTS OF CHLOROFORM. After one or two deep inspirations the patient feels a pleasant languor, attended with a sort of tingling sensation in his extremi- ties; some confusion of the understanding follows, throbbing sounds are heard in the head — numbness succeeds, conscious- ness is lost, the muscles are rigid, and sensibility is much ob- tunded. If the inhalation be continued, the sleep becomes pro- found ; the breathing deep and heavy, regular, sometimes ster- torous, the muscles relaxed, and insensibility complete. The pulse continues regular, though often somewhat feeble, until the inhalation has been carried to a dangerous extent. It then sometimes suddenly becomes decidedly weak, fails rapidly, the breathing becomes irregular and interrupted, and syncope ensuing, the patient expires. Dr. Gilman says that he has frequently seen consciousness survive insensibility. Commonly the sensibility survives con- sciousness, and a patient, apparently asleep, will manifest ex- treme suffering under an operation, by his contortions and cries. Extreme dread of an operation will keep awake both the con- sciousness and sensibility long after the understanding has been narcotized by the anaesthetic. 30* 354 ANESTHETICS. I remember to have administered chloroform for a dentist to a young gentleman who had several molar teeth to be extracted, and who from the peculiar formation of his teeth had suifered exceedingly in previous operations of the kind. Although he was resolutely bent upon having the operation performed, such was his dread that after being brought apparently under the full influence of chloroform, the attempt to touch his mouth aroused him so far as to cause him to say, " Now I perceive that you are adjusting the instrument" &c, describing sensations which really did not exist, as at the time no attempt was mak- ing to apply an instrument. It is remarkable that although a patient may manifest suffering by contortions and cries, yet when the ansesthetic passes off, there is never any recollection of the pain. Whether the patient, under these circumstances, has really derived any advantage from the chloroform, is a ques- tion which I will leave to philosophers. MODUS OPERANDI OF ANESTHETICS. That these agents act upon the nervous system by passing into the circulation, and modifying the blood, is plain enough, but the particular modification which they effect, and the man- ner in which the nervous system is acted upon by it, are as yet unknown to us. The order of affection, as given by Houvers, is this : Eirst the cerebral lobes lose their power, and intellect is im- paired ; then the cerebellum is affected, and the power of regu- lating locomotion lost ; afterwards the spinal marrow, and sen- sation and motion are gone ; lastly, the medulla oblongata, the motive power of respiration, breathing ceases, and death is the result. The pithy remark of Dr. Gilman upon this dogmatical ex- position is a satisfactory comment. "This sounds very well, but it seems to me that any one who has studied this matter by the bedside will be quite unable to reconcile what he then sees with the order of Mr. Houvers ; what, for example, was the state of the cerebrum and cerebellum of the Irishman operated ANESTHETICS. 355 on at the London Hospital, who made faces and jokes while insensible of the pain of an amputation ? (London Med. Gaz. January 22, 1847.) Is the cerebrum and cerebellum affected when a patient in labour takes the handkerchief from her at- tendant, presses it to her face, and expresses in the warmest terms the relief from pain which is afforded her ? All this must manifestly be restudied." CONDITIONS FORBIDDING THE USE 01 ANESTHETICS. Observation of the action of chloroform and ether leads us to consider the administration of them dangerous and improper, 1. To persons labouring under organic diseases of the heart or great vessels. 2. To persons who are subject to cerebral congestions, or whose brain is in any way unhealthy. Epileptic and hysterical patients are not proper subjects for anaesthesia. 3. To persons disposed to haemoptysis or to pulmonary con- gestion, and to phthisical patients in all stages of that disorder. 4. To feeble persons, with a weak circulation ; to the chloro- tic or anaemic. 5. It must be remembered that the nervous system is much more readily impressed by medicinal agents, and especially by narcotics, soon after bleeding ; and when the patient has evident- ly been weakened by recent loss of blood, anaesthetics should be administered with great caution, if at all. ANESTHESIA IN DENTAL OPERATIONS. It being clearly established that chloroform and ether may be so given as to prevent the dread and suffering attendant upon surgical operations, and that the administration of these agents is entirely safe, in a vast plurality of instances, the im- portant question is to be determined, In what cases is it the duty of the surgeon to give the patient the advantage of these anaesthetics ? Pain is the greatest of all bodily evils. Even when not com- 356 ANAESTHETICS. paratively severe, it is dreaded in prospect and borne with im- patience, while the agony of most surgical operations is ap- palling to the stoutest heart. These operations, too, are gene- rally performed upon individuals whose sensibilities have been sharpened, and nervous systems weakened, by severe or long- continued suffering. They are of all others the least able to endure the infliction of the exquisite tortures of surgery. At first thought common humanity seems to require that the benevolent gift of heaven, anaesthetic oblivion, be dispensed to all whose unhappy state may drive them under the surgeon's knife or to the dentist's chair. If anaesthesia were always safe, this would be a just conclu- sion, but unfortunately it is sometimes a fatal gift. How then shall we prescribe limits to its use ? In the higher surgical operations, where recovery from the operation is not certain, statistics seem to show that the danger arising from the use of chloroform is more than compensated by the exemption from shock and pain ; the mortality being less under anaesthesia. In all these cases then, except where circumstances exist which render the inhalation uncommonly perilous, anaesthesia should be preferred. There can be no rea- son to the contrary. The surgeon is as fully warranted to give chloroform in such cases, as he would be to give opium. In obstetric practice, too, the degree of anaesthesia required to make the patient comfortable is not so profound as in surgi- cal operations, and the danger appears to be very inconsidera- ble. In severe cases of parturition, it is evident that the chances of escape to the mother are increased by anaesthesia, therefore the administration, in the hands of a judicious accou- cheur, seems entirely justifiable. In dentistry, the operations do not involve life. The pain, though very great, is not so fre- quently inflicted upon the sick and feeble, and is generally of short duration. It cannot be said that anaesthesia here offers compensation for any mortality which accompanies its use. Cer- tainly it would be better that all should endure the pain occa- sionally inflicted by the dentist, than that the life of one human being should be sacrificed to procure them exemption. Yet ANESTHETICS. 357 anaesthesia has already taken many lives in exchange for what relief it has given to the subjectsof dental operations. Painful experience has shown that the use of anaesthetics has been more dangerous in the hands of dentists than of other administrators, death having more frequently occurred in at- tempts to save the patient from the pain caused by the little operation of extracting a tooth, than perhaps from all the in- stances in which anaesthetics have been administered to prevent the consciousness of suffering in capital operations. The greater danger of anaesthesia in dental operations is easily accounted for. The operation has to be performed upon an organ concealed in the cavity of the mouth. The preliminary stages of the ope- ration, adjusting instruments, &c, cannot be accomplished until the patient has been made unconscious. The mouth then is gene- rally found spasmodically closed, and cannot be forced open without considerable effort. In the mean time, the patient can- not continue the inhalation, the soporific effects of the anaes- thetic pass off, and by the time the operator has accomplished the separation of the gum, consciousness has returned. In an operation upon any other part of the body than the organs through which inhalation is accomplished, the surgeon having the patient in a proper position for the immediate ope- ration, can commence it as soon as anaesthesia is effected, and can proceed without interrupting the inhalation, which can be continued, according to circumstances ; the patient not being profoundly, but continually narcotized. But the dental operator must carry anaesthesia so far as to produce relaxation of the muscles of the jaw ; or what I think is more commonly the case, to so completely overwhelm the consciousness as to obviate that instinctive resistance which seems to linger after volition appears to be suspended. When the patient begins to inhale the chloroform, his mind is intently occupied with the anticipated attack upon his teeth, and his fears are concentrated upon the dread of the attack being pre- maturely made. By his eyes and hands he continually gives signals of consciousness as long as he can, and the last effort 358 ANESTHETICS. of volition is to clench the jaws as firmly as possible. Muscular life being less easily overcome than intellectual, the extreme anesthetic effect of chloroform or ether has to be induced in order to overcome the difficultv. Again, as the dentist cannot continue the administration of the anesthetic while operating, at least not with any regularity, he is obliged to carry the anesthesia so far as to permit a cer- tain degree of it to pass off without the restoration of conscious- ness. In other words, he must produce super anaesthesia* be- cause he must provide against the known evanescence of the condition. Another reason why dental anaesthesia has proved so fatal, is, I doubt not, the position in which the patient inhales the narcotic vapour. Invariably the subject of the operation is placed in a chair, with the head nearly upright ; consequently, when anesthesia is carried so far as to cripple the action of the heart, the patient readily faints ; syncope, the almost or entire suspension of the heart's action, finds the patient in the worst possible condition for reaction, owing to the depressed state of the nervous sys- tem, consequently it often happens that no reaction takes place, and the patient almost immediately expires. That this is the manner in which death occurs in most cases of fatal anesthesia appears to me evident. That occasionally a state resembling apoplexy may be induced, and the patient not recover, may be true ; but apoplexy does not destroy life im- mediately, generally not hastily, unless from copious effusion in the brain, which cannot be supposed to take place in anes- thesia. Cases of profound and fatal apoplexy generally con- tinue for several days, sometimes for two weeks, before death. But death from chloroform is sudden, and always results imme- diately from cessation of the heart's action. Now the action of the heart is kept up under deep and fatal congestion of the brain, until it gradually weakens through exhaustion of vitality, unrenewed by alimentation, rather than from any deadly in- fluence acting upon the organ itself. Again, by regarding syncope as the cause of death in these ANESTHETICS. 359 cases, we have explained the singular fact that anaesthesia has been less perilous to the patient in parturition than under other circumstances. Parturient females are not only not prone to faint, but are almost uniformly in a recumbent position during the administration of the anaesthesia ; a position in which syn- cope cannot occur until the heart's action be enfeebled to the last degree. I am convinced, then, that anaesthetics should always be ad- ministered to the patient in the recumbent position. They should never be administered to a patient in whom the heart's action is at the time very feeble, whether from dread or otherwise. They should never be administered to a patient subject to fainting fits. Since writing the above, I have read several accounts of cases of death from the use of anaesthetics, which tend to confirm me in the opinion that the position of the patient has much to do with the fatality of the inhalation. One of these cases happened in the chair of a dentist, and two in the hands of the general surgeon. In both these latter cases the patient seems to have died from syncope, the result of position. In one instance, the patient was a little girl, 12 years old, who had a tumour to be extirpated from the thigh. The pa- tient was placed upon the side of the bed, in the upright posi- tion, supported (held upright) by proper assistance. The anaes- thesia effected, she was laid down, but the effect going rapidly off, she was again upright. The surgeon goes on to relate that the chloric ether was again administered until the head dropped. The first stroke of the knife, however, roused her so much that it became necessary to restrain her, and at the same time the surgeon directed the sponge to be applied until she should cease to strive. In about three minutes the struggles ceased, the sponge was withdrawn, and in five minutes more the tumour was removed. At this time the pulse and respiration caused alarm. Immediately they commenced giving stimulants, apply- ing ammonia to the nose, dashing water on the face and chest, 360 ANESTHETICS. rubbing and elevating the extremities, exciting artificial respi- ration, and using all the means recommended in such cases, but without avail. The respiration became more feeble, the pulsa- tions of the heart hardly perceptible, and continuing in this state fifteen or twenty minutes, she died. The other case was that of a lad of IT, who came to the office of a surgeon about noon, for surgical aid, on account of a badly lacerated hand. He was pale, and suffering much pain, and "trembled like an aspen leaf, when he was coming to the shop." A mixture of chloroform and chloric ether was administered perseveringly, as it made him sick. When under its influence, the dressing of his hand was commenced, but very soon the assis- tant called the attention of the surgeon to the patient's face. The surgeon continues, "I saw at once that he was either dead or dying, and directed my assistants to help me lay him at once on his bach. I found the pulse at the wrist gone, the action of the heart very feeble indeed, and respiration in a moment ceased, a few heaving inspirations at long intervals, the action of the heart meanwhile growing more and more feeble, and all was quiet — my patient was dead." The surgeon then proceeds, at some length, to express his entire inability to account for the young man's death, until he is relieved by the suggestion of a bystander, that he died of fear. He says, " My conclusion then is, that the fatal conse- quence attending etherization in the present instance, is not owing to any inferiority in the article used, to want of care in its administration, nor to any organic disease in the patient; but that we must look for it in the naturally delicate organiza- tion of the subject, rendering him very sensitive to external impressions, in the shock that the nervous system had sustained in the injury, and last but not least in the influence of fear ; not in any one of these singly, but in the three combined. My conclusion is, that the patient would certainly have fainted under the dressing, whether he had taken the chloroform or not. He was in a fainting condition when he came into the office, "pale and trembling like an aspen leaf;" and that he would faint if kept in an erect position during the dressing was certain. ANESTHETICS. 361 Under these circumstances, to lessen the energy of the nervous system was to render reaction exceedingly doubtful, or impos- sible. The chloroform was given — the nervous centres lulled into insensibility — the patient fainted — there was no reaction, and he died. I have not selected these two cases. They were published in consecutive numbers of the Boston Medical and Surgical Journal, for the present month, and seemed so corroborative of the opinion I have expressed that I have recorded them here. That a careful observation of the fatal cases reported will still further show the importance of position to the consequences of anaesthesia, I have no doubt. I do not mean to say that to one in the recumbent position anaesthesia is always safe, but that to one in the upright position it is always dangerous. The dentist is rarely warranted to administer anaesthetics. If he does so frequently, experience may teach him to expect, that sooner or later he will cause the death of a patient. Upon this supposition he must proceed, and as he cannot pretend to be compelled to risk anaesthesia through the necessity of saving life, he must, if he employs it, assume a most serious and unenviable responsibility. 31 INDEX. A. Abscess, 74 Acids, 44, 46 Aconite, 142 Acute diseases, 49 Adhesion, 79 Anaesthesia in dental operations, 355 cause of death in, 358 Anaesthetics, 346 modus operandi of, 354 conditions forbidding, 355 Aneurismal tumours, 138 Animals, the body of a unit, 25 Antiphlogistic treatment, 87 Antrum maxillare, 85 inflammation of, 86, 311 dropsy of, 86, 306 ulceration of, 84 diseases of, 305 suppuration of, 312 caries, necrosis, and other morbid con- ditions of the bony walls, 313 softening of do., 320 exostosis of do., 320 Aphthae, 83 Arrest of hemorrhage, 233 Arsenic, 114, 148 Atheroma, 131 Atmosphere, 36 density of, 37 B. Bigelow, Dr. H. J., on Anaesthesia, 349 Blistering, 90 Blood, buffy coat of, 56, 70 Bones, caries of, 100 Bony tumours, 133 Brown, Jenny, case of, 280 Burns, 242 C. Caloric, 37 Cancer, 101 of the gums, 254 Cancrum oris, 92 Caries, 44, 80, 95 Causes, mechanical and chemical, 44 mechanical, 46 specific, 40 Cautery, actual, 235 Chapman, Dr., cases reported by, 214 Chemosis, 71 Chill, 50 Chloroform, effects of, 353 Cholera infantum, 180 Chronic diseases, 49 Coagulable lymph, 67 Cold, 37 a depressing agent, 39 Complication, 53 Compression of vessels, 233 Congestion, 61 Consequences of inflammation, 71 Contagions, 40 Continuous disease, 49 Convulsions in dentition, 183 Crusta lactea, 185 Cutaneous eruptions in dentition, 1S4 D. Darwin, remarkable cases reported by, 220 Death from extraction of a tooth, 218 Debility, 40 Dentition, first, morbid effects of, 168 diseases of, 174 second, third, 187 364 INDEX. Diagnosis, 52 Diathesis, strumous, 123 Digestion, 47 Disease, 31 definitions of, 31, 32, 33 causes of, 34 classification of, 61 nature of, 61 Dislocations, 249 of the lower jaw, 250 Donne, M., his experiments upon the saliva of fever patients, 150 Dyspepsia, 153 classification of, 155 causes of, 156 treatment of, 157 E. Ecchymosis, 63 Effects of diseased teeth and gums, 188 Enamel, 44 Endemics, 40 Epidemics, 40 Epilepsy from dental irritation, 194 Epulis, 253 Eruptions, syphilitic, 118 Erysipelas, 66, 68 Ether sul., 346 compared with chloroform, 348 Etiology, defined, 33 treated, 34 Exacerbation, 50 Excitability, nervous, 39 increased, diminished, 39 Exostosis, 133 of the teeth, 135 Eye, painful affection of, cured by ex- tracting a tooth, 198 F, Fever, 61 inflammatory, 68 idiopathic and symptomatic, 69 Fistula, 109 of the gum, 259 Fitch, D., cases reported by, 212 Fractures, 245 of the jaws, 247 Functions, 31 Fungus haematodes, 128 G. Gangrene, 95, 96 Gilman, Dr., on anaesthesia, 350 Glands of the mouth, inflammation of. 82 Glands and gland-ducts, diseases of, 277 Gland, submaxillary, tumours of, 280 parotid, do., 290 Gums, inflammation of, 83 chronic, 93 diseases of, 253 spongy, 260 scrofulous, 261 H. Hemorrhage, 231 of the gums, 262 Halford, Sir Henry, cases by, 222 Hall, Peggy, case of, 287 Harris, Dr. C. A., cases reported by, 204,223, 224 Health, 33 Heat, 37 an excitant, 38 Hepatization, 80 Hildanus, report of cases of headache cured by extraction of a tooth, 219 Do. earache, 220 I. Ichor, 112 Induration, 80 Inflammation, 63 treatment of, 87 of the mouth and adjacent parts, 81 Insects in the antrum, 332 Intermission, 50 Intermittents, 48 neuralgic, 144 Intertrigo, 184 Introduction, 25 Iodine, 127 Iron, salts of, in neuralgia, 143 K. King's evil, 122 Koecker, Dr., remarks upon effects of diseased teeth and gums, 190 cases reported by, 198 Lacerated wounds, 237 Language, medical, 32 Leeching, 90 Life, medical use of the term, 32 definition of, 33 Ligature of vessels, 234 Lips, diseases of the, 264 hare, 264 operation for, 266 INDEX. 365 Lips, adhesion of, 268 contraction of, 268 operation for, by Liston, 269 do. by Mutter, 270 cancer of, 272 Lower jaw, amputation of, 296 Hullihen's operation, 298 Lupus, 125 M. Malaria, 40 diseases caused by, 41 sources of, 42 not homogeneous, 43 prophylactics against, 44 Marasmus, 194 Measles, 160 Melliceris, 131 Mercury, preparations of, 119 Moisture, a cause of disease, 40 Morbid effects of conditions of the teeth and gums, 165 Morbid secretions of the mouth, 149 Mortification, 95 Mumps, 83 Murray, Margaret, case of, 279 Mutter, Dr., operation by, 255 N. Necrosis, 80, 96. 99 Neuralgia, 51, 139 fauci, 141 from diseased teeth, 216 Noli me tangere, 125 O. (Edema, a sign of deep-seated inflam- mation, 67, 71 of the glottis, 82 Ossification, 56 Osteo-sarcoma, 137 Oxygen, 37 Ozaena, 86, 326 Pain, 57 of inflamed parts, 64 Palate, diseases of, 334 Paroxysm, 50 Particular affections of the mouth and adjacent parts, 253 Parulis, 253, 257 Pathology, defined, 33 Peruvian bark, 146 Petit, M., case of headache from dis- eased teeth, 219 | Phlegmon, 66 I Phlyctenas, 186 Phthisis, induced by dental irritation. 210 Physiology defined, 33 Pointing, 16 Polypus, 129, 327 Pregnancy, 164 Preliminary considerations, 31 Progress of disease, 49 Pulse, 53 varieties of, 55 rule for feeling, 56 Pus, 72 laudable, 72 Q. Quartan, 50 Quinine, in neuralgia, 144 Quotidian, 50 R. Ranula, 277 Reaction, 39 Regimen, 60 Remittents, 49 Resolution, 87 Rest of parts, conducive to cure, 59 Rickets, 160 Rush, Dr., cases reported by, 194, 195 remarks on dental irritation, 196 Saliva, its acidity in disease, 150 Salivary fistula, 292 Salivation, 91 mercurial, 161 Scalds, 243 Scarification, 89 Scirrhus, 111 Scrofula, 121 Scurvy, 93, 120 Secretions, modified by inflammation, 66 Sequestrum, 80, 96 Shepherd, Dr., case by, 225 Signs of disease, 52 Simpson, Dr., views of anaesthesia, 348 Smith, Dr. N. R., do., 350 Softening, 80 Specific diseases, 51 Sphacelus, 80, 96 Spina ventosa, 138 Staphyloplasty, 341 Staphyloraphy, 342 366 INDEX. Steatoma, 131 Stomatitis, 83 Strophulus, or red gum, 185 Styptics, 232 Suffering of no part unimportant, 27 Suppuration, 72 Surgery, dental, long degraded, 29 defined, 33 Sutures, 237 Swelling of inflamed parts, 64 Sympathetic diseases of dentition, 179 Sympathy, 26 Symptoms, 31, 48 local, sympathetic, general, 48. Syphilis, 93 of the palate, 337 T. Tartar, 88 Teeth, caries of, 100 dead, 59 necrosis of, 101 Tertian, 50 Therapeutics defined, 33 Tic douloureux, 141 diagnosis of, 141 treatment of, 142 Tissot, observation on diseases of the teeth, 197 Tonsils, inflammation of, 82 Treatment of diseases, 59 Tumours, 128 benign, 130 sarcomatous, 131 encysted, 131 of the salivary glands, 278 U. Ulceration, 76 phagedenic, 79 Ulcers, 103 causes of, 104 classification of, 105 simple purulent, 105 simple vitiated, 106 callous, 107 fungous, 108 sinuous, 109 carious, 110 cancerous, 111 phagedenic, 117 scorbutic, 119 scrofulous, 121 venereal, 115 Upper jaw, tumours requiring amputa- tion of, 294 Liston's operation for, 295 V. Vapour, watery, 37 Vesication, 72 Vitality, an operative element in inju- ries, 38 W. Wens, 131 Westcott. Dr., experiments by, 45 Wounds of the mouth and face, 229 simple incised, 230 lacerated, 237 contused, 239 punctured, 239 gun-shot, 240 HARRIS'S DICTIONARY QF DENTAL SURGERY. LINDSAY & BLAKISTON, PHILADELPHIA, HAVE JUST PUBLISHED A DICTIONARY OF DENTAL SCIENCE, BIOGRAPHY, BIBLIOGRAPHY, AND MEDICAL TERMINOLOGY, BY CHAPIN A. HARRIS, M.D., D.D.S., Author of " The Principles and Practice of Dental Surgery," fyc. fyc IN ONE VOLUME, ROYAL OCTAVO. The work before us fills a void that has Jong existed to those engaged in the practice of dental sur- gery, and the task could not have devolved upon one better calculated to perform it. This branch of surgery is extending so rapidly, and rising to such importance in the community, that a cyclopaedia embracing satisfactory definitions of its technicalities, and a compendium of necessary, important, ana curious collateral information, seemed indispensable. The large and valuable medical and surgical die tionaries of the present day, although invaluable to the student and practitioner of general medical sci ence, contain little that is useful to the practical dentist. To supply this want, therefore, the work before us was undertaken. In it are contained accurate, though necessarily condensed, accounts of the physiological and various pathological conditions of the teeth, and the operations necessary for their cure, together with full descriptions of the instruments and materials needed in them. The work is an enduring monument to the patience and industry of its author, and one that we should consider indi3 pensable to the practitioner of dental surgery, and would gladly see in the library of every physician an