o * » *«* «T °^, O^Pi* «£ W O M • -• f .^f ^ .0 ,o- o« > «. G •«s$Ss!W«. ^ A* * # DENTAL MEDICINE, AS CONNECTED WITH THE STUDY OF DENTAL SURGERY. PRACTICAL TREATISE DENTAL MEDICINE, A COMPENDIUM OF MEDICAL SCIENCE, AS CONNECTED 'WITH THE STUDY OF DENTAL SURGERY. ByTHOS. E. BOND, A.M., M.D., PROFESSOR OP SPECIAL PATHOLOGY AND THERAPEUTICS IN THE BALTIMORE COLLEGE 0> DENTAL SURGERY- THIRD EDITION, REVISED, CORRECTED AND ENLARGED. "H PHILADELPHIA: LINDSAY AND BLAKISTON. 1863. /trsT.'r*- . ' V-fc 1 * Entered according to Act of Congress, in the year 1862, By LINDSAY & BLAKISTON, In the Clerk's Office of the District Court for the Eastern District of Penn- sylvania. 2-.iL- ty-.tL Wm. S. Young, Printer. PREFACE THE THIED EDITION The reception of this work has been more favora- ble than the author expected. It seems to have met a want of students of Dentistry. The author is fully aware of its imperfections, and knows that neither its plan nor execution will abide the test of critical exa- mination. But the book was prepared for a practical purpose, which it seems in some considerable degree to have subserved, and it is quite probable that such al- teration of its plan and increase of its volume as lite- rary taste or scientific requirement would demand might render it less useful to those for whom it was prepared. The author has therefore contented himself with such alterations and additions as he could make with- out' risk of impairing the usefulness of the work. They will be found to be considerable, and it is hoped beneficial — and with them it is respectfully submitted to the kind judgments of those, who, knowing the de- sign of the book, will comprehend the difficulty of preparing it, and be more disposed to consider its practical usefulness than its artistic imperfections. September 1, 1862. PREFACE The Baltimore College of Dental Surgery was or- ganized 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 a profession. With this view it was arranged that the Faculty should consist equally of Dentists and practising Phy- sicians, and to the author of this treatise was intrusted the chair of Special Pathology 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. Endeavoring to avoid the very natural error of exaggerating the value of isolated facts or doubtful statements, upon matters, at once novel and from the circumstances peculiarly in- teresting, he has found that many things which at first he was disposed to regard as unlikely, are, never- theless, 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 Vlll PEEFACE. important to be carefully studied both by the Dentist and Physician. After ten years' experience as a teacher of these sub- jects, he has found it absolutely necessary that a com- pendium of medicine should be furnished, in which should be brought together, in a small compass, such selected information as should meet the wants of the Dental Surgeon, and as none has been prepared by another he has reluctantly undertaken the task. The difficulty of performing it will readily be con- ceived, when it is observed how much was proper and how much was irrelevant: how cautious it was neces- sary, to be, that no needless matter should be intro- duced, 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 sub- ject in such a form as will render it deserving the at- tention of the general practitioner. It is not the custom of our profession to consider any thing unworthy of attention which has any bear- ing, however remote, upon the benevolent pursuit to which we have devoted our lives, but to the most fas- tidious it may be said, that subjects which have been thought worthy the attention of Hunter and Rush, may be investigated by all without fear of degrada- tion. THE AUTHOR. CONTENTS Introduction, PAGE. 13 CHAPTEK I. Preliminary Definitions, 25 CHAPTER II. Etiology, The Atmosphere, Heat and Cold, Malaria, Chemical Causes, 29 32 33 37 39 Symptoms of Disease, Progress of Disease, Diagnosis, CHAPTER III. CHAPTER IY. 43 44 47 CHAPTER V. Treatment of Disease, General Remarks on, . . 56 Catalogue of Disease, ..... 59 CHAPTER VI. Inflammation and its Consequences, ... . 61 Inflammation, ...... 61 Consequences of Inflammation, . . . . . 72 Inflammation of the several parts composing the Mouth, and of the parts adjacent, . . . .83 Inflammatory Fever, ..... 97 Treatment of Inflammation, . . ... .99 Caries, ....... 112 Mortification, or Gangrene, . . . .114 CONTENTS. CHAPTER VII. Ulcers, Local and Constitutional, Simple Purulent Ulcer, Simple Vitiated Ulcer, Callous Ulcer, Fungous Ulcer, Sinuous Ulcer, Carious Ulcer, Cancerous Ulcer,. Ulcers Dependent upon Constitutional Cause, Venereal or Syphilitic Ulcers, Scorbutic Ulcers, Scrofulous Ulcer, PAGE. 121 123 123 125 126 127 128 130 131 136 136 141 143 CHAPTER VIII. Tumors, . . . . . . . . 150 Malignant — Osteo Sarcoma, .... 151 Fungus Hsematodes, Bleeding Fungus, Spongoid Inflam- mation, Soft Cancer, Medullary Sarcoma, . . 152 Polypus, ...... 152 Benign Tumors, ...... 154 Sarcomatous or Fleshy Tumors, .... 154 Encysted Tumors, .... . 155 Bony Tumors, ...... 156 Exostosis of the Teeth, . . . . .159 Tumors occasioned by Enlargement of Blood-Vessels, . 161 Aneurismal Tumors, ..... 161 CHAPTER IX. Diseases of the Teeth and Face dependent upon Morbid Conditions, either general or of other parts, 163 Neuralgia, ....... 163 Neuralgia Faciei, or Facial Neuralgia, . . . 163 Intermittent Neuralgia, ..... 168 CHAPTER X. Morbid Secretions of the Mouth, 174 CHAPTER XI. Morbid Effects of .Conditions of the Teeth, and the parts immediately connected with them, upon the ge- neral system, 192 CONTENTS. XI PAGE. CHAPTER XIL Morbid Effects of First Dentition, . . ; 195 CHAPTER XIIL Sympathetic Diseases of Dentition, Cholera Infantum, Convulsions, Cutaneous Eruptions, . Intertrigo, . Crusta Lactea or Milk Crust, Strophulus, Tooth Rash, Red Gum, . Second Dentition, . Third Dentition, 207 209 211 212 213 214 215 216 216 CHAPTER XIY. Effects of Diseased Teeth and Gums upon the General Health, . . . . . .217 Phthisis Pulmonalis, induced by Dental Irritation, . 241 CHAPTER XT. Wounds of the Mouth and Face, .... 262 Fractures, ...... 279 Fractures of the Jaws, . 282 Dislocations, or Luxations, . . . . 285 Dislocations of the Lower Jaw, .... 286 CHAPTER XYI. Particular Affections of the Mouth and adjacent parts, 288 Diseases of the Gums, ..... 288 Epulis, ....... 288 Parulis, ...... 293 Fistula of th?. Gum of the Lower Maxillary, having an Exte- rior Opening at the Hollow of the Chin, . . 296 Spongy or Fungoid Inflammation of the Gums, . . 297 Hemorrhage from the Gums, .... 299 Inflammation of the Teeth, .... 301 Absorption of the Sockets, ..... 308 CHAPTER XYII. Diseases of tee Lips, ..... 312 Hare-Lip, ....... 312 Adhesion, ...... 317 Contraction, . . . . ... 317 Xll CONTENTS. CHAPTER XVIII. Diseases of the Gland-Ducts, .... 322 Salivary Tumors, . . . . . . 322 Tumors of the Submaxillary Gland, . . . 325 Notes of the Operation, ..... 330 Tumors of the Parotid Glands, .... 336 Salivary Fistula, . . . . . .338 CHAPTER XIX. Tumors requiring Amputation of a part or the whole of the Upper Jaw, ... . . . 341 Amputation of the Lower Jaw, .... 344 CHAPTER XX. Diseases of the Antrum, or Maxillary Sinus, . . 354 Dropsy, or Retention of Mucus, . . . 355 Inflammation, ...... 361 Suppuration, ...... 362 Caries, Necrosis, and other Morbid Conditions of the Bony Walls, 363 Softening of the Bony Walls,- . . . . 370 Exostosis, . ' . . . . . . 371 Fistula of the Superior Maxillary Bone, . . 374 Ozena, ....... 378 Polypi and other Tumors, . . . . 379 Insects in the Cavity, . . ... . 384 CHAPTER XXI. Diseases of the Palate, . . . . 387 CHAPTER XXII. Anesthesia, . . ... . . 400 INTRODUCTION. The body of every animal is wisely contrived and per- fectly 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 obser- vable 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 in- dividual 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 de- signed. Should a naturalist ascertain that a single bone presented to him was constructed for purposes of prey, he would immediately infer that a 1 beast so provided must have had strong muscles and bones of the neck and jaws, to ena- ble it to hold and tear the animals upon which it. was in- tended 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 reception and assimilation of the food thus procured. 14 INTRODUCTION. The body of man must then be regarded as a unit, and though, for the convenience of description, we speak of its multitude of parts, it is a single organization, fed by one aliment, nourished by one blood, vitalized through one ner- vous system, directed to a common purpose, subject to one sovereign will, and pervaded by a general law of conti- nuance, decay and dissolution. 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 con- cert in carrying 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 mo- tion, infinitely complicated 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 certain aptitudes, through which any part more par- ticularly attacked may receive succor from the rest. More- over, 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, im- properly so — and constitutes one of the most interesting and beautiful peculiarities of organized structures. In many instances the dependence of one part upon ano- ther is so direct, and the mode of communication so obvious, that there is no difficulty in detecting the process of sym- 2uv, -with, 7ta&05, suffering — fellow-suffering. INTKODUCTION. 15 pathetic 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 sym- pathy of parts, there is a general interest of the whole organ- ism in the welfare of all its parts; and severe or long-conti- nued suffering in any one, however comparatively unimport- ant, 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 sympathy of disease. It cannot, therefore, be predicated of any organ, that its suffering is necessarily unimportant to the health of the whole system, since experience shows that the danger of al- most all disorders depends very much upon the sympathies likely to be established in the course of their progress, and that the importance of these sympathies is not always deter- mined by that of the organ originally involved. The facts above stated are universally admitted by the medical profession, and for the most part are recognised as important 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 sur- geon is expected to become conversant with all of medi- cine, as necessary to the proper care of any one of the or- * Avrog — w\p, one's own eye — actual sight of the parts of a dissected body. 16 INTRODUCTION. gans of the body. An oculist, unless a thorough physician, would be utterly unqualified to treat diseases of the eye # The obstetrician must extend his knowledge far beyond the uterus, if he would claim a participation in the fellowship of medical science. Until very recently, however, the treatment of the diseases of the teeth seems to have been considered less a proper spe- cialty 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 contented to leave them to the care of any who were willing to take charge of them. Even now, dental dis- eases are rarely mentioned in the medical schools, and eminent professors of surgery have publicly confessed themselves in- competent to teach their students how to extract teeth. 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 con- tinually 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 profession, have turned their attention to den- tistry, and of necessity have applied their previous informa- tion to the augmentation of dental pathology and therapeu- tics : and, finally, the management of the teeth has come to be an acknowledged specialty of medical science, and is ra- pidly advancing in public and professional consideration. It is thus that other departments of the healing art have gradually won their way to their present position and import- ance. Within a period comparatively recent, surgery in all its branches was regarded by physicians with sovereign con- tempt. Barbers were the operators, and mountebanks and old women dressed the sores. Midwifery was, if possible, INTBODUCTION. 17 held to be more despicable, and even within a few years, an eminent body of scientific physicians have declared obstetrics to be unworthy the attention of a polite gentleman. It is necessary to say that surgery and obstetrics are now leading branches of the profession, and are zealously prac- tised by men of the first talents and greatest scientific and lite- rary acquirements. To our country belongs a large share of the honor of placing these two departments of medicine upon their pro- per level with other professional pursuits. The depressed condition of surgery and midwifery was the consequence of the vulgarity and ignorance of those who practised in those departments, and the bad reputation thus acquired was a formidable obstacle in the way of those who attempted to elevate them to the dignity of scientific pur- suits, but patient continuance in laborious and honorable ef- fort 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 educated men, it necessarily fell into the hands of the igno- rant and rude, and precisely as surgery and midwifery have gradually emerged from their barbarous state and attendant dispute, dentistry is now winning its way against all opposi- tion, 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 sur- gery 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 ex- isting between the teeth and the rest x>f the body. These connections are far more important than is generally 2 18 INTRODUCTION, supposed by physicians or dentists. The reader of the fol- lowing pages will probably be surprised to find so great a variety of disorders treated of as directly or indirectly con- cerned 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. I have endeavored to present an elementary view of the disease, from which the dental student may acquire such a knowledge of common facts and general principles as may prove a guide in the application of special- art, and the foun- dation for the building up of such farther scientific acquisi- tions as experience and study may win from faithful profes- sional life. My purpose will have been in good measure at- tained, if perusal of these brief chapters shall awaken desire for more extended medical knowledge, and lure the dental student into the rich fields of learning, that lie all about the narrow and comparatively barren spot occupied by the spe- cialty of dental surgery. A TREATISE ON DENTAL MEDICINE. CHAPTER I. PRELIMINARY DEFINITIONS. 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 at- tended with alterations of the phenomena which experience authorizes 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 detected by our present means of investigation. Many attempts have been made to define the essential na- ture of disease, but all have necessarily failed. It is impos- sible to frame with philosophical accuracy a definition of disturbed or altered conditions, unless we perfectly under- * 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. 3 26 PKELIMUSTAKY CONSIDEKATIONS. stand the nature of the organs ; and the mode of their acts. We cannot understand the ultimate cause of morbid pheno- mena, while 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 medi- cal language does not pretend to the precision of abstract philosophical science. Medical definitions are not to be re- garded as accurately stating the nature of things, but sim- ply as descriptions which may serve for practical purposes. This fact has been forgotten by many eminent medical wri- ters, and their efforts to be absolutely accurate have often led to serious mistakes, and always to confusion of ideas and contradiction of facts. The study of essences belongs to me- taphysics, not to practical science, and having failed to reach any truth by analyzing mind, it will hardly prove success- ful 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 perfectly well to convey what knowledge we have of curative science, they will not bear the test of strict philosophical examination. For example, the word life, as used by medical 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 production of organic acts. Disease means all the morbid phenomena 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 production. Thus a patient may complain of nau- sea; this sickness may be consequent upon defective diges- tion; the defective digestion upon interruption of the func- tion of the liver; the interruption of the hepatic* function * Hepar — the liver. PEELIMINAEY CONSIDERATIONS. 27 upon change of structure in that organ; and that change of structure upon more minute pathological* conditions. Strict- ly speaking, we might regard all this train of evils as symp- toms merely of some obscure and inappreciable change which constitutes the disease. But in that case the Word would be of no practical use. This instance may suffice to illustrate our meaning, and the student may be saved much embar- rassment by keeping the fact thus presented always in his mind. Many false theories and much bad practice have re- sulted from attempts to philosophise in medicine. It is an experimental science, embodying the results of long experi- ence 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 understand the phi- losophy of it; but we know what effect it does produce, and that knowledge is sufficient, and infinitely 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, accurate definition being impossible, all of them are improper ; and many of them strangely ab- surd. We can describe disease readily enough, but we cannot detect and exhibit its primary elements. Probably we would not be practically wiser if we could do so. Life, then, may be considered as the effects produced by organization. Health, the regular and orderly development of these effects. Disease, disorder and irregularity in their manifestation, or impediment to the accomplishment of one or more of them.f Physiology J has to do with the performance of healthy or * Pathological — ua&ug, suffering, koyog, discourse; that which relates to diseased conditions. fRoche and Sanson, Nouvenux Elements. J$U(xt?, nature, XoyOi, discourse. 28 PRELIMINARY CONSIDERATION'S. natural acts, and physiological medicine or hygiene with the preservation of health. Pathology is the science of -diseased condi tions. Therapeutics* the art of applying remedies for the cure or relief of disease. Anatomy f is the study of the body as an organized machine. Surgery,J 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 general reference to practical dentistry. *@spa7Tsvio f I cure. f AvaTf^vw, I cut up. $x««(?> the hand, sQyov, work. $EtiJ, 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 impres- sion upon the outward or interior parts of the body. Thus poison inhaled 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 connection and dependence .of parts ; or by the influence of the intelligence itself, which often embarrasses, 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 mean- ing intended. It must not be supposed that general causes necessarily produce general diseases, and vice versa. A lo- cal cause, acting only upon a very small surface, may pro- duce universal disorder, while a general cause may beget a strictly lpcal disease. A plunge into cold water, drenching the whole surface, may produce nothing more serious than a 30 ETIOLOGY. tooth-ache; while a prick of a finger may cause serious ge- neral disorder and even death. Further subdivisions of causes are based upon the charac- ter of the effects which they produce. Some' stimulate or in- crease the action of the blood-vessels; others debilitate or les- sen such action. Some act mechanically, dividing, tearing, bruising, &c.; others chemically, burning, corroding or de- composing. Predisposing causes are those which exert an influence sufficient to make parts more liable to disorder, without ac- tually disordering them. This term, again, is not absolutely accurate, for we cannot conceive of these causes acting in any other way than by producing 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 im- mediately precede disorder, and are reasonably inferred to have induced it. It must not be supposed, however, that these divisions are absolutely 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 predisposing and the alcohol exciting. On the other hand, a man may become intoxicated, and while thus enfeebled he may be exposed to cold, and fe- ver or inflammation might result. In this case, the alcohol and its effects would be the predisposing, the cold the exci- ting, cause. Some causes are utterly unknown, but are inferred to ex- ist as agents differing essentially from known causes, from A the peculiarity and uniformity of their effects. These are called specific. The causes of scarlet fever and of whooping cough are examples. ETIOLOGY. 31 Almost every thing without and within us may, in some way or other, be productive of disorder to the human body. The air we breathe may carry into the inmost recesses of our system, invisible poisons, to hurt the lungs or spoil the blood ; it may withdraw our heat too rapidly, or it may fail to re- lieve us of our excess of caloric ; it may itself undergo chemi- cal changes which deteriorate its qualities, and render it more or less unfit for respiration. The food we eat may pain or sicken or convulse us. It may suddenly prostrate, or gra- dually destroy us. Water, even when pure, may irritate the disordered organs of digestion, and when impure, may carry unsuspected drugs into the stomach. Even the light of hea- ven may harm the delicate eye, and the sun's propitious 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 pleasure, 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 undergoing change, and in all its parts a law is at work which impels the whole to decay and dissolution. Linked together by exquisite sympathies, traversed by numberless nerves and blood-vessels, performing most delicate and im- portant functions, and pervaded by a powerful moral intel- ligence, whose passions and appetites excite and depress the physical system to its utmost limits of endurance, the parts 32 ETIOLOGY. of the body are continually liable to become diseased, and to radiate disorder 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 dis- ease 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 pro- duction of those diseases which the dental surgeon is expect- ed to treat. THE ATMOSPHERE * The air acts upon us in a variety of ways. By its pres- sure upon us it keeps us in form ; without that pressure the fluids coursing within us would overcome the resistance of- fered 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 element increased or diminished, we must suffer hurt. It is also the vehicle by which watery vapor acts upon our out- ward 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 supposed to produce serious epidemic affections. Persons who ascend high mountains generally suffer much from embarrassed re- spiration, and hemorrhages and pulmonary affections have been traced to changes in the mechanical action of the at- mosphere. * The atmosphere is composed of two great elements, called oxygen and nitrogen, with a small portion of carbonic acid. ETIOLOGY. 33 Unless the supply of air be unequal to the want, the quan- tity of oxygen in the atmosphere has never been found defi- cient; but where persons have resided or been confined in crowded and ill-ventilated rooms, the most serious conse- quences 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 de- crepid, deformed, and even idiotic people, who bear sad tes- timony to the evil effects of depraved air. Heat and cold are universally recognized as having much to do with the causation of disease. Caloric or the matter of heat pervades all bodies, and constantly tends to an equi- librium. The animal heat which is elaborated by some ob- scure process, but little understood, obeys the common law of caloric, and constantly passes off to bodies less warm, or re- ceives increase from those more heated. Our sensations of heat and cold are therefore nothing more than indications of the loss and supply of caloric to our surface. When it passes off in greater quantity than we can supply it with com- fort to ourselves, we complain of cold ; when surrounding bodies draw less from us than we are in the habit of supply- ing, or communicate to us of their own excess beyond our wants, we feel heated. These variations in our state of ca- lorification are not limited in their effect to the production of certain sensations. They are capable of causing great dis- order in the performance of function, and creating morbid conditions of the most serious kind. Heat is an excitant ; cold must therefore be a depressing agent. Heat induces increased action of the heart and ar- teries; cold diminishes that action. But in considering the consequences of agents acting upon the human body, we must always remember that it is a 34 ETIOLOGY. living machine, and is not merely passive under modeling influences. A thorn penetrating the substance of an inani- mate machine, would produce no other consequence than the mere perforation; but should it pierce the human body, it would induce 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 increased action. Cold will not only contract the tissues, but lessen action. Further, heat, if long continued, will exhaust the vigor of the nervous and vascular system, and thus debilitate the whole frame; for it causes the or- gans to work more rapidly than usual— consequently to con- sume 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 circu- lated 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 ap- pear more than commonly vigorous, but the result must be that the supply of means soon falls below the usual consump- tion, and languor, depression or exhaustion results. Heat,* in other words, is an excitant or stimulant, and all agents of this class will enfeeble as a 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 power- fully to overcome morbid influences. This power we call re- action, and its chief phenomenon is increase of vascular ac- *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- 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. ETIOLOGY. 35 tion up to and beyond the natural standard. When cold is suddenly applied to the body, the first effect is to lessen vas- cular action and nervous sensibility; but unless the applica- tion be very long continued, the circulation \vill soon resume its vigor, a glow of warmth will succeed to the chill, and per- haps the heart and arteries may work with a force and fre- quency incompatible with health. In order to explain certain pathological conditions, of very common occurrence in every part of the body, it is also im- portant to observe that when parts are suddenly chilled by the rapid abstraction of their natural heat, their nervous excitabi- lity, 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 summer. To a man nearly frozen, it would be death often to bring him to a blazing fire. Frost bites are often strictly burns in- flicted at very low temperatures, upon parts unusually sus- ceptible 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 out the excitability, and renders the body difficult to be im- pressed. Debility or weakness may be connected with both of these nervous conditions; hence weakness alone is not a characteristic 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; an- other, exhausted by long continued intemperate drinking, *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 accumula- ted 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. 36 ETIOLOGY. might be equally debilitated, but could not be excited by im- mense quantities of distilled spirit. These remarks upon the effects of cold and heat will ena- ble us to understand the mode of production of many parti- cular affections through the agency of atmospheric changes. Excessive moisture in the air is also a common cause of disease, but only because the watery vapor withdraws our heat much more rapidly than dry air, at the same tempera- ture, 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 distances from their source, and apparently when much diluted by atmospheric mixture; and others have never been traced to any local origin, and while apparently poi- soning the air over immense spaces, produce no change in it which is appreciable to our nicest tests. Of the first class are the contagious , which may be propa- gated either by direct contact or by atmospheric infection within short distances : of the second are the causes of ende- mic diseases, and of the third are the inscrutable agents which produce those wide- spread disorders which we call epidemics.* The scope of our work does not include the causes of con- * Endemic, iv^rjfxog', Epidemic, evifrjftos. By endemics we mean diseases largely prevalent in a certain vicinity, and often traceable to a local cause, and always dependent upon such. An epidemic lias no positive connection with locality, and evidently does not spring from a local cause. The yellow fever is an example of an endemic ; cholera of an epidemic. Local causes, however, have much influence in giving efficiency to epidemic causes. Damp and foul air has been observed to give extraordinary activity to the cholera poison. But in such cases we cannot tell whether the result is due to in- crease of the active poison or decrease in the power to resist it. ETIOLOGY. 37 tagions and epidemics ; but as certain endemic diseases fre~ quently exhibit themselves in the mouth and face, and very much embarrass the dentist who may unfortunately be igno- rant of their cause, nature and treatment, it is necessary for us to notice particularly the atmospheric vitiation which causes them. It has been observed, from time immemorial, that the bor- ders of sluggish streams and stagnant pools, and the vicinity of marshy grounds are unwholesome, and that persons who dwell in such places, or even remain there during a short time of certain seasons, are subject to peculiar disorders, not ob- served elsewhere, and evidently not produced from ordinary influences. To the causes of these diseases, which, though unknown in their nature, must be immediately connected with the peculiarities of the locations in which only they act, several names have been given, such as marsh miasma, ma- laria, and marsh poison. To this agent must be attributed by very far the greatest part of endemic diseases, and those which are most destruc- tive of health and fatal to life. The yellow fever of the West Indies and America, the plague of the Mediterranean coasts, the coast fever of Africa, the jungle fever of India, the remit- tent or bilious, and the intermittent or ague of many places, and many other affections which it is unnecessary to men- tion, are the productions of the poisonous emanations from wet soils. We have not as yet been able to discover the nature of marsh poisons. The most careful analysis of air selected from the pestiferous fens has not developed any alteration in the proportion of the elements of the atmosphere, nor any foreign matter whatever. Yet we have sufficient evidence to justify us in believing that the poison does act through the atmosphere, and, the failure to detect, only proves the inadequacy of our means of analysis. 38 ETIOLOGY. Malaria is evolved during the day by the action of the sun upon wet ground containing dead vegetable matter. It as- cends with the watery vapor which is simultaneously disen- gaged, and commonly requires to be precipitated and con- centrated by the cold of evening before it exerts its ma- lign influence. Hence the popular dogma that summer dews are unwholesome ; an opinion based upon the experience of the fact just stated. The danger, however, is not from the dew, but from the concentrated malaria simultaneously pre- sent. In non-malarious regions, dews do no other harm than mere moisture may occasion. They never induce agues nor bilious fevers, dew owing its evil reputation altogether to being often found in bad company — an inference which purity escapes, even more rarely than it does contamination. There are cogent reasons for supposing that the cause of the endemics in question is not one and the same for all of the distinct disorders belonging to the category of malarious diseases, but that each has its separate and peculiar poison, though all are the product of vegetable decomposition under the combined operation of heat and moisture. It would be incompatible with the design of the present work to discuss this and other interesting questions connected with these wide-spread and destructive emanations. The subject, how- ever, is well worthy of the careful attention of every man, and especially of every student of medical science. Igno- rance of facts connected with this subject which might be learned in a few hours, annually causes the death of many, who unnecessarily expose themselves to the assaults of fatal pestilence. The only known prophylactics'" against malaria are the intervention of thick woods between the source of the poison and the house, and the rarification of the evening air of the dwelling by fires. * Ilpo question. In inflammation, the vascular system is more inclined, and the part is sensitive, often ex- quisitely so, to pressure. Spasm is less likely to be attended with high arterial action, and the seat of it is often gratified rather than distressed by pressure. These distinctions, how- ever, are not always to be relied on. It is often very dim- cult to distinguish spasm of the womb from inflammation of the organ and its appendages ; and even colic is sometimes attended with inflammatory symptoms — more or less compli- cation of spasm and inflammation existing. CHAPTEE V. GENERAL REMARKS ON THE TREATMENT OF DISEASE. The first step towards the cure of disease is to remove the cause which has produced it. Unless this can be done, we must be very much embarrassed in our efforts to relieve, inasmuch as the morbid conditions are continually liable to renewal. The impracticability of doing this effectually, forms the most serious obstacle to the successful treatment of many disorders. Children teething during very hot weather are subject to the action of combined causes, which often induce diseases which are very serious and very difficult to be controlled, while the causes continue to act. Dead teeth remaining in the mouth may provoke a series of unpleasant and even danger- ous evils, which cannot be removed while the cause of them remains. It must not be supposed, however, that the removal of the primary cause of the disease will necessarily procure the sub- sidence of the disease itself. If a man pierce his flesh with a thorn, the wound will remain and may give great pain after the foreign body has been extracted ; the effects of a wound from a bayonet or musket ball may manifest themselves in serious and fatal disease long after the instruments of the in- jury have been withdrawn. The same truth holds good in all kinds of injuries by whatever class of agents they may be produced. The absolute rest of a diseased part, when the nature of its function permits, and the least possible exertion of others, is very conducive to cure. TREATMENT OF DISEASE. 57 There are, however, certain exceptions to this rule. Certain mordid conditions of the articulations are improved by exer- cise ; a particular mode of ocular affection requires the light, &c. ; — but the exceptions are few and the rule general. The regimen of the patient, that is his diet, clothing, exer- cise, employment, &c, require judicious management. Finally, the most important part of treatment consists in the skilful application of therapeutical agents, and surgical means ; but of this part of the subject we will treat particu- larly when considering special diseases. The natural idea of remedies is, that to each disease there is an antidote or direct curative, and that good practice con- sists in so distinguishing the one as to be able to prescribe the other. Nothing can be more untrue. We have few me- dicines that even seem to antagonize disease directly, and those, no doubt, act mediately, as other medicaments do. These few medicines we call specifics. They are drugs, the administration of which is often followed by the disappear- ance of certain well-marked disorders, the nature of which is very obscure. The practice of prescribing medicines which act mysteriously to cure disease is called empirical. It may be, nevertheless, good and scientific practice. But it is only in a few instances that empirical practice is justified by long and sure experience. Any system of medicine that is based upon the principle of antidotes or antagonism, is radically wrong, and must be practically destructive of health and life. The human body is not a machine, consisting of isolated parts related to each other only by position, and capable of being separately altered, repaired, or renovated. Nor is disease an abstract thing, to be dealt with directly and overcome by force applied to its own hurtful quality. The human body is an exceedingly complicated organism, whose aggregate ef- forts constitute one life. The nature of the organs and of' 5 58 TREATMENT OF DISEASE. their life is incomprehensible. Disease is, when appreciable to us, only a modification in the structure or function of an inscrutable organ, attended by more or less embarrassment in the work of other organs and inconvenience to the whole life. By certain means we have the power to exalt, depress, and modify the vital activity of parts, and our reason and ob- servation teach us that in the use of these means we may aid very materially in the effort at restoration which nature con- tinues to make until life is extinguished. The treatment of disease consists in thus aiding nature, and requires the exer- cise of the most general knowledge, the closest observation, the purest reason and the quickest intelligence. There is no employment in which the practitioner should rely more on himself and less on his means. Medicine, is the most purely intellectual of the professions. The knowledge of the powers of medicines is a remembrance of facts acquired in the long experience of mankind, especially of men, professionally as well as naturally qualified, to make observations on the phe- nomena of the life of the human body, as they have been de- veloped under the presence of substances not ordinarily used upon it. The use of these medicines requires much more than a recollection of the circumstances under which they have been used before, and the apparent results of their use. It requires a capacity, derived from various sources, to de- termine whether medicines ordinarily followed by given re- sults are likely to be useful in a present case, differing more or less from all others. No two diseased conditions are found to be exactly alike. Though nature admits of boundless re- semblances, she positively forbids u 59 CATALOGUE OF DISEASE. Many of the morbid alterations which seem to constitute disease, or to cause symptoms, have been observed upon the living and the dead subject: many others have as yet escaped detection. We are unable, therefore, to compose a full list of these different conditions of parts, but those which are of common occurrence, and are well ascertained, may be de- scribed as follows : 1. Eedness, swelling, and loss of cohesion of tissues. This is the most common of all modes of alteration, and is the cause of a large part of the disorganizations observed in the body ; it is called inflammation* The local symptoms of this con- dition are heat, redness, swelling, pain, and diminished, al- tered or suspended function. The general symptoms arejpy- rexia, or fever, of a particular type, seemingly connected with altered state of the blood. 2. Stuffing or engorgement of the veins, or congestion. The symptoms are not so well defined as in the first kind. of affection. The local suffering is generally much less, though when certain organs, such as the brain and heart, are the seat of congestion, the pain and discomfort are often very consi- derable. The function of the congested organ is greatly em- barrassed, or altogether suspended. The general symptoms are commonly such as mark diminished action. 3. Eed indurations ; vegetations; fungi, polypi. 4. Vesicles, pustules, suppuration, erosion, ulceration, per- foration, gangrene. * Ilvg, fire — from the burning sensation and heated appearance of patients in fever. (5)* 60 CATALOGUE OF DISEASE. 5. Thickening, granulations, thickness of tissues naturally transparent, adhesions, effusions of serum, false membranes. 6. Conversion of one tissue into another. 7. Gray induration, gelatinous degeneration, tubercles, en- cephaloid matter, cancerous matter. 8. Contraction, dilatation and complete obliteration of na- tural canals. 9. Accidental canals, fistulas, accidental tissues, cysts. 10. Development of gas in cavities. 11. Living bodies in organs. 12. Effusions of blood, collections of blood. 14. Chalky, stony, hairy, horny, and melanotic* produc- tions. 15. Changes of form and relation, wounds, ulcers, disten- tion, lacerations, ruptures, fractures and dislocations. 16. Foreign bodies. 17. Vices of formation/)* The fluids of the body, especially the blood, are doubtless capable of undergoing change primarily, and communicating distress and disease to other parts. But the pathology of the fluids is but very little understood. The same may be said of the nervous matter, of the nature of which we know nothing. The above catalogue is therefore very defective, as it takes no notice of some of the most common and most important of all diseases, such as fever ; and describes as diseases, con- ditions which are only incidental to other, previous, and more important phenomena. Nevertheless, it is as accurate, or nearly so, as the present state of medical science will permit. It is my purpose to select from this list such pathological conditions as are particularly connected with the pursuits of the dentist, omitting none, which, even in a remote degree, concern him, and passing by those in which he has no pro- fessional interest. * MiXoc— black. f Roche & Sanson, Path. Med. Chir. CHAPTEE YI. INFLAMMATION" AND ITS CONSEQUENCES. The most common, and by far the most important of all morbid conditions, is one, the prominent characteristics of which are pain, redness, swelling and heat. This is called Inflammation, and may occur in any part, naturally possess- ing sensibility. It is an unusual, though, we cannot say always perverted, condition of the vessels and blood of the parts concerned ; at- tended with alteration or suspension of its natural function often accompanied with entirely new vital acts, through which tissues are destroyed and reconstructed, vessels perforated or permanently closed, and devastation or renovation of the so- lids procured. It is the great destroyer and preserver of the body, or rather it accompanies the extraordinary vital con- ditions through which organization is broken up or preserved, and often seems as inseparable from the one as the other* Hence it has been called "Nature's Surgeon," though but for it, surgeons and physicians would have little to do. Cer- tainly a degree of inflammation is often inseparable from re- cuperative processes, and though we may imagine the process to be present, without the attendant inconvenience, we are obliged to submit to the union, and invite inflammation to do what neither knife nor ligature can accomplish. From this fact, considerable confusion has arisen among medical philoso- phers as to the terms which should be used in speaking of inflammation ; but practically, there is little perplexity about 62 INFLAMMATION AND ITS CONSEQUENCES. the matter. The student of disease soon learns to distinguish the inflammatory condition that is likely to end well or ill? and to know whether he should interfere to abate or exalt the process. In surgery, inflammation is often not only tole- rable but desirable — in Medicine, it is almost always a thing to be dreaded, prevented, and abated — but even in Medicine there are a few occasions when the physician watches for the active inflammatory process, as the mariner on a dangerous coast watches for the light of day. Inflammation is, in fact, a very comprehensive term, applied to a great variety of conditions in which local vascular activity and deranged cir- culation are prominent features. The influx of healthful blood freighted with reconstructive flbrine — that comes to repair a sudden breach of continuity, and with little distur- bance of surrounding sensibilities, deposits its precious lymph between the gaping lips of the wound — is attendant with red turgescence and is called inflammation. The more copious flow that distends unruptured vessels and forces through their coats a serous exudation, is called inflammation. Should lymph be thrown out, and a mixed tumor be formed, and a new product be created amidst burning and throbbing and gene- ral distress, we call the process inflammation. And should local ruin ensue, and the blood dissolve and tissues break up and chemical laws assert their dominion, we say that inflam- mation has done it all. Nevertheless there is no essential difference between what has been called "healthy and unhealthy inflammation." There are circumstances under which the most unexceptionable character and quality of inflammation proves fatal — and any quality of it may rapidly change and become unhealthy by a modification of the action of the diseased condition, — not reaching to a change in the essential nature of the disease — " Healthy inflammation " is nothing more than such an inflamed condition as, under the circumstances, is likely to end well INFLAMMATION AND ITS CONSEQUENCES. 63 — "its healthfullness" is not in itself, but in its circumstances. An abscess on the surface, and containing perfect pus, an- nouncing certain cure, would be a very "healthful" affair, but a similar one in the liver would be a very "unhealthful" tumor ; or the same superficial abscess, without ceasing to be inflammatory, might suddenly throw out a very unhealthy pus, or cease to provide any, and put on appearances indica- tive of destruction. Certain appearances give reason to believe that the inflam- mation is proceeding towards cure. While these exist, we call the inflammation " healthful." The process of inflammation, supposing a case to go regu- larly through what may be presumed to be its natural stages, is as follows: The exciting cause being applied, (whether it be immedi- ately exciting or depressing, is of no consequence, inasmuch as high action may ensue upon either provocation) blood is sent through the part with augmented velocity. The cause of this is no doubt due to modification of the nervous sensi- bility of the part, but the manner in which this acts is in- scrutable. The capillaries and minute arteries are distended. This may arise from the fact of their being naturally diluted under a certain degree of irritation, as is evident from the reddening of the skin by friction and the phenomenon of blushing ; or from their mechanical distention under increased pressure. Capillaries which previously contained but single files of the red corpuscles, now admit of them rolling through in masses ; and these come crowding in. Y essels. naturally invisible, are visible now, shooting over clear white spaces like lines of fire. A burning pain, modified by the sensibi- lity of the part concerned, accompanies this stage of inflam- mation, and the function of the organ is seriously impaired in proportion to the extent of it involved. The eye, for in- stance, is rendered useless from a moderate degree of super- 64 INFLAMMATION AND ITS CONSEQUENCES. ficial inflammation. As dilatation increases, the blood is checked in its progress through the distended vessels ; more sluggish turgescence ensues, and the thinner part of the blood transudes, and the parts adjacent become more or less dis- tended with extravasated serum, or with the "liquor san- guinis." This condition may amount to little more than healthful excitement ; the vessels being a little too full, and tending to throw off some of their fluid contents ; or it may amount to serious obstruction in the circulation. The condition may remain for a brief period and then sub- side, or may advance to a more vigorous stage of inflamma- tion ; or it may become persistent or chronic, the sensibility becoming accustomed to the new condition, the pain disap- pearing and slow modifications of function or constituent or- ganization resulting. Inflammation increasing, there is ex- tension of the excitement to the arterial trunks that supply the part. More blood and of altered character is sent to the inflamed spot. The capillaries no longer maintain their vi- tal elasticity; they enlarge like mere material tubes under the severe pressure. The circulation moves heavily through the part ; "the red corpuscles are no longer limited to the cen- tral current, but encroach more and more on the lateral and clear " lymph spaces." Exudation is more copious than in the previous stage, and of a different kind. It consists chiefly of " liquor sanguinis," and this is altered from the healthy standard. The fibrin is increased, not only in quantity, but also in plasticity, or tendency to become organized."* Some of the small vessels very commonly give way and permit the altered blood to flow out. The fibrine is diffused among the tissues. Even that which is regularly supplied becomes excessive from the arrest of formative power in the * Miller's Surgery. INFLAMMATION AND ITS CONSEQUENCES. 65 disordered part, and tends to form new structures to be changed into an excretive substance — a fact that plays an im- portant part in the immediate and remote consequences of inflammation. The state of things is thus summed up by the author already quoted: — "The over-distention of the capillaries is established; the capillary power is, for a time, gone ; perhaps in consequence of diminution or actual suspension of their nervous influence, and the coats of the capillaries and other vessels are spongy, softened, and impaired in cohesion, being themselves the sub- jects of structural change. The languor of circulation ap- proaches stagnation, and at some points this has actually oc- curred ; every part of the distended capillaries is occupied by crowded colored and colorless corpuscles . . . Altered liquor sanguinis is exuded in profusion. The attenuated and soft- ened capillaries also give way in their coats, and from the lesion blood is extravasated in mass. Suppuration is in pro- gress by extra- vascular degeneration of the fibrinous exuda- tion, or as some suppose, by a secretive elaboration of it ere yet it has left the vessel. The parenchyma, infiltrated by li- quor sanguinis, pus, and blood, softens and is broken up, and the disintegrated texture becomes mixed with the escaped contents of the vessels. The formative power has ceased, and the opposite condition, a tendency to disintegration from di- minution of vitality, has become established. Disorder of function is complete. Secretion for example, being in the first place arrested, and, when restored, more vitiated than before. In the circulation of the part truly inflamed all is sluggishness and stagnation, but that of the parts around is unusually active. The arterial trunks in the vicinity con- tinue to play with increased energy ; blood continues to be sent, but cannot now be transmitted in its direct course. In the inflamed parts it meets an obstruction, and being sent round another way, it throws a stress on the collateral ves- W INFLAMMATION AND ITS CONSEQUENCES. sels; tliese ; however, retain vigour sufficient for the aug- mented labor and pass the current briskly round." "While the apparatus of deposit is thus unusually busy, that of absorption is in abeyance. During inflammation, the lymphatic and- minute veins do little or nothing as absor- bents." The regular sensible progress of inflammation may then be said to be from a condition of morbid excitation, attended with simple serous effusion through a higher grade of disor- der, attended with exudation of plastic, flbrine and liquor san- guinis; altered condition of the blood; feeble capillary ac- tion; and more complete arrest of function, to the ultimate stage of inflammation, a condition in which there is extrava- sation of blood, destruction of texture and formation of pus, of more or less perfect quality. Mr. Miller shows very clearly that something like this is a natural gradation of inflammation, by pointing to familiar examples, where we constantly observe the several conditions in the natural relation to others of comparative distance from a common centre. In a common abscess we find the cen- tral portion broken up, and the seat of suppuration soft and fluctuating. Beyond this is a less prominent and harder portion marking where the inflammation has been of less active grade, and only caused fibrous effusion ; and exte- rior to this a soft cedematous circle where serous effusion has relieved the smaller vessels. When the suppurative or destructive condition has been reached, inflammation may be said to be at an end, and we have to deal with its consequences. But one of these consequences is inflammation of tissues adjoining those thus greatly impaired, and so — as we rarely lose sight of inflammation in the treatment of the case — we are in the habit of regarding the results above described as terminations or natural conclusions of, or incidents to inflam- mation. It matters little, however, what we call them. INFLAMMATION AND ITS CONSEQUENCES. 67 Pain is a very characteristic symptom of inflammation. It commonly begins with the formation of the disordered con- dition, increases with its augmentation and declines with its abatement. It is therefore a very valuable index to the com- parative condition of the part, and where we cannot see the color, nor note the swelling, nor perceive the heat, we have to rely a great deal upon the single local symptom observable by ns. The subject, therefore, is worthy of particular atten- tion. The cause of the pain in an inflamed part is not very ob- vious. The mechanical pressure of distended parts and strongly pulsating arteries upon irritated nerves, has more or less to do with the suffering. This is evident from the fact that increased pressure intolerably aggravates the pain. The slightest touch sometimes gives agony. In inflammation of the peritoneum, the patient will not bear the pressure of bed-clothes. Indeed, this sensitiveness of an inflamed part to pressure is so characteristic, that it enables us to distinguish spasm and neuralgia from inflammation. Yet it is plain that pressure is not the only cause of pain. The sensibility of the nerves is exquisitely exalted. As we have already said, a touch will sometimes cause a severe pang. The pain ap- pears before the distention, and where distention exists to the most fearful extent there is often no pain at all. Patients die of deep congestions without any acute sensations in the distended parts, and dropsies that press the viscera and distend muscles and skin to a frightful extent, create no such pain as would be felt in a moderate inflammation of the coats of one of the organs subjected to pressure. The pain of inflammation is, as we have said, continuous with it, and is indicative of its degree. It is also characteristic- as regards the tissue or organ in which it is seated ; a valuable fact in diagnosis. Sudden disappearance of acute inflammatory pain indicates 68 INFLAMMATION AND ITS CONSEQUENCES. the occurrence of a change in the condition of the part ; but commonly a very unfavorable one. Inflammation does not suddenly get well — but free effusions may cause abatement of pain — so may the formation of pus — and the occurrence of mortification may relieve it altogether. Patients and their friends are often misled by the natural association of pain with disease, ease with cure. The degree of pain is affected by the natural sensibility of the organ in which it is seated. The skin being exquisitely sensitive, as the sentinel on the outpost of life must be, suffers much more when inflamed than muscle or cellular tissue. The parenchyma of or- gans is much less sensitive than the membrane that invests them. The hard unyielding character of the bones makes the process of inflammation in them very painful, until free discharge of inflammatory products is obtained. The inflamed mucous membrane gives out the burning sensation of the skin, but in a degree proportionate to the distance from the exter- nal tegument. The serous membranes are affected with a sharp, darting, lancitive pain. That of the cellular membrane differs very much according to its positions and relations. When in connexion with the skin, it partakes of the pun - gency which characterizes the inflammation of that sensi- tive organ; when the cellular structure of the internal vis- cera is inflamed, the pain is usually dull or obtuse, in conse- quence of the manner in which these viscera are supplied with nerves. When nerves are the seat of inflammation, very acute, darting pangs are felt, and the surrounding structures are ge- nerally very sore, tender, and more or less inflamed. In in- flammation of the muscles, the sensation is aching, mingled with a feeling of fatigue. The pain is greatly aggravated by motion. Inflammation of ligaments occasions sensations not very different. Pain is more or less severe in proportion to the degree of INFLAMMATION AND ITS CONSEQUENCES. 69 the inflammation, the natural sensibility of organs, the yield- ing or unyielding character of parts affected, and the nature of the disease accompanying the inflammation. Certain spe- cific affections, such as cancer, occasion a peculiarly distress- ing, darting, and burning pain. Slight inflammation of the pulp of a tooth occasions intolerable agony. It is very important to study the natural expression of suffering peculiar to each organ, and indicative of the several forms of disease. Pain is not only characteristic, but it has its own symptoms in the correspondence of position, move- ment, and particularly of the countenance. These are often much more reliable than the words of the patient. The higher the grade and the more rapid the pace of in- flammation, the sharper will be the pain. The danger is not always proportionate, for the disease may benumb or depress the sensibility, and in such case the anxiety as to the result will be in inverse ratio to the pain. Spasm, or violent morbid contraction of a muscular part is attended with great pain. But it appears in full severity at first, relaxes and returns, and is not increased, often some- what relieved by pressure. For instance, a man in spasmo- dic colic presses upon his abdomen ; in inflammation of the bowels he lies upon his back and draws' up his knees to re- lieve pressure to the utmost. In neuralgia the nerve is the seat of violent irregular sen- sations of an exquisitely painful kind; but it remits, disap- pears and returns, — is attended with little vascular excite- ment, and is easily distinguished from the persistent ad- vancing pain of inflammation. Pain is not always reliable as indicating the true place of disorder. The ramifications of the nerves and the mysteri- ous laws of sensation that affect them not uncommonly cause the pain to be felt at a distance from the seat of injury. It frequently occurs that a painful tooth is sound, but is lend- 70 INFLAMMATION AND ITS CONSEQUENCES. ing its nerve to a diseased neighbor. The whole arch of the jaw may be thrown into violent suffering by a single dis- ordered member. The shoulder may ache for the liver, and the knee for the hip, and the head for the stomach. Variety in the pain of inflammation indicates the change of stage in the process of the disease. In the early stage, before organic changes have taken place, the pain is burning or stinging. When suppuration is taking place, it becomes deeper and throbbing. This sensation seems to depend on the great obstruction existing, and the energy of the excited arteries in their attempts to overcome it. It is regarded as a symptom of a suppurative condition, or one that will terminate in sup- puration. The swelling of inflammation depends upon the distention of the vessels, and the accumulation of extravasated fluids. It is greatest when the tissues are least resistant, and by no means measures the amount of disease or danger. Where there is least swelling, as where the inflammation is confined by tight dense structures, the pain is excessive, and destruction of parts certain, unless artificial relief be given. Extravasation relieves the distended vessels, both mechani- cally and by taking off their highly stimulating contents. Redness. The redness of an inflamed part is caused by the greater amount of blood in the part. The vessels are dis- tended with redder fluid owing to the transudation of the se- rous elements. Capillaries ordinarily invisible are made red by an unwonted circulation, and extravasated blood adds its deep, sometimes livid, hue to the picture. The degree of redness varies with the ordinary vascula- rity and transparency of the part and the intensity of the in- flammation. Inflamed skin is less red than mucous membrane, and tendons less red than either. The tint indicates the cha- racter of the inflammation. When the disease is of a high character, the parts being in condition to make vigorous re- sistance to change, the color is bright — in reverse conditions INFLAMMATION AND ITS CONSEQUENCES. 71 we find it darker, even to purple; "great attendant biliary derangement gives a yellowish, red." The color of inflamma- tion is fixed with great tenacity. It cannot be made to dis- appear before the inflammation subsides. Even fainting does not remove this color. It is, therefore, an important signal to the observer. Heat. A sensation of heat, sometimes very distressing, is one of the most common incidents to inflammation. It is partly a sensation and partly a fact. The thermometer shows an actual elevation of temperature, but the distress is out of proportion to the cause. The increase of caloric is no doubt due to the contact of an unusual amount of blood with the capillaries, one of whose functions is to separate caloric from the blood. The disordered and hyper- sensitive condition of the nerves accounts for the exaggerated sensations of the pa- tient. Disorder of functional sensibilities attends inflammation. The eye, even when slightly inflamed, cannot bear the light necessary to vision. The brain cannot endure the stimuli to its ordinary activity. The bladder will not retain its com- mon quantity of fluid. Inflamed, nature seeks rest and re- fuses activity. Hence functional activity is impaired or com- pletely suspended. The secretion of secreting organs is checked, suspended, and then altered. Sometimes it is thicker, more tenacious ; at others, thinner and acrid, reddening, or even excoriating the parts over which it flows. An abundant discharge of thickened secretion often precedes and seems to cause the re- lief of inflamed parts. Inflammation is capable of propagation. It always extends more or less from the point of commencement, but in bodies possessing ordinary power of resistance it is speedily limited, unless the cause of it continue to act. Inflammation spreads more readily in continuous tissues — as the skin, or mucous 72 INFLAMMATION AND ITS CONSEQUENCES. or serous membrane — along which, under favorable circum- stances, it progresses very rapidly. When the powers of life are feeble, this spreading is more likely to take place. In some cases, there seems to be no power remaining to produce the changes necessary to prevent the continuous course of inflam- mation, and then a very trifling commencement may rapidly induce the most serious result. Inflammation sometimes spreads by the absorption of poi- sonous products from one part and conveying them to an- other. CONSEQUENCES OF INFLAMMATION. Inflammation never continues long without the superven- tion of certain results, often of greatly more importance than the primary phenomena we have described. Premising that when it passes away through mere subsi- dence of the heat, redness, swelling, and pain, without the formation of new products or destruction of tissue, the pro- cess is called Resolution, we may enumerate the consequences of inflammation as follows. Chemosis, (Edema, Suppuration, Vesication, Ulceration, Ef- fusion of fibrine, caries, and gangrene or mortification. Chemosis is the extravasation of blood. This is a mecha- nical result brought about both by the distention and pres- sure, and a change of quality in the blood itself. When thus effused it does not coagulate, and it remains in the tis- sues until it is absorbed, which often requires a slow process. (Edema is the extravasation of the serum, or watery parts of the blood. It is apt to attend debilitated condition, and seems to mark a lax condition of the coats of the vessels by which it is exuded. It is generally found in loose cellular structures, where the looseness of tissue affords little support to the walls of the vessels. It often attends a very low de- gree of inflammation, in debilitated subjects, and is unfavor- INFLAMMATION AND ITS CONSEQUENCES. 73 able to recovery ; rather as a sign of debility than from any evil which it is likely to cause. (Edema may exist without inflammation, as when the veins fail to return their blood in due proportion to the rapidity of their supply, either because of mechanical pressure, disease of the heart, or any other cause. (Edema also attends certain specific conditions, as scarlet fe- ver, and may be produced by medicinal agents, as arsenic. When oedema is general, it is called "anasarca."* It is readily detected by the bloated translucent aspect of the skin, and by its loss of elasticity observed by its pitting un- der pressure. Vesication, or blistering, is the effusion of serum under the cuticle and rete mucosum, elevating them above the le- 'vel of the surrounding surface, and separating them from the cutis vera. This may occur as the result of topical ap- plications of an irritating kind, or in consequence of local and constitutional disorders. This condition is frequently pro- duced as part of medicinal treatment, and gives the name of vesicatories to a class of means employed for this purpose. Suppuration, or the formation of a peculiar fluid substance called pus, is one of the most common and important of the consequences of inflammation. Pus, when pure, is thick, cream- like, yellowish, of a faint and peculiar odor, and somewhat sweetish of taste. It is not at all irritating. . To this kind of pus, the terms laudable and healthy have been applied. That which is thin, dark, and irritating, being considered unhealthy, because of the indica- tion it affords of the bad condition of sores, &c, which secrete it. . Although it is true that such pus as is called "healthy," indicates a convalescent state of an ulcer or abscess, yet the inference to be drawn from its appearance attaches exclusively * Ava o-a.Q% — throughout the flesh. 74 INFLAMMATION AND ITS CONSEQUENCES. to the parts which, screte it : while it may herald the abate- ment of local inflammation, it may, nevertheless, give clear evidence of a state of disease incompatible with the integrity of organs, or with life itself. Suppuration of the eye, of the liver, or of the lungs, would be a very serious matter, how- ever " healthy " the pus might be. Some writers have considered suppuration a curative pro- cess, and have regarded the pus as a very valuable covering for the granulations. Although it is true that suppuration often intervenes be- 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 the mucous membranes, without any other apparent change of organization than an increase of the natural vascu- larity. Secondly. On the naturally unexposed surfaces of the body after they have acquired a new organization by in- crease of red vessels, and usually, if not always, by the addi- tion of coagulable lymph ; for it may be questioned whether in any instance the surfaces of the cellular, synovial, serous, and medullary membranes, 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 * * Macartney on Inflammation. INFLAMMATION AND ITS CONSEQUENCES. 75 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 un- der dressings, or in cavities, it becomes very offensive, and often irritating. If it be produced from the irritation of dis- eased 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 muriate of ammonia, which Mr. Hunter considered a pecu- liarity sufficiently marked to distinguish it from mucus, and all other natural secretions, but the accuracy of the test is disputed. Prom the fact that hard inflammatory tumors in the course of inflammation become soft and yielding, and filled with pus, it was naturally supposed that the original solid parts 9 were converted into this fluid. It is now well ascertained that such is not the case, but that pus is furnished by the ar- teries. When pus is enclosed in a cavity formed in the progress of inflammation, the condition is called abscess* * Abscedo — I depart, denoting the loss of substance. 76 INFLAMMATION AND ITS CONSEQUENCES. The phenomena of abscess are very curious, and through them nature succeeds in relieving the body of foreign mat- ters, and repairing extensive injuries. When a part capable of suppuration is subjected to in- flammation 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 around the diseased parts, and between them and those which are healthy, it forms a barrier to the infil- tration 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 process proceeds, the previous contents of the abscess, in- cluding the effused blood, are gradually absorbed, and fresh pus deposited in their stead, so that if the tumor 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 an- nounced 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 tumor becomes softer, and at last fluctuates readily under pressure of the fingers. Yery often, and especially when the disease is extensive, or when it is seated in the viscera, 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 to- wards the surface, and preparing for its evacuation. The bottom of the cavity is constantly contracting and filling up, while the opposite side is thinning and expanding. The ab- sorbents at one side of the abscess are busily engaged in re- INFLAMMATION AND ITS CONSEQUENCES. 77 moving 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 func- tions, supplying pus, and removing mixed ■ fluids from the cavity. The parts lying upon the summit of the abscess are ra- pidly thinned, the tumor is pushed towards the surface, the skin ulcerates, 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 outside of the body. In order to effect this, they will often traverse dense opposing structures when a nearer , opening through more yielding tissues might readily be ef- fected. Sometimes, when an abscess occurs in an important viscus, artificial adhesion will be formed between its surface and an adjoining structure, and a continuous canal being pierced through, then the pus will be ejected upon the sur- face of the body, or into another organ which has external communications. These most curious and interesting facts are so conclusive of wonderful design and contrivance, that it is impossible to regard them in any other light than as manifestations of di- vine 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 irri- tation produced by the vain efforts of nature to relieve the parts, may occasion very serious disease in adjoining struc- 78 INFLAMMATION AND ITS CONSEQUENCES. tures. In some instances of this kind, as in abscess of the gums, or gum-boil, the pus failing to be evacuated, seems to be ultimately absorbed. 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 tumor are not com- posed 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 coagu- lable lymph, parts of which are found as flakes floating in the serum. As the cavities of chronic abscesses are not pro- voked, 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 distance along muscles or under plates of fascia, before they arrive 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 affected by vital processes and open secreting sores pro- 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 progress 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 * Macartney on Inflammation. INFLAMMATION AND ITS CONSEQUENCES. 79 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 constantly becoming effete, and having undergone some mys- terious change, are taken up by the absorbents and carried off to the several waste gates of the system, from which they are ultimately discharged. The bowels, the kidneys, the skin, the lungs, all the emunctories 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 nutritive arteries, are every where depositing new mat- ter. Bone receives bone, muscle is supplied with muscle, and viscus with its peculiar organic matter, so that the in- tegrity and form of each part, and of the whole, are exactly preserved. By some wonderful and inscrutable law, the ba- . lance of supply and demand 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 the wants of the man than the activity of the absorbents. If his vocation calls for in- creased 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 to- gether 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 80 INFLAMMATION AND ITS CONSEQUENCES. is usual ; and should not simultaneously stimulate the nutri- tive vessels ; or, should any circumstances render parts unu- sually susceptible of absorption, that the result would neces- sarily be an obvious loss of parts, and the interruption of their continuity. It is also obvious that the converse of these conditions would be attended with similar results ; for if nu- trition be impeded, either through defect of supply or any cause rendering the part less capable than usual of convert- ing blood into its own tissue, loss of volume, and breach of continuity might occur. For the most part, however, ul- ceration is nothing more than molecular devastation and waste, the products of which do not enter the absorbents at all, but are passed out with the more legitimate fluid pro- ducts of inflammation. 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 cir- culation 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 be- ing no longer needed, it has become foreign matter. The roots of the deciduous teeth are thus entirely removed, and * Fungus — a mushroom — proud flesh. INFLAMMATION AND ITS CONSEQUENCES. 81 the dead fangs of permanent ones are subjected to continual waste from the same cause. That they are not entirely re- moved, is due to the comparative shortness of time which the present term of human life allows for the process, rather than to any resistance they are able to offer to the action of these all-subduing lymphatics. Extraneous substances are generally removed by ulcera- tion. Thus, a ligature will be separated from an artery, or a foreign substance from a wound ; no more of the surround- ing substance being absorbed than is necessary to loosen and dislodge the intruder. The process here is immediately de- structive, not vital. . 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 en- feebled to subserve their natural purpose, they will not be subject to this rapid waste. All parts are not equally prone to ulceration. Skin, are- olar or cellular tissue, and mucous membrane ulcerate far more readily than blood vessels, nerves, or muscles. It is not uncommon to see these laid entirely bare of skin and cel- lular tissue, and bathed in pus, yet resisting disease. Ul- ceration would be much more 'destructive to parts and fatal to life but for this wise arrangement. The effusion of fibrine, more or less plastic, is a very im- portant result of inflammation. Exuded on the free surface of a membrane, it forms an adhesive layer upon it, called false membrane. The presence of this product is often fatal. Fi- brine may be exuded into the interior of parts, separating and * — I spit. INFLAMMATION AND ITS CONSEQUENCES. 109 rounding the teeth, where they are of a deep red. The sore- ness and swelling 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; the enormous tumor of the tongue pushes beyond the lips and hangs out of the mouth, prevent- ing the closure of the jaws; the flow of fluids is prodigious, the patient wastes excessively, gangrene of the mucous mem- brane of the mouth and gums, and. extensive sloughing, of the soft parts and bones sometimes occurs; the teeth are loosened and sometimes drop from their sockets, and occasion- ally the patient expires from exhaustion. A very frequent consequence of extensive mercurial sali- vation and the attendant ulceration and sloughing, is con- traction of the mucous membrane in the neighborhood of the anterior arches of the palate, whereby the patient is prevent- ed 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 temporary relief. In another instance, 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 * Pareira's Elements of Materia Medica and Therap. 110 INFLAMMATION AND ITS CONSEQUENCES. 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 applications 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* A form of disease very nearly resembling salivation, oc- curs 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 we should not have an op- portunity to describe it hereafter, we will do so now. Cancrum oris is a foul fetid ulcer, beginning upon the in- side of the cheek and rapidly sloughing through it until it opens upon the outside. The gums and alveoli are often se- riously involved; the teeth become carious and loose, and drop out ; abscesses form in different parts of the mouth and make openings for themselves in different directions. The progress of the disease is attended by a copious discharge of fetid saliva and mucus. Exfoliations of bone are not unfre- quent, and extensive sloughing sometimes occurs. * 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 Pareira's Elements of Mat. Med. and The- rap. 709. INFLAMMATION AND ITS CONSEQUENCES. Ill The disease generally occurs in ill-fed children, crowded in a hospital or living in low swampy situations. The reme- dies must be tonic and invigorating. The principal, are fresh air and nutritious diet. The best local applications are di- luted 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 particular 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, we refer the reader to an excellent delineation of it in Messrs. Carey & Hart's Edition of Bayer's Plates, PL xxix., 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 the removal of any dead teeth, &c, the gums require the aid of astringent and some- what 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, how- ever, is very improper ; for scurvy is a constitutional affec- tion depending upon long privation of fresh and acescent food, aided by the influence of cold, dampness, &c. It is a disease peculiar 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, we will con- sider it as an idiopathic inflammation of the gums, attended 112 INFLAMMATION AND ITS CONSEQUENCES. 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 color 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 thickened and detached. The proper tissue of the • gums having become to a certain extent fungous, bleeds upon the slighest touch, and is very sensitive. The disease progresses with more or less rapidity, accord- ing to the constitutional health of the patient, and the capa- bility of resistance natural to the organs attacked. Some- times it is confined to a small portion of the gum, at others, it involves the periostea of the fangs and the alveoli, and pre- sents a mass of complicated disorder and devastation. A de- position 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 inflamma- tion has subsided, astringent lotions may be used by way of correcting the habitual looseness of texture.* Caries.^ This term has different meanings when applied to the bones at large and to the teeth. We will first consider the disease of the bones so called. Caries in the bones is a disease analogous to ulceration of * For a more extended description of this disease and its treatment, than is compatible with the scope of this work, see Dr. Harris' Dental Surgery, a work which we will take for granted is in the hands of every scientific den- tist and every student of dentistry. f Kttpsiv — to ahrade. IKPLAMMATION AND ITS CONSEQUENCES. 113 the soft parts, and is very different from necrosis or mortifi- cation 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- colored 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 results 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 frequently happens, the separation of the 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 sub- ject 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 ,114 INFLAMMATION AND ITS CONSEQUENCES. to the active disorganizing process in question. It is certain, however, 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 will do ; showing that in this form of destruction the organs assailed are passive. Mortification or Gangrene. These two words are commonly used synonymously to ex- press 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 mortification 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 soft- ening and crepitation of the part. "When the part has become cold, insensible, black, motion- less, without circulation, motion 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.^ Mortification may result from any cause which prevents the nutrition of a part. Inflammation may so interrupt the cir- culation as to cut off the supply of blood, or the state of the patient's digestion may not afford a supply of nutrient fluid sufficient 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 appreciated disease, When mortification is consequent upon inflammation, the *27r«)catr — to destroy. f Sequestro — I separate. INFLAMMATION AND ITS CONSEQUENCES. 115 quantity of fluids in the part causes a humid state of the sphacelus ; where death has taken place from deficiency of blood the mortified parts are dry and shrivelled. These oppo site conditions have given occasion to the distinction so gene- rally recognised between moist and dry gangrene. This dis- tinction, however, is not so absolute as to be without excep- tion, 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 color. Quesnay states that in one case he saw, the gangrened parts exhibited a remarkable transparency. The black color 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 dis- organization of the gangrenous part, in which the ele- mentary tissue can no longer be distinguished. 2d. Soft- ness and flaccidity. 3d. The fetid and characteristic odour which it inhales. 4th. The sanies, ichor and fetid gas which escape from it. In that variety of gangrene, termed dry, the part presents a black color, a hardness sometimes 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 slough. "When a part has become dead, it seems to act as a depressing 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 expires. Immediately upon the gangrenous change* the pulse becomes soft, weak and frequent, the skin cold, and * Chomel, Elements of Gen. Path. 116 INFLAMMATION AND ITS CONSEQUENCES. the nervous system seems to labor 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 gan- grenous 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 power- ful 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 al- ways 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 granulations gradually push off the gangrenous slough, and supply its place with sound flesh. Inflammation and ulcera- tion, therefore, 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 inflam- mation, support the suppuration and sustain vigorous granu- lations. It is also necessary, that the inflammation in the ad- joining parts be not so great as seriously to impede the circu- lation in them. The surgeon takes his suggestion of remedial treatment from these necessary conditions. If the parts adjacent to the gangrene be cold and livid, and if they show no disposi- tion to throw out the inflammatory cordon sanitaire, he sees the necessity of stimulating applications to rouse the torpid energies of the threatened parts. Cantharides, turpentine, or other remedies of this powerful class will then be put in INFLAMMATION AND ITS CONSEQUENCES. 117 requisition; and 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 anti- cipate the slow process of nature, aud at once remove the gangrene by his knife. The latter process is fraught with this difficulty, that when the surrounding parts are feeble and disposed 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 remain- ing parts. "When the surrounding .parts manifest more excitement than is compatible with their security, depleting and seda- tive treatment must be instituted. As a general rule, how- ever, this will rarely be required, for the vicinage of gan- grene is generally abundantly sedative to the surrounding parts. Necrosis, or mortification of bone, may take place from similar causes to those which produce gangrene of the soft parts. As the bones possess less vitality, they are less capable of resisting disease, and therefore are more prone to die from injuries 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 exquisite organization and complicated func- tions 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 ex- foliation; when it is deeper, a persevering effort is made by the surrounding bone and soft parts, to detach and expel it in the form of splinters, or even of large masses, called se- questra. 118 INFLAMMATION AND ITS CONSEQUENCES. Owing to the density of bone and its deep-seated posi- tion, this is generally a very slow process, requiring months and years for its accomplishment, and often failing alto- gether. 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 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 comminuted state. It is, therefore, gene- rally necessary for the surgeon to cut down to the diseased bone and liberate the sequestrum. Occasionally, however, nature, though unassisted, will accomplish 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 the necrosis or caries may be ascertained very satisfactorily after the formation of the external ulcer. Sometimes 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- colored and fetid sanies, will generally be sufficient evidence of dis- eased 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 procured by art, depends upon the removal of the part so diseased. In necrosis, the parts surrounding the sequestrum are gene- rally in such a state as to return to health after its removal. In caries, the surface of the parts exposed by the operation, often requires the application 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. INFLAMMATION AND ITS CONSEQUENCES. 119 Caries of the bones, as we have seen, is a diseased vital action, 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 month, and afYects dead teeth as readily as living ones. Caries of the teeth generally, perhaps always, begins upon their outer surface, and does not appear to be in any man- ner dependent upon disease, except so far as it may be fa- vored by an unhealthy structure of the teeth, and a morbid condition of the fluids of the mouth. In short, caries of the bones is a vital, that of the teeth, a chemica] process. By instituting a comparison between caries of the teeth and that of other bone, 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 estab- lish 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 we 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 * Harris' Dental Surgery, which see, for a thorough examination and ex- position of this subject. 120 INFLAMMATION AND ITS CONSEQUENCES. inflicted is sufficient to break up the vascular connections 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 vitality does not permit of such effects. 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 detach 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 conse- quence. Necrosed teeth lose their color 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 disease of the soft parts, which would require the removal of the necrosed organs. The manufacture of lucifer matches has introduced a new cause of necrosis of the jaws. The vapor of the phosphoric acid preys upon the periosteum, and induces serious and even fatal destruction of the maxillary bones. It is said that this is not noticed, except when the teeth are carious. " The dis- ease usually begins with moderate periostitis, which thick- ens the membrane and incrusts the jaw with new bony forma- tions. Then acute inflammation supervenes, the new bone exfoliates, the soft parts slough and ulcerate, and necrosis, more or less extensively, destroys the jaws."* * Miller's Surgery. CHAPTEE VII, 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 endeavored to arrange them by their ap- parent 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 al- ready 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 arrange- ment as will enable us lucidly to express what we know of the subject. Once more we remind our readers that medi- cal definitions are not philosophically complete and accu- rate. An important distinction between ulcers is found in the fact that some of them are the result of local injury or dis • ease, and not in any manner dependent for their existence upon constitutional vice, while with regard to others the con- verse is the case ; the local sore being only a consequence of constitutional disorder. As the treatment must differ essen- 122 ULCEES. tially in these different 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 pro- per, is not without difficulty, for local ulcers sometimes in- volve the general health, and are instrumental in setting up diseased constitutional action, in which they themselves par- ticipate, and, on the other hand, ulcers primarily induced by constitutional causes, may continue after the vice of the gene- ral 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 with- out 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 pa- tient, his age and habits, the situation and duration of the sore and its peculiar condition of sensibility, &c, must all have due consideration 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 known to us. * Benjamin Bell on Ulcers. ULCEKS. 123 After ulcers have become chronic, it is sometimes danger- ous 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 suffers severely with a kind of 'plethora, if the discharge be suddenly stopped. The simplest, most practical, and most rational of all the classifications of ulcers we have seen, is that adopted long- since by Mr. Benjamin Bell, and generally superseded by more complicated arrangements, which beget confusion in the mind of the student, and are, after all, not more precise and accurate than the one for which we have professed our preference. Mr. Benjamin Bell classifies ulcers as follows: LOCAL AND CONSTITUTIONAL. 1. The venereal, 2. The scorbutic, 3. The scrofulous. 1. The simple purulent, 2. The simple vitiated, 3. The fungous, 4. The sinuous, 5. The callous, 6. The carious, 7. The cancerous, 8. The cutaneous. It is not our purpose to describe in detail the appearance, nature, and treatment of each of the kinds of sore above enu- merated; but we will confine ourselves 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 but slight inflammation, and furnishes 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 124 ULCEES. with its appearance, because other ulcers, of a less simple and kindly character, must be brought to this condition be- fore 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 sores the pus is white and thick ; the gra- nulations 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 pelli- cle, or film, which afterwards hardens, advances, and forms the permanent covering of the parts previously ulcerated. This white, smooth margin, lost in the surrounding skin or mucous membrane, is 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 dressings. A simple purulent ulcer may very readily be converted into an angry and obstinate sore by improper lo- cal applications, or the occurrence of general constitutional disorder, We may remark here that no sores are cured by applica- tions of any kind; nature only can provide the means by which these breaches can be healed. Nothing is more in- correct or dangerous than the idea that certain dressings have a specific or magical 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 concerned, to aid her in her efforts to bring any particular sore into that condition " which natural means will suffice to relieve." ULCERS. 125 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 dis- charge, termed sanies. 2d. A somewhat red-colored, 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 frequent- ly excoriates the surrounding parts over which it flows. These vitiated ulcers are more apt to occur upon tendi- nous and aponeurotic parts, than in situations abounding with cellular membrane, owing to the frequent motion of these parts, and the continual agitation of the sore. Where- ever an ulcer is seated upon a part of this character, abso- lute rest is necessary to preserve its simple and convalescent character. The cure of these ulcers depends principally upon re- moving the cause which has operated to change their cha- racter for the worse. If the vitiated condition depends upon constitutional causes, these must be combated by the means found most successful in the practice of general medicine; if any local irritant has caused the evil, it must be removed as speedily as possible ; if motion of the part has been in- dulged, it must be restrained. * Benjamin Bell. 126 ULCEES. The local treatment consists in soothing, emollient appli- cations, as it has been found that all those means which al- lay 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 oppor- tunity is afforded for local applications. The best, perhaps, is warm water, frequently taken into and held in the mouth ; or the vapor of hot water received into it repeatedly, and for a considerable 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 inte- rested in the production of the troublesome sore. The difficulty of protecting ulcers in the mouth from the contact of its secretions, and the food and drink, and the im- practicability of dressing them with applications elsewhere serviceable, 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 of a bad quality, and being little sensitive, they are called indolent; if, in addition, the edges become hard and thick- ened, they are called callous. Yery often these callous ulcers are attended with an en- larged condition of the veins of the part, which is called va- ricose. 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 frequent- ly attended with varicose veins. The callous condition of ulcers is the consequence of neglect and bad management. ULCEES. 127 Their cure consists in restoring them as soon as possible to the condition of a simple purulent sore. When the sore is merely indolent, the surface is jet struc- turally capable of producing healthy granulations. All that is needed is to bring it to the right suppurative action. Sometimes the inactivity of the sore results from irritation, either from local or constitutional causes. In such cases it must be soothed by position and soft sedative applications, as warm poultices, or the constitutional impediment to the local action must be removed. When the indolence is not connected with irritation, gently stimulating means can be used to rouse the vessels to greater activity ; in short, to increase the inflammation. When the surface is callous, it must be removed, and this is best effected by lunar caustic. (Nit. Argenti.) A blister over the ulcer is not unfrequently resorted to, but it is less manageable than the caustic. Mechanical pressure is very useful in the management of these sores, particularly where they are seated on the legs When the margin is not elevated and hard, a common roller passed around the entire limb to a point considerably above the sore, will be sufficients When the edges are ele- vated and hard, strips of adhesive plaster carried tightly across from edge to edge, in addition to the roller, create ab- sorption of the indurated parts, and excite active suppura- tion. Whatever means are used, the object is to convert the sore into the simple purulent ulcer, to which condition all must be brought in their way to convalescence. The presence of some foreign matter, or decaying portion of bone, or tendon or fascia, or the passage of some excretion caused to flow from its natural through the artificial chan- nel. Fungous Ulcers. When granulations are large and pale, 128 ULCEES. grow rapidly and rise above the level of the surrounding parts, bleed freely upon touch or slight pressure, and make no attempt at cicatrization, they are called fungous or proud Sesh. Generally they are soft and spongy, but by very long continuance 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-continued inflammation of cellular struc- tures and caries of the bones are very apt to be attended by fungus. It sometimes occurs in ulcers of young and vigorous subjects merely as a kind of exuberant growth, which can hardly be considered as giving an unfavorable 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 irri- tating 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 generally the application of the escharotic will excite the surface of the ulcer sufficiently to cause the growth of firmer granulations. The Sinuous Ulcer. — This name is given to a sore commu- nicating with long and narrow canals, penetrating the cellu- lar membrane and running irregularly under the skin or be- tween 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 parts 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 mat- ULCEES. 129 ter, 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 determina- tion 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.* The cause of sinuses is the want of a free passage for mat- ter, which seeking the most dependent point, readily pene- trates the yielding texture of the cellular membrane and ulti- mately produces ulceration at a point distant from its source. 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, or removing the foreign matter, or restoring the wandering excretion to its former, or, at least, more convenient channel. After this, pressure should be used upon the sinus; if that should fail, stimulating or caustic applications 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, me- dicinal 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. ''Where the sinus is both deep and extensive, it is not necessary to incise its whole space. The inner half will pro- bably follow the curative processes of the outer." (Miller.) * Fistula — a pipe. 130 ULCEES. 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 of- ten 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 rather a dark brown with somewhat of a glassy complex- ion. The granulations generally grow rapidly, but are exube- rant and fungoid. Should the orifice heal either by the ef- forts 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 dow nto the bottom of a carious ulcer, it generally encoun- ters a roughness of the surface of the bone, which plainly indicates its eroded condition. When obstinate sinuses are observed in the gums, dis- charging fetid matter, and containing fungous granulations, we may always be assured that the cause is to be found in the presence 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 at- tending 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 re- garded 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 ULCEES. 131 energy of fire, and the actual cautery must sweep over the diseased surface and rouse it to the exertion of its vitality. When a tooth is the subject of caries, no such frightful treat- ment is necessary. The tooth being passive in the matter, and being acted upon 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 bar- rier 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 mercurial amalgams are exceedingly deleterious, both locally and constitutionally, and ought never to be used as dental fillings. The Cancerous Ulcer — Cancer, or Carcinoma. This terri- ble affection occurs under two forms, called occult and open, or scirrhous and ulcerative. The former variety generally, though not always, precedes the latter, and presents itself in the form of a hard, dense tumor, 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 scirrhus as from a centre. As the disease progresses, the skin ad- heres to the tumor, corrugates or puckers, changes color, 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 irri- table. It discharges a thin fetid ichor, sometimes very exco- riating. Its edges are hard and irregular, reversed and con- torted. Its surface is generally irregular, showing depres- sions or excavations. The sore manifests no tendency to 132 ULCEKS. form healthy granulations, but spreads among the surround- ing tissues which successively harden and ulcerate, and be- come 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 func- tions of life. As blood vessels are destroyed in the progress of the dis- ease, bleeding, more or less profuse, occurs. Cancer, however, presents various appearances. We have seen it occur without preceding scirrhus, present an equal smooth surface 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, ex- ceedingly irritable under all common dressings, and causing a burning pain. When such a sore has resisted the treat- ment which is s found to be successful in ordinary irritable ulcers, and especially when it is seated in a glandular part and follows scirrhus, there can be no doubt of its malig- nant 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 extirpa- tion, and this is confined almost entirely to the latent or scirrhous state. The open cancerous sore rarely yields even to surgical remedies. It is even a mooted question whether the removal of scirrhous tumors is advantageous. Some surgeons contend that where true scirrhus is removed, can- ULCEES. 133 cer soon makes its appearance elsewhere, often in a more malignant form and in a worse location, and that the life of the patient is often shortened by the painful operation en- dured in the hope of cure. It is not by any means easy to settle this question. Sur- geons are in the habit of removing all chronic tumors which are hard and painful, whether they present decidedly carci- nomatous 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 careful not to extinguish it, and we therefore recommend the exsection of scirrhous tumors. To be successful, however, the operation must be performed before the disease has manifested activity by changing the surrounding parts into its own peculiar texture. Even when the cancer has reached the condition of a foul, wasting, and tormenting sore, extirpation by the knife will sometimes be desirable, for the temporary relief it may give the victim. Six years ago, a neighbor of ours was re- lieved of a sore of this kind by amputation of the arm. Since that time, he has been able to attend to the duties of life, the cancer has not reappeared in a decided form, and as he is an elderly man, and carcinoma proceeds slowly in old persons, he may escape a return of the disease, at least, in the aggravated character in which it existed before the am- putation. There is a form of carcinoma called " medullary," " spon- goid," or "fungus nematodes," in which the tumor is elas- tic, grows more rapidly, and after ulceration presents a pro- truding fungous appearance, with a strong tendency to wasting hemorrhages. This kind of cancer is the result of a more thorough pervasion of the constitutional disease, and 134 ULCERS. less power of resistance to the unnatural growth. It is rapidly fatal, and if excised commonly reappears, often in some vital place! 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 extirpated in its latent state, the patient may be entirely relieved from it. Others believe that carcinoma is a consti- tutional disease, 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 attempts at cure of the disease. On each side of the question are presented observations and pathological demonstrations, and authoritative names, and without troubling our readers with a recapitulation of the facts and arguments brought to bear upon this subject, we will content ourselves with suggesting the practical in- ference which seems most rational upon the whole ; which is, that eradication of scirrhus may be attempted with good hope, though not with certainty of success; that the exci- sion of open cancer will be an experiment very doubtful, yet if the reports of surgeons are to be believed, not abso- lutely hopeless; and finally, that under all circumstances the operator must be prepared for a recurrence of the dis- ease. Many specifics have been suggested for the cure of cancer, and many nostrums are yet vended for the purpose of curing these sores. For the most part these are useless nostrums, ULCEES. 135 which have not the least control over cancerous degenera- tion. Some of them are caustic applications, which actually extirpate the diseased part, and are as useful as excision would be. In soma cases, caustic has the advantage over the knife, and probably has been too generally abandoned by surgeons. Cancer doctors often get reputation by at least temporarily relieving patients abandoned to their fate by scientific practitioners. To be sure, the empirics in their ignorance of the distinction between malignant and analogous sores, often apply their escharotics where they do, great mischief, but these blunders do not go before the pub- lic, while apparent cures are trumpeted throughout the land. One young lady, whom we knew, was killed by some appli- cation of the kind, supposed to be an arsenical paste, to a benign ulcer. Cancer sometimes attacks the tongue. We saw a case of this kind, which seemed to have been provoked by the abrasion 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 scirrhous, and the neighboring glands manifested a similar condition. A cause so slight as the retention in the mouth of a bro- ken or eroded tooth, seems, in this case, to have been suffi- cient to excite this fearful malady, in a part, too, where the greatest possible inconvenience and distress must result from its presence. The lips, too, are very frequently the seat of cancer, and the dentist should be careful not to wound these very vas- cular and 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, we will not consider them, but refer the curious reader to the several 136 ULCERS. surgical works in which they are accurately described and their proper treatment 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 character. With the consideration of local or primary sy- philis we have nothing to do, but as the secondary or con- stitutional disorder develops 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 erup- tions, swelling of glands and disease of the periosteum, fas- cia 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 gray- ish, 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 vene- real inflammation 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 distin- guished from all others of the same parts. The disease in the throat is uniformly ulcerative ; this being the first appear- ance of disease in that part.* The syphilitic ulcer always begins superficially, and is not preceded by observable, or at least, by any notable degree of inflammation. This fact will be sufficient to distinguish * Hunter on the Venereal Disease. ULCEUS. 137 these sores from the ordinary open abscess of the sup- purating tonsil. There is also an indolent swelling of the tonsil accompa- nied by an exudation of lymph, which at first sight might be mistaken for an ulcer, and indeed such exudations, when they accompany scarlet fever, are often miscalled sloughs. They may be detached from the subjacent membrane, which is found unbroken. 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 some- times 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 excoriation, 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 ad- hering 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 puri- form expectoration, rapid sloughing of the soft parts, ex- posing the bones and destroying them even as far as the ver- tebra by caries. The palate is frequently destroyed, throw- ing the nose and mouth into one cavity, preventing distinct speech, and causing great discomfort and distress. The den- tist 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 10 138 ULCEKS. 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 yellowish slough, and beyond this for the extent of a quarter of an inch, there is an inflamed margin of a deep crimson color; but there is not much general sloughing of the surrounding parts. Yet the sore extends daily with ex- traordinary 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 thickened edges; a characteristic rather of the unhealthy character and spreading tendency, than of any specific qua- lity of the sore itself. There are several kinds of venereal affections observed in the bones. The periosteum may be thickened and in- flamed. This is a very p'ainful 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 depo- sition of bony matter. Sometimes the periosteum suppu- rates 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 tumor, which may be seen and felt externally. If this tumor is laid open, a glairy fluid is eva- cuated; the periosteum is found to be somewhat thickened, * Babington. ULCERS. 139 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 communicates 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 con- stitutes the worm-eaten caries.* 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 posi- tively 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 eruptions 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 sMn, or vice versa, there must be extraordi- nary 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 in- flamed skin, and often by dead cuticle. These often ulcerate and leave behind them a peculiar copper-colored blotch. Another form of syphilitic eruption, is that of small red acuminated pimples, sometimes scattered regularly over the surface, at others arrayed in groups. Scaly eruptions are also common, and sometimes a pus- tular 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 vene- real origin. * Babington. 140 ULCEES. Mr. Hunter says, when syphilis attacks the tongue, it sometimes 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 gene- rally diffused, 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 means, and the other denying the necessity of these medicines. Without^pretending to any claim to decide a question so ably supported on either side, we will briefly remark, that mercury will certainly cure the disease, except in a few un- common cases, where it exists in a kind of combination with scrofula; and secondly, that mercury will do this without injury to the patient, and generally with as little inconve- nience as can attend the use of less certain remedies. With- out hesitation, therefore, we recommend its use; especially, in constitutional or secondary 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 ge- neral rule, however, we prefer the proto-chloride or calo- mel to any other preparation. It is more certain than blue pill, and perhaps than any other mercurial medicine, and can be used with more safety than the deuto-chloride (corrosive sublimate.) Our common practice is to give a grain of calo- mel, 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 tender- ness of the mouth will generally indicate the predominance ULCERS. 141 of mercurialization in the system, and be attended by heal- ing of the venereal sores, and disappearing of other symp- toms 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 mercu- rial influence. When scrofula exists in union with syphilis, the iodide of mercury may be used. Scorbutic Ulcers. — Scorbutus is a barbarous half Latin name, given by medical writers to scurvy, a constitutional affection depending upon privation of vegetable food, under circumstances calculated to weaken the energies of the sys- tem, and which was long a terrible scourge to seamen, soldiers and the inmates of prisons. It has frequently been con- founded with other affections, a mistake which has led to se- rious consequences. In the year 1700, the celebrated Boer- haave treated with mercury four hundred soldiers thus af- fected, and killed them all. The term scurvy, is applied to sponginess and ulceration of the gums from any cause, but this i#an impropriety. Scorbutus, or true scurvy, is always a constitutional affection, never occurs when patients have lived upon diet sufficiently vegetable, and, in short, can only be expected to occur in ships, camps or prisons : happily since its character has be- come known, it is rarely seen now, even in these places. As it would be of little use to our readers, we will not in- troduce here a full discussion of this subject, which has ceased to be of much interest, even to the general practi- 142 ULCERS. tioner; but will content ourselves with a very few remarks upon it, referring those who may be curious to know more of this subject to a very interesting article upon it in the Cy- clopaedia of Practical Medicine, written by Mr. Kerr. Scurvy is a general disease characterized by debility, foe- tor of the breath, sponginess and turgidity of the gums, livid subcutaneous spots, particularly of the roots of the hairs, ecchymoses, spontaneous hemorrhages and frequent contrac- tion 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 swollen, itch and bleed upon touch; they are deep red, soft and spongy : soon fungous and putrid. Bleeding occurs fre- quently from the mouth and other parts, and the breath is very offensive. 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. 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 hemor- rhage becomes more profuse and general; the increasing dyspnoea is accompanied 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 be- comes suddenly quick and laborious, and death unexpect- edly puts a period to the disease. * Cyclop. Prac. Med. ULCEES. 143 The prevention and cure of scurvy consist simply in pro- viding 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. Me- dicine 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 clanger 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 us to mention it ; our chief purpose in doing so, however, is that our readers may have a proper knowledge of the mean- ing 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 per- ceive ; but it is singular that the corresponding Greek word is also derived from a word (p^ooc) signifying a hog. Whether those who originally described the disease were aware that swine are subject to it, or whether, as is most probable, 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 tumors 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. 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. 144 ULCEES. The pathology of scrofula is not well understood. It seems to affect particularly the' lymphatic system; the glands, especially the subcutaneous and mesenteric, being most fre- quently the parts which first manifest the local influence of the constitutional vice. Yery often, however, its ravages are confined to internal 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 consumption. Although persons of all temperaments are subject to scro- fula, yet those who possess what is called the lymphatic tem- perament, are much more liable to it than others ; and as this system is predominant in children and women, they are more exposed to scrofula than adults and men. 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 color, which are soft and easily attacked by caries; a large head ; straight and narrow chest ; large abdomen, -end soft and flabby flesh. Persons presenting these external ap- pearances are generally amiable, and often very sprightly Phthisis, from ;§o?, wax. J A^* — pap or pulp. 156 TUMOKS. Owing to the yielding nature of the contents, this is a tedious and troublesome process. Sir Astley Cooper recommended to cut through the sac at once, and then to dissect it out ; and doubtless this is the more easy method, inasmuch as the divided edges of the cyst may then be held by the forceps. Encysted tumors occurring in the mouth should be attended to as soon as they are perceived. Bony Tumors. — 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, lamellated, &c, according to the density of the tumor, and the disposition 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 distention or sepa- ration of their parts, the disease is not at all similar to the dense tumor produced by the presence of an unnatural quan- tity of bony substance. Thickening of the periosteum sometimes occasions an ap- parent 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 dif- ferent seats, viz.: between the external surface of the bone and the periosteum, constituting periosteal exostosis ; and in the medullary membrane and cancellated structure, forming medullary 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 cha- racter, containing 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 ir- *E£, out of, and oa-nov, a bone. TUMORS. 157 regularity of ultimate nutrition, a process which cannot be comprehended. The structure and consistence of exostosis present great differences. Sometimes, especially when the tumor 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 tumor is entirely cellular, and formed of a few broad laminae intercepting extensive spaces, which are filled with matter, different from the me- dulla, and of various quality. This case is denominated the lamina ted 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 va- riety of the disease differs essentially from osteo-sarcoma, notwithstanding external appearances. The case here al- luded 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 de- posited, 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 disease. 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 degree of pressure without distress. But where the exostosis is so situated that its bulk can only be accommodated by * Cooper. Surg Die. 158 TUMOKS. pressing upon dense and unyielding structures, or upon nerves or blood vessels, or where the enlargement impedes muscular motion, these tumors may occasion very serious con- sequences. The action of the flexor muscles of the leg has been seriously interfered with by an exostosis in the neigh- borhood of the knee. An exostosis of the orbit has dis- placed the eye. Sir Astley Cooper narrates a case of this kind, where two exostoses, growing from the antra, pushed out both eyes, and finally produced death by pressure upon the brain. In another instance, an exostosis of the sixth or seventh cervical vertebra, stopped the circulation in the ra- dial 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 irregular deposit of bony matter; and provocations, otherwise trivial, will often determine local osseous enlarge- ments. Sometimes these provocations are perceived, as when they consist in some form of external force, as blows, pres- sure, &c. ; more frequently the determining cause is as ob- scure as the constitutional vice. Exostosis is always very hard, sometimes painful, often insensible. The firm resistance of the tumor, and its adhe- sion to a bone, will generally enable us. to distinguish it from other tumors. Exostosis is commonly gradual and slow in its growth; * Surgical Essays. TUMORS. 159 but the fungous, or medullary swelling of the bones, is often rapid in its development. The latter form of disease is at- tended with very severe pain, and often with much constitu- tional irritation. Exostosis of the Teeth. The fangs of the teeth are more frequently the seat of ex- ostosis 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 impediments to safe and easy extraction of the teeth. The disease is always developed upon the root ; generally at the extremity, sometimes upon the sides : frequently the whole fang is involved, though not so equally as to present a symmetrical enlargement. Mr. Thomas Bell says that the substance thus added, dif- fers from the natural bone, being harder, yellowish, and slightly transparent. As the swelling progresses, the pres- sure 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 propa- gated to the tooth, soon exposes the cavity to the action of external agents, and tooth-ache leads to extraction. Mr. Bell says that the continued irritation sometimes occasions thick- ening of the periosteum and suppuration, and the case be- comes one of simple alveolar abscess. Exostosis of the fangs sometimes occasions neuralgic suf- fering 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 affec- tion of the fangs, which her medical attendants had entirely overlooked. The eyelid of one eye had not been opened for 160 TUMOES. two months, and the secretion of saliva was so abundant from the irritation that it flowed out whenever the month 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 pur- pose of having this 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 upper lip to half the size of a hen's egg. The tumor was opened, and a large quantity of dark- colored, very fetid matter was discharged, which for a short time afforded considerable relief. The tumor, 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 manner above described. The tumor was opened again, and about three table spoonfuls of black matter, resembling thin tar, was 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 completely in a few weeks. A great number of cases, illustrating the variety and ex- tent of the mischief occasionally resulting from exostosis of * Dictionary of Dental Science, article Exostosis, TUMOKS. . 161 the teeth., are recorded by writers upon the subject. The den- tist, 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 enlarge- ment of the fang. It is a very common disease, and in some individuals affects many, or even all their teeth simulta- neously. Sometimes exostosis unites several teeth together. In a specimen presented to the Baltimore College of Dental Surgery, by Dr. GL R. Hawes, of New York, the three superior molar teeth of one side are thus united. In another speci- men, presented by Dr. Blandin, of Columbia, S. C, two up- per molars are united; and in a third, presented by Dr. Ware of Wilmington, K. C, there is a deposition of bone on the roots of a first superior molaris, 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 ne- cessary lest in the effort to tear away the enlarged bulb, the alveolus 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. TUMOKS OCCASIONED BY ENLAKGEMENT OF BLOOD-VESSELS. 1. Aneurismal* Tumors. A tumor caused by the distention 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. An aneurismal tumor may generally be detected by the throbbing or pulsating sensation which it communicates to the hand upon pressure. Sometimes, however, when an * Avsv^ewsti — to dilate. 162 , TUMOES. 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 compared to the feeling of a " shattered quill." As fatal accidents have occurred from thoughtlessly opening tumors of this description, it is always important to examine every tumor carefully before thrusting a lancet into it. The pathology and treatment of aneurism do not come properly within the scope of the present work. CHAPTEE IX. DISEASES OF THE TEETH AND FACE DEPENDENT UPON MOR- BID CONDITIONS, EITHER GENERAL OR OF OTHER PARTS. 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, nnless the affection be of a kind to lessen their sensibility, they become the seat of very severe suffering, which is called neuralgia. It may be asked whether all painful sensations are not seated in the nerves? we answer that they are; yet the dis- tinction between neuralgia and other pains, is that in the case of the former, the nerves are concerned primarily ra- ther than as instruments : 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 dis- tinction. 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 neurilema, or the nervous pulp. In fact, the ultimate nature of the nerves is too little known to permit us to ha- zard an opinion upon this subject. * Ntv^ov, a nerve, and a\yog, pain. 164 NEUEALGIA. Neuralgia is a very acute pain which generally commences suddenly, and occupies a single spot, from which as the at- tack progresses in violence, it radiates by pangs or flashes to the surrounding nerves. The pain is generally sharp and darting or burning, and may be distinguished, among other characteristics, by this, that in its radiations it follows the threads of the nerves without extending to the adjacent structures. There is no heat, redness, nor swelling, the ab- sence of which is sufficient to distinguish the disease from inflammation. The pain, after continuing for a longer or a shorter time, rarely longer than a few hours, abates, generally suddenly, and disappears to return with equal rapidity, if the proper provocation be repeated. 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 affection, 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 in obedience to remedies, or through the action of unknown laws, which regulate the ebb and flow of nervous influence, it abates rapidly and leaves the patient entirely free from suffering. It does not return until some provocation be applied, when it will suddenly re-appear, 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 NEUKALGIA. 165 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 we must speak at length presently. Neuralgia of each kind may be located in various nerves. The scope of our work makes it necessary for us to notice but one speciality of the disease. Neuralgia Faciei, or Facial Neuralgia. To this subject we would particularly invite our readers, as it is one which it is most important for all dentists to un- derstand. The reason will be seen in the sequel. Neuralgia faciei is sometimes called tic douleureux. The word tic means a sudden twitching or convulsive movement, and as this is sometimes noticed in the faces of persons suf- fering with neuralgia of that part, the term tic douleureux or painful tic, was given to the affection. Neuralgia faciei is seated in some of the branches of the fifth pair of nerves, and the first and second branches are more commonly its seat. The pain is therefore most fre- quently 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 confident 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 tooth-ache, and frequently ignorant dentists have extracted tooth after tooth, and have at last abandoned the patient to his aggravated suffering. The diagnosis of this malady is not difficult. From all acute inflammatory conditions it may be readily distinguished 166 NEUKALGIA. 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 tooth-ache depending upon exposed nerves, it may be diagnosed by the evident centralizing of the pain in a cer- tain 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 exquisitely sensitive pulp exposed. The treatment of pure neuralgia faciei is palliative and cu- rative. The palliative treatment consists in the use of such means as are calculated to allay the pain of the paroxysm. The curative consists in the employment of such remedies as ex- perience has shown to be most useful in restoring the health of the patient. Of palliative means, warmth is one of the most important. Cold aggravates the pain intensely, and will almost always excite a paroxysm of pain in a patient subject to neuralgia. "Warm or even hot applications to the face are therefore important aids in allaying the suffering. Counter-irritants, 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 lau- danum, and in some severe cases, or when the patient has be- come accustomed to the effects of the drug, this dose will re- quire increase or repetition. * Narcotics, from ia$xo