Glass Book COPYRIGHT DEPOSIT DENT AL MEDICINE. AS CONNECTED WITH THE STUDY OF DENTAL SURGERY PRACTICAL TREATISE DENTAL MEDICINE, COMPENDIUM OP MEDICAL SCIENCE. AS CONNECTED WITH THE STUDY OF DENTAL SURGERY BY THOS. E. BOND, A. M., M. D. PROFESSOR OF SPECIAL PATHOLOGY AND THERAPEUTICS IN THE BALTIMORE COLLEGE OF DENTAL SCBGERY. PHILADELPHIA: LINDSAY & BLAKISTON. 1851. / Entered, according to the act of Congress, in the year one thousand eight hundred and fifty-one, by Lindsay 8c Blxkxston, in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. 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 practicing Physi- cians, and to the author of this treatise was entrusted 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, neverthe- less, well attested and established facts; and, after ma- ture investigation, he has become fully convinced that the relations of the teeth and their appendages with other, and even with vital, parts, are sufficiently impor- tant 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 anything unworthy of attention which has any bearing, however remote, upon the benevolent pursuit to which we have devoted our lives, but to the most fastidious it may be said, that subjects which have been thought worthy the attention of Hunter and Rush, may be in- vestigated by all without fear of degradation. THE AUTHOR. Baltimore, Dec. 31, 1850. MY FATHER, THIS WORK IS RESPECTFULLY DEDICATED, B Y HIS SON CONTENTS PAGE. Introduction, . . . . . . . 13 CHAPTER I. Preliminary Considerations, . . . .19 CHAPTER II. Etiology, ....... 23 The Atmosphere, ...... 25 Heat and Cold, ...... 26 Malaria, ....... 30 Chemical Causes, ..... 31 CHAPTER III. Symptoms of Disease, ..... 35 Progress of Disease, ...... 36 CH APTER IV. Diagnosis, ....... 39 CHAPTER V. Treatment of Disease, ...... 47 CHAPTER VI. Nature of Disease, . . . . . . 49 Inflammation, ....... 51 Consequences of Inflammation, .... 54 Inflammation of the several parts composing the Mouth, and of the parts adjacent, ..... 64 Inflammatory Fever, ..... 71 Caries, ........ 81 Mortification, or Gangrene, .... 82 X CONTENTS. CHAPTER VII. PAGE. Ulcers, . . . . . . .89 Local and Constitutional, . . . . . 91 Simple Purulent Ulcer, . . . . .91 Simple Vitiated Ulcer, ..... 92 Callous Ulcer, . . . . .93 Fungous Ulcer, ...... 94 Sinuous Ulcer, ...... 95 Carious Ulcer, ...... 96 Cancerous Ulcer, . ..... 97 Ulcers Dependent upon Constitutional Cause, . . 100 Venereal or Syphilitic Ulcers, .... 100 Scorbutic Ulcers, . . . . . 104 Scrofulous Ulcer, ... . 106 CHAPTER VIII. Tumors, . . . . . . . . 113 Malignant — Osteo Sarcoma, . . . .113 Fungous Hsematodes, Bleeding Fungus, Spongoid Inflam- mation, Soft Cancer, Medullary Sarcoma, . . 114 Polypus, . . . . . 115 Benign Tumors. . . . . . .116 Sarcomatous or Fleshy Tumors, . . . 116 Encysted Tumors, . . . . . .117 Bony Tumors, . . . . . 118 Exostosis of the Teeth, . . . . .120 Tumors occasioned by Enlargement of Blood-Vessels, . 122 1. Aneurismal Tumors, . . . . .122 CHAPTER IX. Diseases of the Teeth and Face dependent upon Morbid Conditions, either general or of other parts, . 123 Neuralgia, . . . . . . .123 Neuralgia Faciei, or Facial Neuralgia, . . . 124 Intermittent Neuralgia, . . . . .127 CHAPTER X. Morbid Secretions of the Mouth, . . . 133 CHAPTER XI. Morbid Effects of Conditions of the Teeth, and the parts immediately connected with them, upon the gen- eral system, ...... 149 CONTENTS. XI CHAPTER XII. PAGE. Morbid Effects of First Dentition, . . . 151 CHAPTER XIII. Sympathetic Diseases of Dentition, . . . 161 Cholera Infantum, . . . . . .162 Convulsions, ...... 164 Cutaneous Eruptions, ..... 166 Intertrigo, . . . . . . . 166 Crusta Lactea or Milk Crust, . . . .167 Strophulus, Tooth Rash, Red Gum, . . . .167 Second Dentition, . . . . . . 168 Third Dentition, ...... 169 CHAPTER XIV. Effects of Diseased Teeth and Gums upon the General Health, . . . ... 170 Phthisis Pulmonalis, induced by Dental Irritation, . . 190 C.HA PTER XV. Wounds of the Mouth and Face, . . ._."'•. 209 Fractures, ...... 224 Fractures of the Jaws, ..... 226 Dislocations, or Luxations, ..... 228 Dislocations of the Lower Jaw, .... 229 CHAPTER XVI. Particular Affections of the Mouth and adjacent parts, . 231 Diseases of the Gums, ..... 231 Epulis, 231 Parulis 235 Fistula of the Gum of the Lower Maxillary, having an Exte- rior Opening at the Hollow of the Chin, . . . 237 Spongy or Fungoid Inflammation of the Gums, . . 238 Hemorrhage from the Gums, ..... 240 CHAPTER XVII. Diskases of the Lips, ...... 243 Hare-Lip, 243 Adhesion, ....... 247 Contraction. ...... 247 Xll CONTENTS. CHAPTER XVIII. PAGE. Diseases of the Glands and Gland-Ducts, . . . 253 Salivary Tumors, ...... 253 Tumors of the Submaxillary Gland, .... 256 Notes of the Operation, ..... 260 Tumors of the Parotid Glands, . . . .266 Salivary Fistula, ...... 267 CHAPTER XIX. Tumors requiring Amputation of a part or the whole of the Upper Jaw, ...... 271 Amputation of the Lower Jaw, .... 273 CHAPTER XX. Diseases of the Antrum, or Maxillary Sinus, . . 283 Dropsy, or Retention of Mucus, .... 284 Inflammation, ....... 289 Suppuration, ...... 290 Caries, Necrosis, and other Morbid Conditions of the Bony Walls, 291 Softening of the Bony Walls, ..... 298 Exostosis, ....... 298 Fistula of the Superior Maxillary Bone, . . . 300 Ozena, ....... 304 Polypi and other Tumors, ..... 305 Insects in the Cavity, ..... 310 CHAPTER XXI. Diseases of the Palate, . . . . .313 INTRODUCTION. The body of every animal is wisely contrived and perfectly fitted for the purposes it is intended to subserve. Every part, however minute, is necessary to the complete performance of the work of the whole; and a beautiful unity of purpose, and a necessary dependence of parts, are observable throughout the organization. So remarkable is this unity, and so certain this dependence, that a naturalist, by examining a fragment of any one of the bones of an animal, may determine the character of -the indivi- dual it represents. Having ascertained the size, figure, &c, of any bone, he may infer, with infallible certainty, that every other part of the body to which it belonged was formed in perfect proportion to this part, and with strict reference to the purposes for which this particular portion was designed. Should a natu- ralist ascertain that a single bone presented to him was con- structed for purposes of prey, he would immediately infer that a beast so provided must have had strong muscles and bones of the neck and jaws, to enable it to hold and tear the animals upon which it was intended to subsist ; hind legs of such a formation as to enable it to spring upon its prey ; claws to seize and hold it, and a digestive apparatus suited to the reception and assimilation of the food thus procured. Those who are familiar with the writings of Cuvier, will not need to be reminded of his beautiful reasoning upon this subject. 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 nervous system, directed to a common purpose, subject to one sovereign will, 2 14 INTRODUCTION. and pervaded by a general law of continuance, decay and dis- solution. As one part of the body is identified with all the others, it is necessary that a certain organic consent shall subsist between the several parts, in order that they may act in concert in car- rying on the business of life. For instance, the eyes must act together; the muscles of the trunk must aid the muscles of the limbs, and many more agreements of motion, infinitely compli- cated and astonishingly rapid, must subsist between different members of the body. The body has more to do than to perform certain acts by which it may be continued in being. It is, from its nature, liable, and from its condition exposed to injuries. It is con- tinually assailed by enemies from without and within. It has, therefore, certain signals of suffering, and is endowed with cer- tain aptitudes, through which any part more particularly attack- ed may receive succor from the rest. Moreover, the parts being connectedtogether by extension of common tissues, by blood- vessels and by nerves, the morbid conditions of one may readily be propagated to another. All this concert of parts, whether healthy or morbid, is called sympathy ;* though, in the case of healthy action, improperly so — and constitutes one of the most interesting and beautiful peculiarities of organized structures. In many instances the dependence of one part upon another is so direct, and the mode of communication so obvious, that there is no difficulty in detecting the process of sympathetic action or suffering that may be observed between them. In other cases, this concert of action depends upon undiscovered links of union, and is known to exist only upon the evidence of common observation. Besides this sympathy of parts, there is a general interest of the whole organism in the welfare of all its parts ; and severe or long continued suffering in any one, however comparatively unimportant, will commonly induce a general derangement of health, and may involve the whole body in serious and even fatal disorder. * Sw, with, rta9oi, suffering — fellow-suffering;. INTRODUCTION. 15 Although in many cases no change in the structure of mor- bidly sympathizing parts might be discovered upon autopsic* observation, yet there is good reason to believe that sympathy is in fact a transfer or propagation of actual molecular change, and every physician knows that a disorder, primarily of little importance, may prove fatal by involving vital organs in a sym- pathy of disease. It cannot therefore be predicated of any organ, that its suf- fering is necessarily unimportant to the health of the whole system, since experience shows that the danger of almost all disorders depends very much upon the sympathies likely to be established in the course of their progress, and that the impor- tance of these sympathies is not always determined by that of the organ originally involved. The facts above stated are universally admitted by the medi- cal profession, and for the most part are recognized as impor- tant practical truths ; so much so, that the study of particular parts as isolated from the rest, with a view to treat certain local affections as independent phenomena, has long since fallen into disuse, and every physician and surgeon is expected to become conversant with all of medicine, as necessary to the proper care of any one of the organs of the body. An oculist, unless a thorough physician, would be utterly unqualified to treat dis- eases of the eye. The obstetrician must extend his knowledge far beyond the uterus, if he would claim any participation in the fellowship of science. Until very recently, however, the treatment of the diseases of the teeth seems to have been considered less a proper specialty of medicine, than a mere mechanical craft, requiring in the operator little more than manual dexterity and physical force. Surgeons and physicians were generally profoundly ignorant of the importance of these organs to general health, and were con- tented to leave them to the care of any who were willing to take charge of them. Even now diseases of the teeth are rarely mentioned in the medical schools, and eminent professors of ' Avroi — w+, one's own eye — actual sight of the parts of a dissected body. 16 INTRODUCTION. of surgery have publicly confessed themselves incompetent to teach their students how to extract them. In the course of time, however, men of inquiring minds and studious habits, finding themselves in the practice of a rude and imperfect art, the deficiencies of which were continually forced upon their observation, have been constrained to investigate the relations of the teeth to surrounding and distant parts. Well read medical men, waiving the general practice of the profes- sion, have turned their attention to dentistry, and of necessity have applied their previous information to the augmentation of dental pathology and therapeutics ; and, finally, the manage- ment of the teeth has come to be an acknowledged specialty of medical science, and is rapidly advancing in public and pro- fessional consideration. It is thus that other departments of the healing art have gradually won their way to their present position and impor- tance. Within a period comparatively recent, surgery in all its branches was regarded by physicians with sovereign contempt. Barbers were the operators, and mountebanks and old women dressed the sores. Midwifery was, if possible, held to be yet more despicable, and even within a few years, an eminent body of scientific physicians have declared obstetrics to be un- worthy the attention of a polite gentleman. It is unnecessary to say that surgery and obstetrics are now the leading branches of the profession, and are zealously prac- ticed 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 proper level with other professional pursuits. The depressed condition of surgery and midwifery was the consequence of the vulgarity and ignorance of those who prac- ticed them, and the bad reputation thus acquired was a formida- ble obstacle in the way of those who attempted to elevate them to the dignity of scientific pursuits, but patient continuance in laborious and honorable effort has eventually succeeded in ac- complishing the desired result. INTRODUCTION. 17 The practice of dental surgery was long degraded, from causes precisely similar to those evil influences which so long depressed kindred branches of the art. Disregarded by edu- cated men, it necessarily fell into the hands of the ignorant and rude, and precisely as surgery and midwifery have gradually emerged from their barbarous state and attendant disrepute, dentistry is now winning its way against all opposition, to its proper consideration. It is a matter of honest pride, that our country is again foremost in this laudable work. The purpose of the present work is to treat of dental surgery as a distinct and proper specialty of medicine, and to present to the reader a digest of information, prepared with particular reference to the morbid connexions certainly existing between the teeth and the rest of the body. These connections are far more important than is generally supposed by physicians or dentists ; and 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 concerned in the production of pathological conditions observed in the mouth ; and his surprise will perhaps be greater to find so many and so serious diseases of other organs traced to their primary seat in morbid conditions of the teeth. Yet the object of the author has been to condense this treatise as much as consistency would permit, and to admit nothing foreign to the subject properly under consideration. TREATISE ON DENTAL MEDICINE. CHAPTER I PRELIMINARY CONSIDERATIONS. The human body is liable to changes which more or less disturb the regular and healthful performance of the many functions* necessary to the completeness of its life, or in other words, to disease. These changes are commonly 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 de- tected by our present means of investigation. Many attempts have been made to define the essential nature of disease, but all have necessarily failed. It is impossible to frame with philosophical accuracy a definition of disturbed or altered conditions, unless we perfectly understand the nature of the organs, and the mode of their acts. We cannot under- stand the ultimate cause of morbid phenomena, while ignorant of the essential nature of life itself, as manifested in the healthy performance of function. * 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. t Symptoms are those observable differences from the healthy perform- ance of function which lead us to suspect and often to detect disease. 20 PRELIMINARY CONSIDERATIONS. It is important to the student to know that medical language does not pretend to the precision of abstract philosophical science. Medical definitions are not to be regarded as accu- rately stating the nature of things, but simply as descriptions which may serve for practical purposes. This fact has been forgotten by many eminent medical writers, and their efforts to be absolutely accurate have often led to serious mistakes, and always to confusion of ideas and contradiction of facts. The study of essences belongs to metaphysics, not to practical science, and having failed to reach any truth by a analyzing mind, it will hardly prove successful in its attempts upon the body. We wish it then to be clearly understood, that medical terms are to be received in a conventional sense, and that, while they serve 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 nausea ; this sickness may be consequent upon defective digestion ; the de- fective digestion upon interruption of the function of the liver; the interruption of the hepatic* function upon change of structure in that organ ; and that change of structure upon more minute pathologicalf conditions. Strictly speaking, we might regard all this train of evils as symptoms merely of some obscure and inappreciable change which constitutes the disease. But in that case the word would be of no practical use. These instances may suffice to illus- trate our meaning, and the student may be saved much * Hepar — the liver. t Pathological— xo0o$, suffering, xoyof, discourse ; that which relates to diseased conditions. PRELIMINARY CONSIDERATIONS. 21 embarrassment by keeping the fact thus presented always in his mind. Many false theories and much bad practice have resulted from attempts to philosophise in medicine. It is an experi- mental science, embodying the results of long experience and protracted investigation. As such it is true, and worthy of all confidence. It is impossible to tell why any medicine produces its effect — we do not understand the philosophy of it ; but we know what effect it does produce, and that knowledge is suffi- cient, and infinitely more important. I will not trouble my readers with a recapitulation of the many definitions of disease proposed by eminent writers, let it suffice to say, that all of them are improper, and many of them strangely absurd. We can describe disease readily enough, but we cannot detect and exhibit its primary elements. Probably we would not be practically wiser if we could do so. Life, then, may be considered as the effects produced by or- ganization. Health, the regular and orderly development of these effects. Disease, disorder and irregularity in their mani- festation, or impediment to the accomplishment of one or more of them.* Physiology! has to do with the performance of healthy or natural acts, and physiological medicine or hygiene with the preservation of health. Pathology is the science of diseased conditions. Therapeutics^ the art of applying remedies for the cure or relief of disease. Anatomy§ is the study of the body as an organized machine. Surgery,]| manual or mechanical medicine. Etiology, *$ the science of morbific causes. In the present treatise, it is our purpose to examine the etiology, pathology and treatment of morbid conditions, with a special reference to practical dentistry. * Roche and Sanson, Nouveaux Elements. § Avatsfxvco, I cut up. t Sikhs, nature, Xoyos, discourse. || X«p, the hand, tpyov, work. t©£part£vw ; I cure. IT Etfu-s, cause. ETIOLOGY. 23 CHAPTER II. ETIOLOGY. Causes of disease may be external or internal. By external causes we mean all those agents which are independent of our own organization, whether they produce their impression upon the outward or interior parts of the body. Thus poison 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 em- barrasses and sometimes overwhelms the physical machine. By general causes, we mean such as affect simultaneously a large part of the corporeal system. By local, those which are very much circumscribed in their sphere of action. These terms, like most others used in descriptive science, are not philosophically precise, since every cause must be supposed to act upon some structures to the exemption of others ; but they are sufficiently accurate to convey the meaning intended. It must not be supposed that general causes necessarily produce general diseases, and vice versa. A local cause, acting only upon a very small surface, may produce universal disorder, while a general cause may beget a strictly local disease. A plunge into cold water, drenching the whole surface, may pro- duce nothing more serious than a tooth-ache ; while a prick of a finger may cause serious general disorder and even death. Further subdivisions of causes are based upon the character of the effects which they produce. Some stimulate or increase the action of the blood-vessels; others debilitate or lessen such action. Some act mechanically, dividing, tearing, bruising, &c; others chemically, burning, corroding or decomposing. Predisposing causes are those which exert an influence suffi- cient to make parts more liable to disorder, without actually disordering them. This term, again, is not absolutely accurate, 24 ETIOLOGY. for we cannot conceive of these causes acting in any other way than in the production of disease, which doubtless they do, but in so feeble a degree as to give out no symptom of its existence. Exciting or efficient causes are those which immediately precede disorder, and are reasonably inferred to have induced it. It must not be supposed, however, that these divisions are abso- lutely descriptive of certain agents which permanently belong to either of them. A cause which predisposes in one instance may excite in another, and vice versa. For example, a man may be exposed to intense cold, and while extremely chilled he may drink a large quantity of ardent spirits, and fever may en- sue. In this instance the cold would be regarded as predis- posing and the alcohol exciting. On the other hand, a man may become intoxicated, and while thus enfeebled he may be exposed to cold and fever or inflammation might result. In this case, the alcohol and its effects would be the predisposing, the cold the exciting, cause. Some causes are utterly unknown, but are inferred to exist as agents differing essentially from known causes, from the pe- culiarity and uniformity of their effects. These are called spe- cific. The causes of scarlet fever and of whooping cough are examples. Almost every thing without and within us may be in some way or other productive of disorder to the human body. The air we breathe may carr,y 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 relieve us of our excess of caloric ; it may itself undergo chemical changes which deteriorate its qualities and render it more or less unfit for respiration. The food we eat may pain or sicken or con- vulse us. It may suddenly prostrate, or gradually 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 heaven may harm the delicate eye, and the sun's own heat exhaust the strength or inflame the brain ; while that all-pervading and powerful agent which we call electricity, entering our bodies at will, and playing upon ETIOLOGY. 25 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 un- dergoing change, and in them all, is at work an irresistible law, which impels the whole to decay and dissolution. Linked together by exquisite sympathies, traversed by numberless nerves and blood-vessels, performing most delicate and impor- tant functions, and pervaded by a powerful moral intelligence, whose passions and appetites excite and depress the physical system to its utmost limits of endurance, the parts of the body are continually liable to become diseased, and to radiate disor- der throughout the whole. It will be impossible for me to introduce into the present work a full examination of each of the many causes of disease which might be worthy of particular notice. I will only ask the attention of the reader to the consideration of such as are most important to us, as being concerned in the production of those diseases which the dental surgeon is expected to treat. The Atmosphere* The air acts upon us in a variety of ways. By its pressure upon us it keeps in form ; without that pressure the fluids coursing within us would overcome the resistance offered by the coats of their vessels, and universal turgescence, interruption of function, and death would ensue. It furnishes us with the oxygen necessary to preserve the vitality of the blood. Were the natural proportion of this » The atmosphere is composed of two great elements, called oxygen and nitrogen, with a small portion of carbonic acid. 3 26 ETIOLOGY. element increased or diminished, we must suffer hurt. It is also the vehicle by which watery vapor acts upon our outward and inner surface, and the medium by which caloric or the matter of heat is brought into contact with us. It is therefore the means by which we feel those hygrometrical changes which have so much to do with our health, and the vicissitudes of temperature which, as morbific causes, are hardly less important. Increase in the density of the air has been known to produce serious epidemic affections. Persons who ascend high moun- tains generally suffer much from embarrassed respiration, and hemorrhages and pulmonary affections have been traced to changes in the mechanical action of the atmosphere. Unless the supply of air be unequal to the want, the quantity of oxygen in the atmosphere has never been found deficient ; but where persons have resided or been confined in crowded and ill-ventilated rooms, the most serious consequences have often resulted. When the deficiency of air is not so great as to produce rapid and violent results, the health often languishes, the complexion fades, the strength fails, and diseases of various kinds make life wretched, and shorten its duration. In the gorges of mountains are often found decrepid, deformed, and even idiotic people, who bear sad testimony to the evil effects of depraved air. 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 equilibrium. The animal heat which is elaborated by some obscure process, but little understood, obeys the common law of caloric, and constantly passes off to bodies less warm, or receives increase from those more heated. Our sensations of heat and cold are therefore nothing more than indications of the loss and supply of caloric to our surface. When it passes off in greater quan- tity than we can supply it with comfort to ourselves, we com- plain of cold; when surrounding bodies draw less from us than we are in the habit of supplying, or communicate to us of their own excess beyond our wants, we feel heated. These variations in our state of calorification are not limited in their effect to the ETIOLOGY. 27 production of certain sensations. They are capable of causing great disorder in the performance of function, and creating morbid conditions of the most serious kind. Heat is an ex- citant, cold must therefore be a depressing agent. Heat induces increased action of the heart and arteries ; cold diminishes that action. But in considering the consequences of agents acting upon the human body, we must always remember that it is a living machine, and is not merely passive under modeling influ- ences. A thorn penetrating the substance of an inanimate ma- chine, 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 in- creased 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 debili- tate the whole frame ; for it causes the organs to work more rapidly than usual — consequently to consume more of the means of action, while it adds nothing to those means. It does not increase the amount of blood, nor enrich its quality, but it causes it to be more rapidly circulated and consumed; it provides no ad- ditional nervous energy, but causes greater expenditure of it. In the course of such unusual consumption and expenditure, the parts appear more than commonly vigorous, but the result must be that the supply of means soon falls below the usual con- sumption, and languor, depression or exhaustion result. 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 * It will be perceived that we use this word in the popular sense, as conveying the idea of a certain sensation. When we speak of heat as an external 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. 28 ETIOLOGY. body a recuperative power, which exerts itself powerfully to overcome morbid influences. This power we call reaction, and its chief phenomenon is increase of vascular action, up to and beyond the natural standard. When cold is suddenly applied to the body, the first effect is to lessen vascular action and ner- vous sensibility ; but unless the application be very long con- tinued, the circulation will soon resume its vigor, a glow of warmth will succeed to the chill, andperhaps the heart and arteries may work with a force and frequency incompatible with health. In order to explain certain pathological conditions, of very common occurrence in every part of the body, it is also im- portant to observe that when parts are suddenly chilled by the rapid abstraction of their natural heat, their nervous excitability, 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 patients cannot endure protracted and painful operations in the winter as patiently as in summer. To a man nearly frozen, it would be death to bring him to a blazing fire. Frost bites are nothing more than burns inflicted at very low temperatures, upon parts unusually susceptible through the abstraction of heat. If this be true of cold, the converse is true of heat. Pro- tracted heat, as indeed the long action of all stimulants, wears 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 char- acteristic of any disease, it is merely a circumstance of it. A man half-starved would be very weak, and might be too much excited by a single glass of fermented liquor : another, exhausted by long continued intemperate drinking, might be equally * This is true in the case of the sudden diminution of any of the essen tial means of life. If food be withdrawn for a considerable time, the accu- mulated 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. ETIOLOGY. 29 debilitated, but could not be excited by immense quantities of distilled spirit. These remarks upon the effects of cold and heat will enable us to understand the mode of production of many particular affections, through the agency of atmospheric changes. Excessive moisture in the air is also a common cause of disease, but only because the watery vapor withdraws our heat much more rapidly than dry air, at the same temperature, would do. Air is also the vehicle through which aerial poisons of various kinds are brought to act upon us. We have mentioned specific causes, as the unknown agents which produce peculiar and uniform disorders. Some of these causes can only produce their effects through the air when it is highly charged with the poison ; others can act at great dis- tances from their source, and apparently when much diluted by atmospheric mixture; and others have never been traced to any local origin, and while apparently poisoning the air over immense spaces, produce no change in it which is appreciable to our nicest tests. Of the first class are the contagious, which may be propagated either by direct contact or by atmospheric infection within short distances: of the second are the causes of endemic diseases, and of the third are the inscrutable agents which produce those wide spread disorders which we call epidemics* The scope of our work does not include the causes of con- 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 ignorant of their cause, nature and treatment, it is necessary for us to notice particularly the atmospheric vitiation, which causes them. •Endemic, tvS^oj; epidemic, (rttS^oj. By endemics we mean dis- eases largely prevalent in a certain vicinity, and often traceable to a local cause, and always dependent upon such. An epidemic has no connection wiih locality, and evidently does not spring from a local cause. The yellow fever is au example of an endemic ; cholera of an epidemic. 3* 30 ETIOLOGY. It has been observed, from time immemorial, that the borders 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, malaria and marsh poison. To this agent must be attributed by very far the greatest part of endemic diseases, and those which are most destructive 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 remittent or bilious, and the intermittent or ague, of many places, and many other affections which it is unnecessary to mention, are the produc- tions of the poisonous emanations from wet soils. We have not as yet been able to discover the nature of marsh poison. The most careful analysis of air selected from the pestiferous fens has not developed any alteration in the pro- portion 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 atmos- phere, and the failure to detect only proves the inadequacy of our means of analysis. 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 concen- trated by the cold of evening before it exerts its malign influ- ence. Hence the popular dogma that summer dews are un- wholesome; 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 present. ETIOLOGY. 31 There are cogent reasons for supposing that the cause of the endemics in question is not one and the same for each of the distinct disorders belonging to the category of malarious dis- eases, but that each has its separate and peculiar poison, though all are the product of vegetable decomposition under the com- bined operation of heat and moisture. It would be incompat- ible with the design of the present work to discuss this and other interesting questions connected with these wide-spread and destructive emanations. The subject, however, is well worthy of the careful attention of every man, and especially of every student of medical science. Ignorance of facts con- nected 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 in- tervention of thick woods between the source of the poison and the house, and the rarification of the evening air of the dwell- ing by fires. It is not necessary to particularise the mechanical and chem- ical causes which may injure the human body generally, nor would it be consistent with our purpose to examine in detail the effects of aliments, occupation, &c, in the occasional pro- duction of disease. These considerations belong to general hygiene, and if introduced here, would swell our work to an inconvenient size. We shall, therefore, only allude to those matters as we may have occasion in the progress of our dis- cussions. In organs endowed with a high degree of vitality, the laws of chemical affinity are inoperative, being subordinate to an in- explicable and all-controlling law of life. This, however, is only true within certain limits, for some chemical agents will always enter into combination with the animal tissues, whether living or dead, when brought into contact with them. The enamel and even the bony structure of the teeth are acted upon very readily by many acids, both vegetable and mineral, which combine with the earthy base, lime, and form * ripo<}>w\aSis, — prophylaxis, from rtpofv\a,Gou — I guard against. 32 ETIOLOGY. new compounds with it, breaking up of course, the integrity of the organ. The enamel is a crystalline mineral substance and possesses no vital organization, consequently it is quite as lia- ble to be acted upon by chemical agents while in its normal place, as it would be when separated from the body. It is therefore very easy to perceive, that this external defence of the tooth may be very easily penetrated and the ivory of the organ laid open to the action of alimentary matters and fluids of the mouth. It is from this cause that what is called caries results. Unfor- tunately the word is used to express an affection of the bones entirely different from the peculiar disorganization called caries of the teeth. The former is a modified vital process, analogous to ulceration of the soft parts, the latter is a chemi- cal erosion. Dr. Westcott has published* the results of some interesting experiments made by him for the purpose of test- ing the activity of certain chemical agents upon the teeth. The mode of these experiments was as follows : A water bath was prepared, kept constantly at 98° by a spirit lamp, and regulated by a thermometer. In these were placed vials containing the substances to be tested. In each of these was placed a human tooth — care being taken to select those of as similar organization as possible, and whose enamel was perfect. A hundred articles, such as are most commonly used as food, condiments or medicine, were thus tested, and uncommon care was taken to watch the progress of the chemical action upon the teeth, subjected to such application. The results of these experiments are summed up by Dr. Westcott in the following propositions : 1st. Both vegetable and mineral acids act readily upon the bone and enamel of the teeth. 2d. Alkalies do not act upon the enamel of the teeth. The caustic potash will readily destroy the bone by uniting with its animal matter. * Vide Amer. Journal of Dental Science, Sept. 1843. ETIOLOGY. 33 3d. Salts, whose acids have a stronger affinity for the lime of the tooth, than for the base with which they are combined, are decomposed, the acids acting upon the teeth. 4th. Vegetable substances have no effect upon the teeth until after fermentation takes place, but all of them capable of acetic fermentation, act readily after this acid is formed. 5th. Animal substances, even while in a state of putrefac- tion, act very tardily, if at all, upon either bone or enamel. On examining the teeth, subjected to such influence, the twentieth day after the experiment, no visible phenomena were presented except a slight deposit upon the surface of a greenish slimy matter, somewhat resembling the green tartar often found upon teeth in the mouth. « Acetic and citric acid so corroded the enamel in forty-eight hours that much of it was easily removed with the finger nail. Acetic acid or common vinegar, is not only in common use as a condiment, but is formed in the mouth whenever substan- ces liable to fermentation are suffered to remain about the teeth for any considerable length of time. Citric acid, or lemon juice, though less frequently brought into contact with the teeth, acts upon them yet more readily. Malic acid, or the acid of apples, in its concentrated state, also acts promptly upon the teeth. Muriatic, sulphuric, and nitric acids, though largely diluted, soon decompose thejteeth. These are in common use as tonics.* Sulphuric and nitric ethers have a similar deleterious effect ; these are used frequently as diffusible stimulants. The acids of some of the salts also corrode the teeth. Super tartrate of potash, or cream of tartar, destroys the enamel very readily. This article is frequently used to form an acidulated beverage. (It is also the basis of certain popular dentifrices, which whiten the teeth by corroding their surfaces.) Raisins so cor- roded the enamel in twenty-four hours that its surface present- ed the appearance and consistency of chalk. Sugar had no effect until it had undergone acetous fermen- tation. * Tonics are medicines which invigorate the system, or impart tone to the muscular fibres. CHAPTER III. SYMPTOMS OF DISEASE. All changes of normal phenomena observed to attend dis- eases are called symptoms. Sometimes we know nothing more of the disease than that it causes certain appearances, and in fact we are commonly compelled to regard the symptoms as the evils to be combatted, and to rely mainly upon experience for the proper means of relief. The skill of the physician and surgeon is chiefly exercised in interpreting these signs correctly and pur- suing their indications to the desirable result. Sometimes a case will present but a single symptom, as pain in a tooth; at other times, while one particular symptom in- dicates the seat and nature of the primary malady, a number of secondary and collateral signs will claim attention and clamor for relief, and again all the morbid appearances may be so general and vague as to afford no satisfaction as to the na- ture and seat of the disease. Local symptoms are those which present themselves in the very seat of the disease ; sympathetic, such as are manifested in other organs than that primarily affected, and which are depend- ent upon the distant disease, being due to their relations with it through the brain, spinal marrow and sympathetic nerves. General symptoms are such as affect a large part of the body simultaneously. Generally speaking the local symptoms are the most import- ant as they indicate the seat of the disease upon the extent and intensity of which the suffering of the sympathizing organs de- pends. It is always exceedingly important to detect these lo- cal symptoms and deduce from them correct knowledge of the pathological condition they represent. But this is often a mat- ter of great difficulty, as the greater intensity and obtrusiveness 36 SYMPTOMS OF DISEASE. of sympathetic symptoms may deceive us and we may readily mistake them for local symptoms. Sympathetic symptoms are worthy of careful attention, for though caused by distant disorders, yet they manifest real dis- turbance in the organs to which they belong. And it often happens that these sympathizing organs suddenly assume dis- eased conditions of the most alarming character. The judi- cious physician will watch them carefully, especially if the brain be the seat of them. General symptoms are those manifested by the heart and ar- teries, and the nervous system, which, acting throughout the whole system when disordered, give out everywhere signs of distress. Progress of Disease. A disease is said to be continuous when its prominent symp- toms are not interrupted by any law of the disorder, from the commencement to the end of it. We have an instance of this in continued fever. We use the term intermittent to distinguish a very important class of disorders, characterized by regular periodical disap- pearance and return of symptoms. Such are agues. Remittents are those diseases which present, as a character- istic symptom, a periodical abatement of intensity, very mani- fest, though not amounting to intermission. The bilious fever of our country belong to this class. Diseases are said to be acute when they run their course rap- idly: Chronic* when they occupy a comparatively long time in their progress. The student must not suppose that the term acute, necessa- rily implies violence or intensity. It is true that violent dis- orders are commonly of brief continuance, but it does not fol- low that all diseases of brief continuance must be severe. Neither is it true that chronic diseases are less serious than those which are more rapid, for the reverse is very frequently the case. The terms acute and chronic have reference to dura- tion and not to intensity. *XpoK>s — time. SYMPTOMS OF DISEASE. 37 As a general rule, all diseases abate their severity early in the morning and increase it in the evening. This increase is called an exacerbation ; if very severe, a paroxysm. This last term has a peculiar meaning when applied to intermittents. The phenomenon of intermission is one of the most curious and inexplicable of all observed by the physician. The dis- eases characterized by this peculiarity consist of an indefinite number of attacks or paroxysms, each of which, after having exhibited a succession of conditions, disappears, leaving no symptom of disease, except the exhaustion of the patient be considered such. After a certain time of intermission or ex- emption, another attack is sustained, and so the disease pro- gresses, by alternate paroxyms and departures. Each parox- ysm consists of a chill or cold stage, a fever or hot stage, and a sweating stage in which the fever disappears, and the intermis- sion commences. If there be a paroxysm in every twenty-four hours, the dis- ease is called a quotidian ;* if it occur on alternate days, a ter- tian,! if there be two days of intermission, a quartan,! &c. Sometimes there will be two paroxysms a day, a double quotidian ; sometimes two paroxysms on alternate days, dou- ble tertian ; or, the double tertian may consist in the daily oc- currence of a paroxysm, at hours coinciding, or the alternate days. Many other modifications of periodicity occur in the disease, but the intermission is distinct in all. The quo- tidian and tertian are by far the most common forms of ague. It not unfrequently happens that the paroxysms occur regu- larly, but do not prevent the ordinary succession of chill, fever and sweat, but merely cause excessive pain in some sensitive part, usually occupying but little space. This pain obeys the law of intermission and periodicity as other forms of paroxysms do, and is known as intermittent neuralgia. || It is very import- ant that the dentist should be well acquainted with this form of disease, as it frequently occurs in the teeth and parts about the • Quotidian — quotidies, daily. f Tertian — tertius, three. X Quartan — quartus, fourth. || Neuralgia, from ytvpov, neuros, a nerve, and cayoj, algos, pain. 4 38 SYMPTOMS OF DISEASE. jaws, &c, and maybe easily confounded with tooth-ache from local causes ; a mistake which has caused the infliction of much unnecessary pain and the loss of valuable teeth. Remittent diseases are characterized by a remarkable diurnal abatement of their symptoms, not amounting to intermission, but apparently analagous to it. Some of the most fatal dis- eases which afflict the human family are of that class. For ex- ample, yellow and bilious fever. Certain diseases always present the same symptoms, and in the same order, and perseveringly run through them all un- checked by treatment, or the circumstances of age, sex, con- stitution, &c, which powerfully control other diseases. The small pox, measles, hooping-cough, &c, are examples of this class. They arise frrm specific causes, and are sometimes called specific diseases, though this term includes other dis- eases of entirely different character. CHAPTER IV DIAGNOSIS. Diagnosis* The art of following symptoms to their proper pathological cause and ascertaining the character, location and extent of disease, of which they are the signs. This, of course, involves the discrimination of one kind of disorder from all others, and is often extremely difficult, sometimes im- possible. When one or more local symptoms are prominent beyond others, we may sometimes ascertain at once the seat of the disease, but even in such cases we must not decide until we shall have ascertained whether these local symptoms are primary or sympathetic ; an inquiry which often requires much general knowledge of disease, and a capacity for close consec- utive reasoning. When our attention is first called to a patient, we often en- counter a large number of symptoms of different kinds, proceed- ing from various organs and all calling for relief. In the midst of this general out-cry of organs, the attentive observer will generally detect one voice of distress more earnest than the rest, and directing his inquiry to the part thus designated, he frequently comes at once upon the cause of the general trou- ble. The local signs are always the most important, and withal, often the most obscure. The first thing to be done, then, in the conduct of diagnosis, is to ascertain whether there are any local signs ; next to discover, whether any or all of them are sympathetic, and if so, of what primary affection, and lastly to consider whether the general and sympathetic symptoms cor- roborate our suspicions, that is, whether they can all be ac- counted for upon the supposition that we have found the local *Ata xivoaxu. I know through. 40 DIAGNOSIS. cause, and whether any are absent which are uniformly or com- monly concurrent with similar conditions to those supposed to exist. It sometimes happens that diagnosis will detect disease in two or more organs simultaneously, or complication. It would of course be impossible for any man to conduct a diagnosis properly upon any case of disease unless he should be acquainted with diseased conditions generally, and particu- larly with the relations and sympathies of parts. The dental surgeon is not prepared to investigate symptoms occurring in the mouth until he can detect those which are sympathetic, and trace them to their source. Were he guided only by a promi- nent local symptom, he might make serious mistakes. For in- stance, a female may complain of violent pain in a tooth, which may in fact be entirely due to sympathetic connexion with the uterus, and not at all dependent upon any diseased condition of the tooth in which it occurs. The mode of distinguishing dental diseases and those of the parts adjacent to the teeth and mouth is fully set forth in works of dental surgery. We will, therefore, omit any particular directions upon this subject ; but we would earnestly urge upon every dentist to extend his knowledge until it shall em- brace the entire subject of diseases and their cure. Independently of the necessity of diagnosing the local affec- tions, it is always important to ascertain those conditions which are immediately represented by general symptoms: or more correctly, it is always important to ascertain how far the nerv- ous centers and vascular system are participating in a disor- der. A number of symptoms, very variable and difficult to be described, announce general nervous sympathy and the degree in which it exists, but the connexion of the vascular system with a diseased state, is for the most part determined by the pulse* i. e. by the beating of the arteries due to the propulsion of blood through them. The artery which is generally examined for this purpose is the radial, which is of sufficient size, and passing near the sur- face at the wrist is most conveniently situated for examination. * Pulsus.— Lat. DIAGNOSIS. 41 The frequency, quickness, force or resistance, volume and any peculiar sensations given by the pulsation, are all subjects for observation, and contribute to the discovery of the nature, seat and degree of disease. Since the days of Galen, judicious and successful physicians have paid much attention to the pulse as a guide to correct di- agnosis and practice, and although it is too common in this day to hear this symptom decried as uncertain, yet the fact is, that to those who know how to interpret its communications, it furnishes the most valuable of all our means of diagnosis. In order to understand the morbid pulse, it is necessary to be well acquainted with its healthy conditions, for it is only by comparing its pulsations with the natural standard that we are able to detect morbid variations. The pulse differs in frequency at different periods of life. In infancy it is much more frequent than in mature life, and be- comes slower in old age. In infants* under two years of age the number of pulsations is above one hundred in a minute; in adult age, about seventy, and somewhat less in advanced life. These numbers, however, are susceptible of great varia- tion. Whylt mentions a case where a healthy woman had a pulse of one hundred and twenty ; and instances have been known where the natural pulse has amounted to only thirty-six or forty. The pulse of females is usually somewhat more fre- quent than that of men, and owing to the nervous sensibility of the gentler sex, is more readily excited by mental emotions, &c. The healthy pulse is accelerated by exercise, and mental ex- citement. It is often more frequent in the evening than in the morning, after a full meal, or the use of exciting drinks, and in pregnancy. It is also often very much accelerated after co- pious evacuations and under circumstances of great prostra- tion. It is diminished by the horizontal posture, by rest, by moderate bleeding, and by the influence of certain drugs, such as digitalis and the tartrate of antimony. •Some writers, as Billard and Valleix as«ert that the pulse of young infants is not near so frequent as is generally supposed. See Cliornel, Gen^ eral Pathology, p. 171. 4* 42 DIAGNOSIS. Indeed, the frequency of the pulse is subject in so great a degree to the control of idiosyncrasy* and accident, that no positive inferences can be drawn from this solitary symptom, unless the habitual pulse of the patient be known. Chomel says, "I have seen a lady whose pulse during the par- oxysms of intermittent fever did not beat above sixty per min- ute, to the great astonishment of her physician. This astonish- ment would have ceased had he counted the number of pulsa- tions during the intermission, these being not above forty per minute." Quickness and frequency are not synonymous terms. Frequency has reference to the number of pulsations in a given time, as a minute ; quickness to the time required for the completion of a single pulsation. Slowness is opposed to frequency, not to quickness. Thus we may have a slow quick pulse ; that is, one in which the beats in a minute are fewer than natural, but each particular beat is rapidly performed. For an opposite to quick, physicians frequently use sluggish or laboring. The natural pulse is soft or compressible : that is, it readily yields to gentle pressure with the finger. The hard pulse is the reverse, offering considerable resistance to the obliteration of its channel by pressure. Tense, wiry, firm, &c, are used to express modifications of hardness. Differences are also observed in the volume or size of the pulse. Sometimes it is full and open, at other times, small and contracted. It is called regular when the beats succeed one another in natural order, irregular, or interrupted, when the regular succession is broken by omissions of pulsation. Certain conditions, too, are attended with peculiarities of the pulse. In aneurism of the heart, or large arteries, it im- parts a peculiar thrilling sensation to the hand, which has more aptly, than is usual in such illustrations, been compared to the sensation which would be imparted by the passage of a fluid through a shattered quill. Ossification of the coats of the ar- teries destroys their elasticity, and of course renders the pulse very hard. The hard pulse is usually attended by a peculiar * Idiosyncrasy — tStoj avrxpoatj — peculiar constitution. DIAGNOSIS. 43 condition of the blood, which when drawn and coagulated, presents a yellowish lymphy surface, which is called the buffy coat, with but few exceptions, a very important sign of inflam- matory action.* The following precepts for feeling the pulse, though very minute, are nevertheless worthy the attention of those who are inexperienced in it. Long habit imparts to the fingers an extraordinary accuracy of sensation in this respect- but until it shall be acquired, it is not easy to form correct con- clusions without all the care demanded by these rules. The physician should wait until the patient has recovered from the emotion produced by his presence, requesting him to preserve absolute silence, and to remain in the sitting or hori- zontal posture. v The pulse may be examined at the temples, lateral parts of the neck-, arm, thigh, wrist, and wherever the arteries are sufficiently large and superficial ; but the radial ar- tery is generally preferred at the place where it ceases to be covered by the muscles of the forearm, opposite the radio-car- pal articulation. If the patient be up, he should be placed in the sitting posture, if in bed, he should be upon his back, so that he may neither incline to the right or left, and thus impede the circulation of blood in the arteries. The arm should be placed nearly in a state of extension, and sustained in its whole length, so that the muscles may be relaxed. The fore- arm should be nearly prone, that it may, upon the cubital edge and the radial edge be a little raised. Care should be taken that no bandage or clothing impede the flow of blood in the axilla, at the elbow or any other point. All bandages should be removed so that there be the least possible compression. By means of these various precautions, we may be certain that there is no foreign obstacle to the flow of blood through this vessel. The artery of the left side should be felt by the right hand, and vice versa: the four fingers placed parallel on the same line, should be applied over the track of this vessel ; the index finger should be nearest the hand of the patient, and the little finger applied lightly, should be the first to receive the impulse * The buffy coat is also seen upon the blood drawn from pregnant fe- males. 44 DIAGNOSIS. of the blood ; at the same time that the four fingers are placed over the radial artery, the thumb, or rather the palm of the hand should rest upon the dorsal face of the forearm, thus afford- ing solid support to the fingers by which the pulse is examined. The latter should at first receive a slight lateral movement in order to ascertain the situation of the vessel. When the fin- gers are all placed upon the artery, the pressure should be gradually increased and diminished several times in succession, so as to appreciate the influence of the pressure upon it, and thus more easily ascertain its different qualities. Twenty or thirty successive pulsations should in this manner be examined. It is not without advantage to examine the pulse in the two arms alternately, or at once : it should also, in particular cases, be examined in other places wherever it may throw light upon the diagnosis. It may be also examined several times, or at least a second time, before leaving the patient. However mi- nute these precepts may appear, they cannot be neglected without inconvenience. — Chomel, Elem. General Path. The inferences of pathological conditions to be drawn from the several above mentioned differences of the pulse, will be explained, as far as the purpose of this treatise requires, when we come to treat of particular diseases. Pain is one of the most common and important symptoms of disease. It is this which usually gives the first intimation of disorder, and drives the patient to medicine for relief. It is very important that the physician and surgeon should know how to interpret this sign, and in order to this, much general knowledge of parts and symptoms is necessary. An uninstructed observer naturally infers that the pain is always felt in the part diseased, and that its intensity accu- ratelyrepresents the degree of the disorder. But such prima facie opinions are often very erroneous. We have already remarked, that a part may sympathise with a local disease seated in a distant and dissimilar organ. It also hap- pens frequently, that diseases of the nervous centers, and of the nerves themselves, occasion pain at the extremities of these organs of sensation, instead of at the point actually attacked. DIAGNOSIS. 45 Violent pain in the nerves of the face may depend upon dis- ease located in the brain or intermediate parts ; and similar conditions are noticed in other nerves. Nor does the degree of pain represent necessarily the de- gree of the disease which causes it. Some parts are much more sensitive than others, the most important organs being least sensitive. The quality of sensation does not necessarily belong to living bodies, but is distributed to the several parts, arbitrarily, yet with wonderful wisdom and mercy. Pain is intended to warn us of danger and compel us to preserve the integrity of the body ; it is therefore set as a sentinel chiefly upon the out-posts of life. The external surfaces being much more sensitive than others. Those most carefully protected, being least profusely endowed with this watchful property. Hence it happens that the brain, heart, and lungs may be very seriously diseased without causing much, or indeed, any local pain, while an unimportant injury to the eye or skin will cre- ate great distress. The nature of the disease may often be guessed from the character of the pain, as it is burning, scalding, fixed, fugi- tive, darting, throbbing, &c. As pain does not point out with certainty the seat of the disease, and as its intensity does not necessarily indicate the degree of the change producing it, neither does its abatement or disappearance prove the relief or cure of the disorder. In many instances it certainly does so, but very often it does not. Pain may be lulled by the action of causes which lessen the sensibility, as by narcotic medicines, by the exhaustion in- cident to protracted sufferings, by morbid conditions of the nervous centers, or the nerves themselves, or by absolute loss of vitality. It sometimes happens that the sudden cessation of violent pain is a most fatal symptom, as showing that morti- fication has occurred in the diseased part. Pain is often intermittent and disappears only in obedience to a law of disease, not of health. CHAPTER V 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, inas- much 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 ac- tion 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 pro- voke a series of unpleasant and even dangerous 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 injury 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. There are, however, certain exceptions to this rule. Certain morbid 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. 48 TREATMENT OF DISEASE. 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 particularly when considering special diseases. CHAPTER VI. NATURE OF DISEASE. Many of the morbid alterations which seem to constitute dis- ease, 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 differ- ent conditions of parts, but those which are of common occur- rence, and are well ascertained, may be described as follows : 1. Redness, 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 tissues : it is called inflammation* The local symptoms of this condition are heat, redness, swelling, pain, and diminished, altered or suspended function. The general symptoms are pyrexia, 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 affec- tion. The local suffering is generally much less, though when certain organs, such as the brain and heart are the seat of con- gestion, the pain and discomfort are often very considerable. The function of the congested organ is greatly embarrassed or altogether suspended. The general symptoms are generally such as mark diminished action. 3. Red indurations ; vegetations ; fungi, polypi. * rivp fire — from the burning sensation and heated appearance of pa- tients in fever. 5 50 NATURE OF DISEASE. 4. Vesicles, pustules, suppuration, erosion, ulceration, per- foration, gangrene. 5. Thickening, granulations, thickness of tissues naturally transparent, adhesions, effusion of serum, false membranes. 6. Conversion of one tissue into another. 7. Gray induration, gelatinous degeneration, tubercles, ence- phaloid matter, cancerous matter. 8. Contraction, dilatation and complete obliteration of nat- ural 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- tion. 15. Changes of form and relation, wounds, ulcers, disten- sion, lacerations, ruptures, fractures and dislocations. 16. Foreign bodies. 17. Vices of formation. f 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, condi- tions, 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, con- cern him, and passing by those in which he has no profes- sional interest. * Mttoj — black. fRoche &. Sanson. Path. Med. Chir. NATURE OF DISEASE. 51 Inflammation. The most common, and for several reasons the most import- ant of all morbid conditions, is one which is characterized by redness, swelling, pain, and increased heat. This is called inflammation, and may occur in any parts naturally possessing sensibility. Alteration or suspension of the natural secretions is a constant attendant upon inflammation, and when seated in organs which do not secrete it, arrests, or more or less embar- rasses, the performance of their functions. The redness of an inflamed part is caused by the presence of red globules in small vessels which naturally carry only the serous or white part of the blood, and frequently, in addition to this, to the escape of blood from ruptured vessels and its deposit in sur- rounding tissues. This is called chemosis, or ecchemosis* The presence of red globules in the serous vessels, or capil- laries seems to be the essential fact in inflammation; the other phenomena being apparently consequent upon this error of cir- culation. It has hence been the anxious desire of pathologists to ascertain the cause of this irregularity in hope that such knowledge might lead to more sure modes of relief. It is not my purpose to recapitulate the several theories, which have been constructed by learned and ingenious men, in order to explain the phenomena of inflammation. The condition thus named is compatible with very different states of the general system and also of the tissues immediately concerned, and therefore no statement of the pathology, and no plan for treat- ing this form of disease can be uniformly correct. All patho- logical conditions attended by heat, redness, swelling, and pain are considered inflammatory, whether the parts immediately concerned be in a sthenicf or asthenic state. Theorisersupon inflammation have been much perplexed to re- concile the distension of the capillaries with the apparently exci- ted state of the parts : for distension or yielding of the walls of the vessels being connected in their minds with the idea of force * Ex, out of. X^oj, humor, f 1Qtvo$, strength. 52 NATURE OF DISEASE. overcome, or of relaxation, they suppose, that in inflammation the capillaries are less active and resistent, or in other words, comparatively passive; such being the case, it appears ra- tional to use exciting applications in order to arouse the ca- pillaries to exertion, so that they may empty themselves of su- perfluous blood, and resist the influx of unusual quantities of that fluid. The fact is, however, that the capillaries expand when excited, and thus draw to themselves an additional amount of blood, by a simple hydraulic law. They are not pas- sive, because distended ; but are distended in consequence of activity. Familiar examples will show the truth of this opinion. If the cheek be held close to a burning body, the skin will be reddened ; in other words, the effect of the stim- ulus will be to dilate the capillaries, and attract to them a large volume of blood, suffering red globules to enter their canals. On the other hand, if cold water or ice be applied to the skin, it grows pale and shrinks, showing the contraction of the ca- pillaries when their activity is diminished. The erectile tissues furnish us with an example of the operation of a similar law. The swelling of an inflamed part depends upon the presence of an unusual amount of blood in it, and upon the effusion of serum, blood, or lymph, or pus, consequent upon the engorge- ment. The cause of the pain in inflamed parts is not very plain. At first sight it might appear to be due to the mechanical dis- tension, but a moment's reflection will enable us to perceive that such cannot be the cause, for we may subject healthy parts to engorgement and distension, causing redness and swelling without pain. A string tied around the finger will cause the extremity of the organ to swell exceedingly, and be- come lividly red, yet this condition is not attended with pain, while inflammation of the same part is extremely agonizing. The pain of inflamed parts is so much modified by peculiar- ity of structure as often to enable the observer to distinguish the seat of the disease by the character of its sensation. As a general rule, the external parts are the most sensitive. The skin when inflamed is affected by a burning or scalding sensa- 1 NATURE OF DISEASE. 53 tion, often intermingled with itching, even more distressing than the burning itself. The inflamed mucous membrane par- takes of this sensation, though generally in less degree, unless in superficial situations. The serous membranes when inflamed, cause a sharp darting lancilive pain. The pain of the cellular membrane under sim- ilar circumstances, differs very much according to its position and relations. When in connexion with the skin, it partakes of the pungency which characterizes the inflammation of that sensitive organ ; when the cellular structure of the internal viscera is inflamed, the pain is usually dull, or obtuse, in con- sequence of the manner in which these viscera are supplied with nerves. When nerves are the seat of inflammation, very acute, dart- ing pangs are felt, and the surrounding structures are generally very sore, tender, and more or less inflamed. When the mus- cles are inflamed, the sensation is aching, mingled with a feel- ing of fatigue. The pain is greatly aggravated by motion. Inflammation of ligaments and bones, causes sensations not very different. Pain is more or less severe in proportion to the degree of the inflammation, and is also much modified by peculiarities in the nature of the disease, and the condition of the parts affected. Certain specific affections, such as cancer, occasion a peculiarly distressing, darting, and burning pain : slight in- flammation of the pulp of a tooth produces intolerable agony, &c. Pain does not always proceed from inflammation : it may attend very opposite conditions. Ice held upon the skin will cause great suffering. The secretions of organs are very materially modified by in- flammation. If it be slight, the natural secretion may be slightly increased, more often with increased secretion there will be an obvious alteration of it. Sometimes it is thinner and acrid, reddening, or excoriating the parts over which it flows : sometimes it is thicker, and more tenacious, often, es- pecially if the inflammation be severe, it is much diminished, or altogether suspended. An abundant discharge of thickened 5* 54 NATURE OF DISEASE. secretion often precedes, and seems to be the means of relief of the inflamed parts. It has become common to designate inflammation of the different parts by attaching the common termination "Ms" to the Greek name of the part affected. Thus, stomatitis indi- cates inflammation of the atopa, stoma, or mouth — gastritis, of the yaatpov, gastron, or stomach. Sometimes the suffix is added to a latin name, as conjunctivitis ; in some instances, terms descriptive of inflammation, have become so firmly fixed in our nomenclature as still to be continued, though as excep- tions to the rule. Thus, pneumonia signifies inflammation of the lung ; rheumatism, of the muscles. The term myitis is sometimes used instead of rheumatism. The Consequences of Inflammation. Inflammation never continues long without the supervention of certain results, often of greatly more importance than the phenomena we have described. When it passes away with- out consequences, we call the process resolution. The consequences, or as they are sometimes considered, the accidents of inflammation, vary according to the degree of its violence, the nature of the part, the general health of the pa- tient, &c, &c. The consequences of inflammation are chemosis, oedema, suppuration, vesication, ulceration, permanent alteration of texture, caries, and gangrene or mortification, or the absolute death of a part. Sometimes, also, by the effusion of a plastic substance, called lymph, adhesion is formed between surfaces, naturally, or artificially, separate ; but as this adhesive inflam- mation is more often a reparative and conservative than nox- ious process, we will not include it among the consequences before mentioned. ' Chemosis is the extravasation of blood in the progress of inflammation. This is not a mere mechanical fact, for the blood under these circumstances is evidently changed from its NATURE OF DISEASE. 55 ordinary condition. It is no longer coagulable, and remains in the tissues into which it has escaped until absorbed ; which is often a very slow process. (Edema is the extravasation of the serum or watery parts of the blood. It is apt to attend debilitated conditions 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 degree of inflammation, in debilitated subjects, and is unfavorable to re- covery ; 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 fever, and may be produced by medicinal agents, as arsenic. When cedema is general, it is called "anasarca."* It is readily de- tected by the bloated translucent aspect of the skin, and by its loss of elasticity observed by its pitting under pressure. Vesication, or blistering, is the effusion of serum under the cuticle and rete mucosum, elevating them above the level of the surrounding surface, and separating them from the cutis vera. This may occur as the result of topical applications of an irritating kind, or, in consequence of local or constitutional disorders. This condition is frequently produced 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 a 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 term laudable and healthy have been applied. That which is thin, dark, and irri- •Am aapf — throughout the flesh. 56 NATURE OF DISEASE. tating, being considered unhealthy, because of the indication it affords of the bad condition of sores, &c. which secrete it. Although it is true that such pus as is called ''healthy," in- dicates a convalescent state of an ulcer, or abscess, yet the in- ference to be drawn from its appearance attaches exclusively to the parts which secrete it : while it may herald the abatement 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, however "healthy" the pus might be. Some writers have considered suppuration a curative process, 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 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 increase of red vessels, and usually, if not always, by the addition of coagulable lymph ; for it may be questioned, whether in any instance the surfaces of the cellular, synovial, serous, and medullary 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 surface of the peculiar structures, called granulations, the vascularity of which exceeds that of all the natural surfaces of the body. NATURE OF DISEASE. 57 The pus formed on the granular surface of an ulcer is the best example of this kind.* Some parts of the body have a much greater disposition to form pus when inflamed, than others. The cellular tissue, skin, and mucous membrane are very prone to suppurate, while the fibrous tissues manifest no disposition to it. Pus is modified by the nature of the part where it is formed, by the constitution of the individual, by various accidents, occurring in the process of its formation, and by certain ob- scure laws which control the phenomena of those affections, which are called specific. It will also present different ap- pearances, as it may be mixed with other fluids, as blood, saliva, bronchial mucous, &c. If pus mixed with blood, serum, &c, be long confined under dressings, or in cavities, it becomes very offensive, and often irritating. If it be produced from the irritation of diseased bone, it is also very fetid. When thin, mixed with blood, and evidently "unhealthy" it is called "sanies." When pus is irritating, it is so, not to the surfaces which secrete it, but to the adjoining healthy structures over which it flows. Pus is heavier than water, and this quality frequently ena- bles us to distinguish it from mucus. It is coagulable by muriate of ammonia, which Mr. Hunter considered a peculi- arity sufficiently marked to distinguish it from mucus, and all other natural secretions, but the accuracy of the test is disputed. From the fact that hard inflammatory tumors in the course of inflammation become soft and yielding, and filled with pus, it was naturally supposed that the original solid parts were converted into this fluid. It is now well ascertained that such is not the case, but that pus is secreted by the arteries. When pus is enclosed in a cavity formed in the progress of inflammation, the condition is called abscess. f The phenomena of abscess are very curious, and through * Macartney on Inflammation. t Abscedo — I depart, denoting the loss of substance. 53 NATURE OF DISEASE. them, nature succeeds in relieving the body of foreign mat- ters, and repairing extensive injuries. When a part capable of suppuration is subjected to inflam- mation of the required intensity, some of the small vessels give way, and blood is effused into the surrounding parts Simultaneously with this rupture, or nearly so, the arteries be- gin to throw out a peculiar plastic matter, which is called co- agulable lymph. This is capable of becoming organized, and being thrown round the diseased parts, and between them and those which are healthy, it forms a barrier to the infiltration of extravasated fluids. By some strange process, to us altogether inscrutable, the walls of lymph become vascular, and capable of performing the vital functions of secretion and absorption, and by them the pus is furnished. As this secretion proceeds, the previous contents of the abscess, including the effused 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 de- layed, the cavity will be found to contain only pure pus. The process of suppuration is announced by some relief of local symptoms, and a change in the character of the pain. It loses its burning sensation and becomes throbbing, at the same time, the tumor becomes softer, and at last fluctuates readily under pressure of the fingers. Very often, and especially when the disease is extensive, or when it is seated in the vis- cera, the formation of abscess is announced by shivering or chill. While the arteries of the walls are depositing the pus, other processes equally obscure are moving the abscess towards the surface, and preparing for its evacuation. The bottom of the cavity is constantly contracting and filling up, while the opposite side is thinning and expanding. The absorbents at one side of the abscess are busily engaged in removing mat- ter, while the arteries at the other, are as actively supplying new material ; at the same time, a temporary organ, made for the occasion, faithfully performs its peculiar functions, supply- ing pus, and removing mixed fluids from the cavity. NATURE OF DISEASE. 59 The parts laying upon the summit of the abscess are rapidly thinned, the tumor is pushed towards the surface, the skin ul- cerates, an opening is made, and the pus evacuated. Though an abscess may discharge itself any where, there is evidently a strong disposition in such tumors to find their way to the out- side of the body. In order to effect this, they will often tra- verse dense opposing structures when a nearer opening through more yielding tissues might readily be effected. Sometimes when an abscess occurs in an important viscus, artificial adhe- sion will be formed between its surface and an adjoining struc- ture, and a continuous canal being pierced through, then the pus will be ejected upon the surface of the body, or into an- other organ which has external communications. These most curious and interesting facts are so conclusive of wonderful design and contrivance, that it is impossible to regard them in any other light than as manifestations of divine and superintending Providence. Foreign bodies are removed precisely in the same way as pus. When the abscess has reached the surface, a thin point appears, which is soon perforated by a very small opening through which the pus slowly oozes. The appearance of this thin projecting spot is called "pointing." Sometimes the parts which surround the abscess are too dense to permit the passage of the matter. When this is the case, great pain is often caused by the pressure, and the irrita- tion produced by the vain efforts of nature to relieve the parts may occasion very serious disease in adjoining structures. In some instances of this kind, as in abscess of the gums, or gum-boil, the pus failing to be evacuated, is ultimately ab- sorbed. When the attempt is made to form an abscess by weak or scrofulous constitutions, and in situations where the cellular substance is lax, the progress of the disease is very different. The first extravasation is serum, which passes easily into the loose cells of the cellular membrane with little or no injury to their structure. The parietes of the tumor are not composed in the beginning of organized and vascular lymph ; no genuine 60 NATURE OF DISEASE. pus, therefore, is found in such cavities in the first instance ; the fluid they contain is serous, mixed with coagulable lymph, parts of which are found as flakes floating in the serum. As the cavities of chronic abscesses are not provoked, either by severe tension, or the quality of the contained fluid, there is no preparation made for some time to remove their contents. These collections, therefore, often traverse a considerable dis- tance along muscles, or under plates of fascia, before they ar- rive at the skin, which ulcerates very slowly ; after which, the cavities may inflame, their interior surface become more highly organized, and secrete genuine pus.* Ulceration is the process by which solutions of continuity are 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 recognize 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 away ; and the difficulty is not solved by the fact, that only small portions are thus removed. Yet, there can be no doubt that such is the case, and we may silence, if not satisfy, the objector, by suggesting the equal difficulty of understanding how parts form themselves ; both facts, as Mr. Cooper ob- serves, are equally well confirmed. Every part of the body is continually undergoing waste and reparation. It seems that the molecules of tissues are con- stantly becoming effete, and having undergone some 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 * Macartney on Inflammation. NATURE OF DISEASE. 61 lungs, all the emunctories are continually at work, and all ulti- mately discharging the debris of the system. At the same time that this disintegration is going on through the action of the absorbents, another set of vessels, the nutri- tive arteries, are every where depositing new matter. Bone receives bone, muscle is supplied with muscle, and viscus with its peculiar organic matter, so that the integrity and form of each part, and of the whole, are exactly preserved. By some wonderful and inscrutable law, the balance of supply and de- mand is equally adjusted, yet not so positively as to lead us to infer that the action of the one set of vessels regulates that of the other. In childhood, the supply exceeds the waste, and the body grows ; in maturity, the supply is regulated more by the wants of the man than the activity of the absorbents. If his vocation calls for increased strength of arm, the very use of the organ, instead of consuming, augments its volume. In truth, the two sets of vessels seem to be independent of one another, yet, like other parts, they naturally work together for the production of the phenomena of life. It will readily be perceived that if any circumstance should increase the activity of the absorbents of a part beyond what is usual, and should not simultaneously stimulate the nutritive vessels: or, should any circumstances render parts unusually susceptible of absorption, that the result would necessarily be an obvious loss of parts, and the interruption of their conti- nuity. It is also obvious that the converse of these condi- tions would be attended with similar results ; for if nutrition be impeded, either through defect of supply, or any cause ren- dering the part less capablethan usual of converting blood into its own tissue, loss of volume, andbreach of continuity might occur. Ulceration may result from any of these causes. Pressure is a common cause of ulceration, and acts probably by inter- rupting the circulation, and nutrition of a part. Pressure may produce absorption and waste without causing ulceration, and the dentist when fixing artificial pieces in the mouth must be careful so to adjust his plates and springs as to avoid both of these evils. 6 62 NATURE OF DISEASE. Inflammation probably produces ulceration in a manner somewhat similar; viz. by causing such impediment to circu- lation, as prevents nutrition from being properly performed. It is also probable, that the blood itself, undergoes changes under the influence of inflammation, which render it less ca- pable of supplying the loss of parts. Diseased parts, and those which from any cause have be- come useless, and these only are liable to be wasted by absorp- tion. Unhealthy products, such as fungus,* are often removed with wonderful rapidity, and even bone will be removed when being no longer needed, it has become foreign matter. The roots of the deciduous teeth are thus entirely removed, and the dead fangs of permanent ones are subjected to continual waste from the same cause. That they are not entirely removed, is due to the comparative shortness of time which the present term of human life allows for the process, rather than to any resistance they are able to offer to the action of these all-sub- duing lymphatics. Extraneous substances are generally removed by ulceration. Thus, a ligature will be separated from an artery, or a foreign substance from a wound: no more of the surrounding substance being absorbed than is necessary to loosen and dislodge the intruder. By ulceration, also, dead parts are separated from the living, and the decomposed fragments removed to make room for new matter. Sometimes ulceration seems to produce great devastation, and is then called phagede?iic.\ In such cases, it is evident that the ulceration is only the consequence of the destruction, not the cause, for, until the parts have become too much enfee- bled to subserve their natural purpose, they will not be sub- ject to this rapid absorption. Adhesion is often consequent upon inflammation, though like ulceration, it is not always dependent upon inflammatory action. It is a process by which nature unites parts, either * #oy« — I eat. f Fungus— a mushroom — proud flesh. NATURE OF DISEASE. 63 naturally, separate, or artificially divided. The bond of union is coagulable lymph. This process is of immense importance, in checking hem- orrhage, closing fissures, and in providing means of safe transit for pus, from the viscera to the surface. Both of these processes are sanitory. Mr. Hunter calls ul- ceration the natural surgeon, and declares that even in the spreading of an ulcer, there may be considerable advantage ; and another writer very properly observes, that the same re- mark would apply to the effusion of lymph. The one acts like the surgeon that unites parts ; the other like the one who removes them, because they are not fit to remain ; and it would not appear more justifiable to call adhesion and ulceration in- flammatory processes, than to consider the operations of sur- geons themselves as particular modes of inflammation. Inflammation may result in a permanent change of struc- ture. Parts may become denser and harder, or, indurated; sometimes certain structures under the influence of slow in- flammation are softened : sometimes a permeable cellular struc- ture, as the lungs, becomes changed into a dense impermeable structure, like liver, or hepatized :* and sometimes accidental inflammation begets, in persons and parts inclined thereto, mor- bid growths of a specific character. The most disastrous result of inflammation is the absolute death of a part, reducing it to the condition of a foreign body, and subjecting it to the play of chemical affinities. When this takes place in soft parts, it is called gangrene or mortification ; in bones, necrosis. The dead soft parts, when separated by ulceration from its connexion with living parts, is called sphacelus,! or slough, a fragment of dead bone is called sequestrum.:}: Caries is a condition of bone somewhat analogous to ulcer- ation of soft parts. Caries of the teeth is the result of chem- ical agents acting from without, and decomposes their struc- ture, they are, however, subject to necrosis as other bony tis- sues, and the fact of their being liable to a peculiar erosion, does # Hepar — the liver. + 2af« — I destroy. X Sequestro — I separate. 64 NATURE OF DISEASE. not probably exempt them from the kind of caries observed in similar structures. If such idiopathic caries does occur in the teeth, it must be very rare, and is always confounded with the erosive caries peculiar to these structures. Inflammation of the several parts composing the Mouth, and of the parts adjacent. The mouth is very complicated and exquisitely organized. It subserves a variety of very important purposes. Speech, mastication, insalivation, taste, inhalation, and expiration, are all performed in this small, but admirably constructed cav- ity. Such numerous and complicated functions require the presence of various and delicate organs closely packed togeth- er, and a large endowment of nerves and blood vessels. Glands are hidden in every part of the walls of the cavity, their ducts perforate its floor, and open on its sides; nerves and blood vessels of extraordinary size creep along every bony channel, and spread in expanded network over the whole surface, while the mucous membrane with its innumerable crypts and follicles covers the whole, and connects every sentient part with the sympathies of the external and internal surface. Into the cavity thus constructed, and thus exquisitely en- dowed, air of different temperature is constantly rushing ; food and drink of various kinds are received ; secretions are poured out, remains of aliment and of the natural fluids undergo change, and medicinal agents of various kinds are made to pass. Besides all this, the mouth is the seat of the extraordinary process by which two sets of teeth are matured and evolved, and one of them removed by a physiological, and the other, to a greater or less extent, by a morbid disintegration. Under these circumstances, it is not wonderful that inflammation fre- quently occurs in the mouth, and that it should be attended there with severe suffering. As the cellular tissue enters largely into the composition of NATURE OF DISEASE. 65 the structures of the mouth, the form of inflammation most common in that cavity, is what is called phlegmon.* Phlegmon is the common form of healthy inflammation in organs composed largely of cellular tissue. It generally re- sults from some local cause, as a blow, pinch, or other me- chanical injury, or from the irritation of acrid matters, or for- eign substances. Sometimes, however, it depends upon con- stitutional causes. When phlegmon is seated in the subcutaneous cellular tis- sue, it presents a hard circumscribed red tumor, which is gen- erally very painful. At first, the sensation is burning and dart- ing, subsequently as the tumor softens, throbbing, or pulsating. After a longer or shorter time, according to the intensity of the inflammation and nature of the affected parts, fluid is felt to fluctuate in the tumor; in other words, an abscess, filled with pus, has been formed, the skin ulcerates, the matter is dis- charged, and the cavity is obliterated. What is called a boil is the best example of genuine phleg- mon. It is a possible thing for a phlegmon to terminate natu- rally by resolution, but this very rarely happens, unless the in- cipient inflammation be actively combated by the resources of art. In by far the greatest number of cases the best treatment fails to prevent suppuration, after the phlegmonous tumor has been fairly formed. Circumstances of position may vary the phenomena of pleg- mon. If it be seated in important viscera, the constitutional symptoms will predominate very remarkably over the local dis- tress : if it be formed under aponeuroses or muscles, the ten- sion occasioned by the resistance of these unyielding tissues greatly aggravates the pain while it prevents the swelling. The matter not being able to escape is extravasated among the adjacent tissues and communicates irritation, and inflammation as far as it reaches. Ultimately an opening may be made at a distance from the seat of the abscess : the pus may traverse a tortuous channel, the cavity not being properly emptied, may first heal, and a sinus, or sinuous ulcer, may be the consequence. * Phlegmon — ^Xtyui, phlego, I burn. bb NATURE OF DISEASE. The pathological characteristic of phlegmon is the effusion of coagulable lymph, by which the inflamed parts are walled in, and the pus confined within the cavity and made subject to those obscure and curious processes by which it is ultimately evacuated. It is this limitation which gives to phlegmon its hard resisting character, and which by impeding the circula- tion, causes the deep red hue which does not disappear upon pressure. To the same distension of vessels is due the pecu- liar pain of these inflammatory tumors. There is another form of inflammation which differs, m some important particulars, from phlegmon, and is called erysipelas. This form of disease is peculiar to the skin, and mucous membrane, and is far most usually met with in the former or- gan. It differs from phlegmon, particularly in this, that it is not circumscribed by lymphy barriers, but is diffused until gradually lost in healthy parts. The effusion which occurs in erysipelas is serous. When the skin only is affected, the serum is effused un- derthe cuticle, and occasions vesications. Sometimes thecellular tissue beneath the skin becomes inflamed together with it, and putting on its own phlegmonous condition, though imperfectly developed, forms a compound disease, which has been called phlegmonous erysipelas. The effused serum, and unhealthy pus, diffused through the loose cells of the cellular tissue, carry destruction to this substance, far and wide, among the muscles and beneath the skin, while the latter organ ulcerating, and sloughing rapidly, gives way before the advancing inflammation. This aggravated affection takes place in persons of debilitated constitutions, and as the result of wounds, and specific poisons. In erysipelas, the circulation of the skin is not impeded, and therefore the pressure of the finger on the skin temporarily res- olution moves the red color. The pain is burning, or stinging. Simple erysipelas does not tend to form pus, but ends by res- tion or effusion. The constitutional symptoms attending it, are generally much more serious than those resulting from phlegmon. * Eptw — I draw. lltXai, near — from the tendency to involve surround- ing pans. NATURE OF DISEASE. 67 Sometimes this form of disease occurs in the mouth, as the consequence of wounds, and even as an idiopathic affection. Sudden death is sometimes produced by the effusion of serum about the glottis — as the result of erysipelas affecting the la- rynx. This affection is called oedema of the glottis. Phlegmonous inflammation frequently occurs in the glands of the mouth, the tonsils, the gums, the pulps of teeth, the lining membranes of the alveoli and antrum, and the tongue. Erysipelous inflammation in these parts is rare, but sometimes occurs in the mucous membrane, lining the gums, cheek, and palate. The submaxillary glands often take on inflammation from the effects of cold, and from the irritation produced by the presence of diseased roots in the alveoli of the lower jaw. The pain and difficulty of mastication, with the swelling of the gland, readily indicate the seat and character of the disor- der. Unless the inflammation be speedily subdued, and es- pecially if it be the consequence of diseased teeth, the gland readily suppurates, discharging a very fetid pus, either into the cavity of the mouth, or externally, under the jaw. When the opening takes place internally, the flow of pus into the mouth is very disagreeable, and the access to, and lodgment of, alimentary matters in the suppurating gland often keep up the inflammation until an external issue is secured. Removal of the diseased teeth generally causes a speedy cure. Of other remedial means we will discourse hereafter. Inflammation in these, as in all glandular structures, is apt to leave permanent indurations. Inflammation of the tonsils is of very common occurrence. Its most common exciting cause is cold. The inflammation is generally very acute, rendering deglutition, and even speech, very difficult, sometimes impossible. It is generally attended by severe constitutional symptoms. Tonsilitis or cynanche tonsillaris usually terminates by res- olution, but very often by suppuration. Permanent enlarge- ment and induration often ensue upon repeated attacks of the disease, and the swollen tonsils sometimes offer serious ob- struction to respiration. When this is the case, they may be 68 NATURE OF DISEASE. removed with little difficulty, and without subsequent incon- venience. The palate and uvula are often the seats of inflam- mation. The latter is liable to erysipelas and oedema. These little organs are also subject to a chronic inflammation and slow suppuration, which gradually wastes them away. The parotid gland is rarely the seat of inflammation, ex- cept when it is the seat of a peculiar specific disorder, which is called cynanche parotidea or mumps. Inflammation of the lining membrane of the mouth is called stomatitis* Simple inflammation of this membrane is characterized by increased redness, swelling, and heat, but it rarely occurs ex- cept in connection with inflammation of the tonsils, larynx, or pharynx, or as the consequence of the irritation of denti- tion, or of acrid, or stimulating matters taken into the mouth for the purpose of allaying tooth-ache. In such cases it ter- minates by resolution. It is much more common to find this inflammation present- ing the appearance called "apthse." These are grayish or whitish specks, which look like ulcers, and are described as such by some authors, but which are ex- udations from the inflamed mucous membrane — when these fall off, the parts beneath are red and irritable, the cuticle being peeled off, and the cutis vera exposed. This disorder is generally supposed to indicate a correspond- ing disease of the surfaces of the digesting organs. It at- tends some forms of constitutional disorder, and constitutes a peculiar infantile disease, called thrush, of which we will have occasion to say more in connexion with dentition. The gums are very liable to inflammation, which is charac- terized by redness, swelling, soreness, and often by very severe aching pain. The most common cause of inflammation in these parts, is the irritation produced by dead teeth. We have already ob- served that dead parts are subject to the same laws which affect foreign bodies lodged in the flesh, and nature removes * Xrcyia— the mouth. NATURE OF DISEASE. 69 them, or attempts their removal, by instituting inflammation and ulceration around them. In other words, it is provided in the fundamental laws of the animal economy, that dead parts shall irritate the surrounding parts and produce in them, those conditions which naturally lead to the expulsion of the offenders. But dead teeth are firmly set in the jaw, and withal, are of too dense structure to be readily softened and absorbed. It hap- pens, therefore, that they remain long after their partial or com- plete disorganization, to plague the soft parts with which they are connected. The gums under these circumstances are kept in a state of chronic inflammation, and are rendered exceed- ingly sensitive to the action of irritants. Cold, or any local application of an exciting kind, will, under these circumstances, occasion aggravation of the chronic affection, and cause acute inflammation, of a severe character, which is remarkably liable to end in abscess. The chronic inflammation is often attended with ulceration around the decayed tooth ; the soft parts being separated therefrom, in the vain attempt of nature to remove them. In consequence of the long continued and unavailing ulceration, an imperfect attempt is made by the vessels of the gums to supply the loss of parts by granulations. These are unhealthy, spongy, loose, and incapable of cicatrizing : in other words, they are fungus. These fungus growths bleed freely upon being touched with a brush, or hard body, and being constantly destroyed and renewed, add much to the fetor of the fluids of the mouth, which under these circumstances, is often intolera- ble. Inflammation of the pulp, and the lining membrane of its cavity is commonly, perhaps always, the consequence of caries of the bony structure of the tooth, and exposure of its sensitive internal parts to the action of external agents. It gives rise to violent pain, which only subsides to be renewed again, by contact with any hard body, or irritating substance. This inflammation may continue for a considerable length of time, passing through successive suppurations, and, ultimately, completely destroying the vessels and nerves of the pulp, and with them, the vitality of the tooth. 70 NATURE OF DISEASE. Sometimes the matter formed within the tooth perforates the alveolus and the gum, and forms a fistulous* orifice into the mouth, through which putrid fluids are continually weeping. This is what is called alveolar abscess, and can only be reme- died by extraction of the tooth. The matter of alveolar abscess will sometimes be discovered at a great distance from its source. The following case which occurred in my practice, and which is related in Prof. Harris' Dental Surgery, as the most singular case of alveolar abscess which ever fell under his observation, affords a striking in- stance of this fact. The subject was a lady about thirty years old. She con- sulted me on account of a continual dripping of pus from be- hind the curtain of the palate, which she attributed to some disease of those parts, and which had annoyed' her for a year previous. Upon a close examination of her mouth and throat, I could discover no tumor or any indication of a deposit of matter except two protuberances, each nearly as large as a hazlenut, situated behind the two superior central incisores. Being strongly inclined to believe that the matter came from these abscesses, I requested the advice of Prof. Harris, who fully coincided in my suspicions. Upon our joint advice, the pa- tient submitted to lose these valuable teeth, and was rewarded by cure of the troublesome complaint which had caused her so much uneasiness. The maxillary sinus, or antrum, is covered by a membrane which nearly resembles the mucous covering of the mouth. This is frequently the seat of inflammation. From the pro- tected situation of this cavity, locked in on every side by bone, and covered by thick integuments, it is not apt to be affected by ordinary agents, acting from without, but the teeth of the upper jaw frequently send their roots into it, and thus affect it readily, when happening to become diseased, they are qual- ified to provoke disorder in neighboring parts. Even when • Fistula — a pipe, a canal whose sides and edges are hard and incapa- ble of adhesion. NATURE OF DISEASE. 71 they do not penetrate the floor of the antrum, they are often separated from it by a partition so very thin as to afford no ade- quate protection to the antral membrane against the propa- gation of inflammation. When the membrane of the antrum is inflamed, it pours out a vitiated secretion, which accumulates for some time before it produces sufficient uneasiness to excite the attention of the patient. The pain of inflammation depends upon the degree of pressure to which the parts are subjected, and the peculiar structure of the antrum prevents much suffering from thi cause until the cavity is completely filled. Generally, however, some dull pain is felt in this region in the course of the inflammatory action, but the patient commonly refers it to the teeth. After a while, however, the distension of the walls of the cavity produce more serious suf- fering : matter escapes through the nose or mouth, and a hard bony tumor indicates the projection of the antral walls. The fluid thus accumulated is usually not pus, but vitiated mucous. The disease has been very improperly called dropsy* of the antrum, for the contents are by no means serous. The discharged matter, having been long retained, is gen- erally very offensive. Ulceration may also take place in the membrane of the an- trum, and pus of a very fetid quality be exuded through the nose, and when an opening exists, through the mouth. This condition forms one of those exceedingly distressing, and often incurable cases of disgustingly fetid breath, which are called ozena. Sometimes, when the disease is permitted to proceed with- out proper remedial means being used, the walls continue to swell ; the bones soften, the tumor opens, and a fetid dis- charge flows through the aperture over the cheek. hiflammatory Fever. Fever,f or pyrexia,! is a morbidly increased activity of the heart and arteries, the proximate cause of which is little under- * I25wp — water, f Ferbeo — I burn. J m>p— fire. 72 NATURE OF DISEASE. stood, but which is attended with general disturbance of func- tion. Merely increased action of the heart and arteries is not fever, for such excitement may be purely physiological and attended with no functional distress. Violent exercise and mental emo- tions will frequently cause the vascular system to work with vastly greater energy than usual, while the individual who is the subject of the accelerated circulation will not be at all mor- bidly affected. But in fever, the increased vascular action is the effect of disturbing morbid causes. Often, perhaps always, the blood itself has undergone change, and the vital fluid thus altered, being supplied to all the organs, begets universal disorder of function. Fever is either idiopathic,* or symptomatic. By idiopathic fever, we mean that form of it which ap- pears to us to represent the primary, or original disorder,! being the first observable affect of the morbific cause. Such fevers are not, so far as we know, preceded by a local disease, whose existence and intensity are represented by the vascular action. We cannot, in the present state of our knowledge, go behind the fever to find out its immediate cause, structural change or functional error. Symptomatic, or secondary fevers, or as they are often called, from the nature of the conditions they most frequently repre- sent, inflammatory fevers, are merely consequent upon local disease, having no independent existence, but rising and fall-ing with the flow and ebb of the disorder they repre- sent. These two conditions, though called by the common name, fever, are entirely distinct and different in their cause, nature, progress, and treatment, and are only allied together, by the fact, that each of them is attended with morbidly increased vascular action. Neither is symptomatic fever a unit; for when it repre- sents inflammation, it differs essentially from the vascular con- *tft,o$, proper, or peculiar. | Ila0o$, disease. NATURE OF DISEASE. 73 dition, which is consequent upon another state, which is called irritation, and which seems to consist in a merely aug- mented sensibility of a part, and the distress occasioned through it. The sensible peculiarity of inflammatory fever consists in two elements ; the hardness of the pulse, and the buffy coat of the blood. In all kinds of fever the pulse may be quick and frequent, but as a general rule, to which the exceptions are very few, we may regard hardness as indicative of inflammation. When blood is drawn in a full stream from the veins of a patient laboring under inflammatory fever, it will, upon coagu- lation, present a fibrinous surface of a yellowish hue, the abundance of which, will, to a great extent, mark the inten- sity of the inflammation it represents. Very often, too, it will assume a peculiar form, being depressed in the center, and raised at the edges ; an appearance which is called "cupped," though the resemblance is nearer to a saucer. It generally happens that this appearance is more manifest after the disease has progressed several days than in its incip- iency ; and is often more observable upon a second, than a first bleeding, a fact which has led to the very erroneous opinion, that the abstraction of blood favored this kind of alteration. The best mode of observing this buffy coat is to catch the current of blood in a deep narrow vessel, such as a wine or jelly glass. Inflammation of fibrous tissues produces more of the buffy coat than is found consequent upon the same disease in other structures. It must be remarked, however, that the buffy coat is found upon healthy blood drawn from pregnant women. It is occa- sionally, but rarely met with when the circulation is morbidly active from other causes than inflammation. Mercurialization also imparts this appearance to the blood.* * The author had one patient laboring under slight enlargement of the heart, whose blood always presented a buffy coat. In a somewhat exten- sive practice of nearly fifteen years he has never found the blood of an inflammatory patient without it. 7 74 TREATMENT OF INFLAMMATION. Treatment of Inflammation. In all cases of inflammation it is desirable to bring about the disappearance of the disease without any disorganization of structure. In other words, to accomplish cure by resolution. When this cannot be effected it is important to lessen suppu- ration, and if possible to prevent, or, at least, limit mortifica- tion. The first step towards accomplishing the cure of inflamma- tion is to remove, if we can, the cause which produces it. This will often render further treatment very simple and easy, or altogether unnecessary. Where the gums, or lining mem- brane of the antrum are inflamed through the irritation caused by diseased or dead teeth, no treatment short of their removal will do any good : and this will generally be a sufficient aid to nature. Even when the soft parts are suppurating, they will speedily heal after the irritant has been removed. The treatment of inflammation proper, consists in general and local means. With the exception of a few employed to relieve chronic inflamed conditions, these remedial measures are comprised under the general name antiphlogistic * and are all intended to lessen the vascular action, of the general or local circulation. Antiphlogistic treatment is negative or positive. The neg: ative consists in withholding every local application likely to excite the vessels, or irritate the morbidly sensitive nerves of the part : and preventing the taking of such drinks or aliment as would tend to sustain the morbidly active circulation. In hort, the withdrawing as far as possible of all local and gen- eral excitants. The positive treatment consists in the use of means which lessen vascular action and diminish nervous sensibility. The general remedies are blood-letting, purgatives, diaphoretics, * Anti, against — Phlogiston, the old name for the cause of heat. TREATMENT OF INFLAMMATION. 75 and low diet; among the local are blood-letting, from the affected part, or its immediate vicinity ; cooling, emollient, sedative, and astringent applications, and counter-irritants. When pus has been formed in a cavity, it is often necessary to evacuate it by an artificial opening: sometimes, even after the tumor has opened spontaneously, a counter-opening is ne- cessary. Treatment of Inflammation and Abscess of the parts composing the Mouth. It is rare that inflammation of these structures require general treatment. Sometimes, however, they are sufficiently serious to occasion inflammatory fever, and call for decided constitu- tional remedies. When such is the case, the patient should be bled from the arm until a decided impression shall have been made upon the circulation, and the operation must be re- peated, until the desired effect be accomplished. If the bowels of the patient be constipated, saline cathartics should be em- ployed. Nauseating remedies, such as tartar emetic, will also be found useful in lessening the general inflammatory action and withdrawing the nervous sensibility from the affected part. In most cases, however, the dental surgeon will only need to employ local remedies. We have already said that when the inflammation is conse- quent upon the presence of diseased teeth, or parts of teeth, they must be removed. This being done, the inflammatory action will commonly subside and speedily disappear. The teeth are liable to a peculiar calcareous deposit, called tartar,^ or salivary calculus, which adheres with great tenacity to X Tartar, or salivary calculus, is composed, according to Berzelius, of Phos. lime and magnes. 79.00 Salivary mucus and salavine, 13.50 Animal matter, 7.50 100.00 76 TREATMENT OF INFLAMMATION. them, and insinuating itself under the edges of the gums, detaches them from the teeth, and acting as a perpetual irri- tant, inflames, and often ulcerates them. This substance is deposited from the saliva under certain conditions of that fluid, and is most liberally deposited upon the teeth nearest to the salivary ducts and upon those of the lower jaw. When it contains a larger proportion of earthy salts, it is hard, and brittle; when the animal matter is in ex- cess, it is soft and moist. Under which ever of these forms it appears, its removal is indispensable to the successful treat- ment of the disease of the gums which it causes. Sometimes this can be effected by the brush alone ; often the hard mineral substance requires to be broken up and elevated by an instru- ment of steel. When once removed, its subsequent accumu- lation must be prevented by persevering use of water and the brush. It often happens that the gums will be inflamed through the agency of teeth, the disease of which is not sufficiently serious to authorize their removal ; again, inflammation may occur in the gums from causes independent of the teeth, as from cold, irritating applications, bruises, &c. In order to prevent acute inflammation of the gums from passing rapidly to suppuration, it is necessary to use free local depletion. This may be done by scarification, or by leeching. Scarification is nothing more than slightly incising the gum and causing its superficial vessels to bleed. It is a remedy of doubtful utility, and often does more harm than good. It is obvious, that, any wound inflicted upon an inflamed part must increase the inflammation to a certain extent, and unless the quantity of blood taken away be more than sufficient to counterbalance the additional evil inflicted, the patient will lose by the operation. Scarification produces copious bleed- ing for the instant, but the clean superficial wound is soon closed by coagulum, and lymph, and the oozing of blood con- tinues but a short time. TREATMENT OF INFLAMMATION. 77 When the gums present the condition called fungus, scarifica- tion will cause much freer bleeding, owing to the increased vascularity of the part. Under such circumstances it is an im- portant means of cure. Leeching is a far more effectual process. It is true that wounds are made by the leeches deeper and more irritating than those inflicted by the lancet, but the flow of blood continues very much longer and the quantity discharged is far greater. Two or three leeches placed upon a gum will often cause a bleeding which will continue for several hours, and will cure severe inflammation in almost as brief a space of time. In order to be effectual, leeching should be employed in the early stage of inflammation. If delayed until matter has begun to form, no benefit can be expected, except, perhaps, in the les- sening of the quantity of pus. Other local applications are of little or no use in the treatment of acute inflammation of the gums. Their position prevents the continuance of any fluid upon their substance. Cold water, how- ever, may be used by repeatedly filling the mouth with it. This remedy is serviceable only in slight inflammations. All stimula- ting applications used to irritate the surrounding parts and thus alter and divide sensation so as to relieve pain, ultimately aggra- vate the disease, It is erroneously supposed that the increased flow of secretions which is occasioned by the irritation, must relieve the vessels and abate the inflammation, for the very irrita- tion attracts to these parts a larger supply of blood than usual, and augments secretion only by increasing arterial activity * Where the inflammation is excessive, leeching and blistering behind the ears or under the jaws may be resorted to. As great and long continued suffering frequently attends this disease, full opiates at night may be given with great advantage; securing at once temporary relief and grateful repose, and aiding materially the efforts of nature to remove the inflammation. Inflammation from mechanical violence must be treated upon the same principles. *Ubi irritatio, ibi fluxus — where there is irritation, to that place will be the flow, is a well known medical adage. The law applies to the nervous as well as the vascular system. 8 78 TREATMENT OP INFLAMMATION. The gums are liable to inflammation of a specific character. When mercurial preparations have been used to a certain extent differing much in different individuals, a constitutional impression is obtained, which announces itself by a peculiar tenderness and inflammation of the gums and an increased secretion of mucus and glandular fluids into the mouth. This is called salivation or ptyalism * The first symptoms of this mercurialization are observed in an increased tenderness and some swelling of the gums which exhibit a pale rose color, except at the edges surrounding the teeth, when they are of a deep red. The soreness and swelling now rapidly increase, the discharge of mucus and saliva becomes excessive, and is accompanied by a very peculiar and disagreea- ble 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 cov- ered with ulcers; the enormous tumor of the tongue pushes beyond the lips and hangs out of the mouth, preventing the closure of the jaws ; the flow of fluids is prodigious, the patient wastes exces- sively gangrene of the mucus membrane of the mouth and gums, and extensive sloughing of the soft parts and bones sometimes occur; the teeth are loosened and sometimes drop from their sockets and occasionally the patient expires from exhaustion. A very frequent consequence of extensive mercurial salivation and the attendant ulceration and sloughing, is contraction of the mucus membrane in the neighborhood of the anterior arches of the palate, whereby the patient is prevented from opening the mouth, except to a very slight extent. In one case this condi- tion 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 an- other 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.f * Ptyalism — salivation from tt»u — I spit. fPareira's Elements of Materia Medica and Therap. TREATMENT OF INFLAMMATION. 79 It sometimes happens as a consequence of salivation, that ad- hesions form between the mucus membrane of the lips and cheek and that of the gums; very much deforming the face and lessen- ing the usefulness of the mouth. A great variety of remedies have been suggested and employed 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, occurs occasionally in children, and sometimes it is said even in adults. It is ulceration of the inside of the cheek, causing gangrene and a copious secretion of fetid saliva. It is called Cancrum oris. This disease is not properly inflammatory, being rather a con- sequence of debility, but lest we should not have an opportunity to describe it hereafter, we will do so now. Cancrum oris is a foul fetid ulcer, beginning upon the inside of the cheek and rapidly sloughing through it until it opens upon, the outside. The gums and alveoli are often seriously involved ; the teeth become carious and loose, and drop out; abscesses form in different parts of the mouth and make openings for them- selves in different directions. The progress of the disease is at- tended by a copious discharge of fetid saliva and mucus. Ex- foliations of bone are not unfrequent and extensive sloughing sometimes occurs. The disease generally occurs in ill-fed children, crowded in a hospital or living in low swampy situations. The remedies must be tonic and invigorating. The principal, are fresh air and nutritious diet. The best local applications are diluted mineral acids; burnt alum, sul. zinc, tinct. of myrrh, &c. *It is important to remark that salivation, however severe, does not neces- sarily prove the previous administration of mercury. For some curious observations on this subject, see Pareira's Elements of Mat. Med. and Therap. 709. 80 TREATMENT OF INFLAMMATION. 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, through very rarely, attends Syphilis. As it is impossible to describe the peculiar appear- ance of this ulceration by words only, so as to enable the prac- titioner to detect it upon sight, we refer the reader to an excel- lent delineation of it in Messrs. Carey & Hart's Edition of Rayer's Plates, PI. 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 removal of any dead teeth, &c, the gums require the aid of astringent and somewhat stimu- lating lotions, such as port wine and water, weak brandy and water, myrrh, infusion of Peruvian bark, &c. There is a common form of disease which is usually called scurvy or scorbutus of the gums. This designation, however, is very improper; for scurvy is a constitutional affection 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 consider it as an idiopathic inflammation of the gums, attended by sponginess of structure, recession of their margins and frequently, destruction of the alveolar processes. When affected by this disease, the gums present a swollen ap- pearance. Their color is dark-red or purple ; they feel elastic under the finger, and when pressed, pus oozes out between 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 fungus, bleeds upon the slightest touch and is very sensitive. CARIES. 81 The disease progresses with more or less rapidity according to the constitutional health of the patient, and the capability of resistance natural to the organs attacked. Sometimes it is con- fined to a small portion of the gum, at others, it involves the periostea of the fangs and the alveoli, and presents a mass of complicated disorder and devastation. A deposition of bony matter sometimes takes place in the bottom of the sockets and the teeth are loosened and drop out. The treatment of this disease does not differ from that of the ordinary inflammatory conditions previously described. Indeed it is not specifically different. All irritating bodies such as decayed teeth and roots must be removed : irregularities of denture corrected : tartar also taken away : the gums depleted : and after active inflammation has sub- sided, 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 the soft parts, and is very different from necrosis or mortification of these parts. The bones are vital organs, supplied with arteries, nerves, veins, absorbents and cellular tissue. Like soft parts they grow and waste, undergo disease and accomplish reparation. The denser the texture of a bone the less liable it is to be attacked by caries, and for this reason the bones of children are more susceptible of it than those of adults. In caries the bone undergoes a change by which its texture is softened and broken down ; fungus flesh which bleeds very readily grows up in the interstices formed upon the surface 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 dentist and every student of dentistry. ■{• Kei£Eiv — to abrade. 8* 82 MORTIFICATION OR GANGRENE. 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 diseased part by surgical means, and, as is often necessary, the applica- tion of the actual cautery upon the new surface. The latter means is not absolutely indispensable, the former probably is, unless, as sometimes 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 dis- solved in them, upon the salts of which the tooth is mainly composed. It is yet a mooted question whether the teeth are ever subject to true caries, such as affects other bony structures. I have already remarked that this disease is not apt to occur in the denser osseous structures, and the close texture of the teeth renders them particularly unlikely to be thus effected. Yet it might be too much to say that they are never subject 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 express absolute death of apart, but by some writers the term gangrene is restricted to that condition which immediately precedes death, and Sphacelus* applied to the latter condition, while mortifica- tion is a general term covering both conditions. According to this use of the terms, gangrene represents the * Isxxtt v — to destroy. MORTIFICATION OR GANGRENE. 83 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 softening and crepita- tion of the part. When the part has become cold, insensible, black, motionless, 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 circu- lation as to cut off the supply of blood, or the state of the patients 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 appre- ciated disease. When mortification is consequent upon inflammation, the quantity of fluids in the part causes a humid state of the sphacelus ; where death has taken place from deficiency of blood the morti- fied parts are dry and shrivelled. These opposite conditions have given occasion to the distinction so generally recognized between moist and dry gangrene. This distinction, however, is not so absolute as to be without exception, yet it is correct to a considerable extent. Different parts assume different appearances when gangrenous, " 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 mucus 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 indepen- dently of mortification, and the latter may exist independently of the other. The principal characteristics of gangrene are, 1st. Complete disorganization of the gangrenous parts, in which the elementary tissue can no longer be distinguished. 2d. Softness • Sequestro — I separate. 84 MORTIFICATION OR GANGRENE. and flaccid ity. 3d. The fetid and characteristic odour which it enhales. 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 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 gangrenous part, being absorbed, prove poisonous to life ; but if this were the case, similar effects would result from the much more extensive mortifications which frequently occur in the skin, muscles and bones, without those serious constitutional results. The effect must rather be attributed to the powerful sympathy which exists between the viscera and the nerves of organic life. Where nature makes an effort to check the spread of gangrene, which, except in the instances referred to, she almost always does, a red line of inflammation is first drawn around the affected part. Ulceration soon takes place along this line, and a suppu- rating 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 ulceration, therefore, are the means employed for the removal of dead parts, and for limiting the pro- gress of devastation. In order to effect this, it is necessary that the vitality of the adjoining parts be sufficient to produce healthy inflammation, support the suppuration and sustain vigorous granulations. It is also necessary, that the inflammation in the adjoining parts be Dot so great as seriously to impede the circulation in them. * Chomel, Elements of Gen. Path. MORTIFICATION OR GANGRENE. 85 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 disposition to throw out the inflammatory cordon sanitaire, he sees the necessity of stim- ulating applications to rouse the torpid energies of the threatened parts. Cantharides, turpentine, or other remedies of thi3 powerful class will then be put in 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 anticipate the slow process of nature, and 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 neces- sarily inflicts injury. The result often is the appearance of the disease in the remaining parts. When the surrounding parts manifiest more excitement than is compatible with their security, depleting and sedative treatment must be instituted. As a general rule, however, this will rarely be required, for the vicinity of gangrene 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 fre- quently necrosed than they are, depend 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 functions of other organs. Necrosed bone is thrown off by a process very analogous to that which is instituted for the separation of sphacelus. Where the mortification is superficial, it is removed by exfoliation: when it is deeper, a persevering effort is made by the surrounding bone and soft parts, to detach and expel it in the form of splinters or even of large masses, called sequestra. 86 MORTIFICATION OR GANGRENE. Owing to the density of bone and its deep seated position, this is generally a very slow process, requiring months and years for its accomplishment, and often failing altogether. For after long continued fruitless efforts to get rid of the dead part, nature frequently attempts to supply the deficiency caused by its loss and forms new bone around it, leaving orifices in this bony case, through which the matter may find a vent. When this arrange- ment has been made, the sequestrum cannot be expelled by natural efforts, except in a fluid or very comminuted state. It is, therefore, generally necessary for the surgeon to cut down to the diseased bone and liberate the sequestrum. Occasionally however, nature, though unassisted, will accom- plish the expulsion of very large sequestra. In one recorded case, a piece of bone seven inches long, was thus expelled: such cases, however, are very rare. The presence of necrosis or caries, may be ascertained very satisfactorily after the formation of the external ulcer. Some- times the canal will be so straight as to permit a probe to reach the diseased part, and when this is not the case the presence of an obstinate ulcer, evacuating dark-colored and fetid sanies, will generally be sufficient evidence of diseased bone. It is rarely possible to distinguish necrosis from caries, until the sequestrum has become so fully detached as to be moveable. 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 generally in such a state as to return to health after its removal. In caries, the surface of the parts exposed by the operation, often require the 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. 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 mouth, and affects dead teeth as readily as living ones. Caries of the teeth always begins upon their outer surface, and does not appear to be in any manner dependent upon disease, MORTIFICATION OR GANGRENE. 87 except so far as it may be favored 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 chemical 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 analagous to ulceration in soft parts, and constantly discharges a fetid sanies, and frequently throws out granulations of fungus flesh. These are phenomena which dental caries never exhibits, and they establish 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 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 destroyed 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 * Harris' Dental Surgery, which see, tor a thorough examination and exposition of this subject. 88 MORTIFICATION OR GANGRENE. processes in the bone they are unable to remove the evil. Chro- nic disease is, therefore, commonly the consequence. 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 CHAPTER VII. ULCERS. An ulcer is a running sore : or, in medical language, a solution 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 apparent phenomena, others by their pathological conditions, and others by the modes of cure to which they severally yield, while some have seized upon accidental modifying circumstances as a reason for multiplying subdivisions already too numerous. It is impossible to systematize in pathological science, so as to provide for all the numberless modifications which may be produced in disease by the causes which influence vital action. We must content ourselves with such an arrangement as will enable us lucidly to express what we know of the subject. Once more we remind our readers that medical definitions are not philosophically complete and accurate. An important distinction between ulcers is found in the fact that some of them are the result of local injury or disease, and not in any manner dependent for their existence upon constitu- tional vice, while with regard to others the converse is the case ; the local sore being only a consequence of constitutional disorder. As the treatment must differ essentially 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 proper, is not without difficulty, for local ulcers sometimes involve the general health, and are instrumental in setting up diseased consti- tutional action, in which they themselves participate, and, on the 9 90 ULCERS. other hand, ulcers primarily induced by constitutional causes, may continue after the vice of the general system has been corrected. The causes of ulcers are various, but can generally be reduced to the following classes: 1. Predisposing causes. All those conditions of the system, or of any of its parts, which debilitate structures or so alter their vital action as to impede recuperative processes. Fever, scrofula, syphilis, and scurvy, are examples of this kind. 2. Exciting or immediate or local causes: such as wounds, bruises, abscess, suppuration, gangrene, abrasion of the skin from any cause. 3. From the combination of these causes. A slight scratch or excoriation that in a sound constitution would heal without any trouble, in a habit tainted with disorders as above mentioned, will frequently produce a very disagreeable and tedious ulcer.* The prognosis of ulcers, must, of course, depend upon the results of a full consideration of the causes and conditions in- volved in any particular case. The constitution of the patient, his age and habits, the situation and duration of the sore and its peculiar condition of sensibility, &c, must all have due considera- tion 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. After ulcers have become chronic, it is sometimes dangerous to heal them until we shall have provided an artificial drain, by seton or issue. The system having once become habituated to the discharge of ever so small a quantity of matter, often sutlers 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 compli- cated 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. * Benjamin Bell on Ulcers. ULCERS. Mr. Benjamin Bell classifies ulcers as follows : LOCAL AND CONSTITUTIONAL. 1. The simple purulent, 1. The venereal, 2. The simple vitiated, 2. The scorbutic, 3. The fungus, 3. The scrofulous. 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 alwavs 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 with its appearance, because other ulcers, of a less simple and kindly character, must be brought to this condition before ultimate cure. The simple purulent ulcer is always produced by some local injury, as wounds, burns, &c, happening to persons of sound general health. In this kind of sores the pus is white and thick; the granula- tions small, firm, florid, and pointed. As soon as they have reached the level of the surrounding parts, those next the edges become smooth, and are covered by a whitish pellicle, or film, which afterwards hardens, advances, and forms the permanent covering of the parts previously ulcerated. 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 con- clusion is formed. Such ulcers require no treatment except to be kept clean, and protected from any interference with the natural process which is Listening to cure. 92 ULCERS. A little dry lint will accomplish all that can be done by dress- ings. A simple purulent ulcer may very readily be converted into an angry and obstinate sore by improper local applications, or the occurrence of general constitutional disorder. We may remark here that no sores are cured by applications of any kind ; nature only can provide the means by which these breaches can be healed. Nothing is more incorrect or 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." 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 dis- eased part, or constitutional causes, the progress towards cure is arrested, the discharge from a sore may present one of the fol- lowing appearances : 1st. It may be a thin, limpid, sometimes greenish discharge, 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 frequently excoriates the surrounding parts over which it flows. These vitiated ulcers are more apt to occur upon tendinous and aponeurotic parts, than in situations abounding with cel- lular membrane, owing to the frequent motion of these parts, and the continual agitation of the sore. Wherever an ulcer is seated upon a part of this character, absolute rest is necessary to preserve its simple and convalescent character. * Benjamin Bell. ULCERS. 93 The cure of these ulcers depends principally upon removing the cause which has operated to change their character for the worse. If the vitiated condition depends upon constitutional causes, these must be combatted by the means found most suc- cessful 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 indulged, it must be restrained. The local treatment consists in soothing, emollient applications, as it has been found that all those means which allay the pain in such sores, tend also to alter their condition to that of the simple purulent ulcer. When the sore is seated in the mouth, but little opportunity is afforded for local applications. The best, perhaps, is warm water, frequently taken into, and held in the mouth ; or the vapor of hot water received into it repeatedly and for a considerable time. The dentist should look closely in such cases for causes of irrita- tion in diseased teeth and fangs, and also ascertain whether con- stitutional causes are interested in the production of the trouble- some sore. The difficulty of protecting ulcers in the mouth from the con- tact of its secretions, and the food and drink, and the impractica- bility 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 station- ary, rather than progressive, secreting but little, and that of bad quality, and being little sensitive, they are called indolent ; if, in addition, the edges become hard and thickened, they are called tedious. Very often these callous ulcers are attended with an enlarged condition of the veins of the part which is called varicose. This condition of the veins is very embarassing 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 9* 94 ULCERS. these parts, they are, in these situations, most frequently attended with varicose veins. The callous condition of ulcers is the consequence of neglect and bad management. Their cure consists in restoring them as soon as possible to the condition of a simple purulent sore. This can only be done by removing the indurated surfaces. The most expeditious way of effecting this, is to pare away the edges and surface of the sore with a scalpel, thus converting the lesion into a wound of the simplest kind : but as few patients will sub- mit to the pain of this procedure, the application of caustics is generally preferred. By freely touching the surface of the ulcer with nitrate of sil- ver or caustic potassa, a slough is produced, which, coming away after some considerable time, leaves after it a healthy, granulating surface. Fungus Ulcers. — When granulations are large and pale, grow rapidly and rise above the level of the surrounding parts, bleed freely upon touch or slight pressure, and make no attempt at cicatrization, they are called fungus or proud flesh. Generally they are soft and spongy, but by very long continuance they may acquire considerable hardness. Fungus is not. uniformly sensi- tive : generally it is not at all remarkable in this respect ; occa- sionally, however, it is very sensitive. It is but imperfect granu- lation, and may arise from any cause which tends to interrupt the convalescence of an ulcer. Long continued inflammation of cellular structures and caries of the bones are very apt to be attended by fungus. It sometimes occurs in young and vigorous subjects merely as a kind of 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 irritating cause vitiating the character of the ulcer, it may be destroyed very readily by sprinkling upon it some burnt alum or touching it with lunar caustic. Fungus has not sufficient vitality to resist the impression made by agents of this class, and generally the appli- cation of the escharotic will excite the surface of the ulcer sufficiently to cause the growth of firmer granulations. ULCERS. 95 The Sinuous Ulcer. — This name is given lo a sore communi- cating with long and narrow canals, penetrating the cellular mem- brane and running irregularly under the skin or between the muscles. These sinuses generally have more than one opening through which pus is discharged. Originally they are the artificial channels through which the contents of abscesses or the fluids produced from carious parts escape from 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 matter, the whole presents the appearance of an irregular ulcer, connected with some primary source of matter, and forming openings wherever the nature of the part causes a determination of matter to the surface. Should the sinus remain for a long time without cure, its sides and the edges of its orifices become hard, and it is then called a fistula.* This term, however, is most frequently applied to artificial canals which connect with some natural passage. The cause of sinuses is the want of a free passage for matter, which, seeking the most dependent point, readily penetrates the yielding texture of the cellular membrane and ultimately 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. If the edges and sides of the ulcer be too hard to undergo the necessary adhesive process, stimulating or caustic application 3 may be used with advantage. Sometimes it is necessary to lay open these tortuous canals to the primary abscess, a process which at once gives free escape to the matter, and by exposing the sides of the sore to the influence of the air and proper medicinal applications, generally causes a wound which readily heals from the bottom with healthy granulations. Sinuses situated in the mouth should always be treated in this way, unless they are connected with diseased bones or teeth, or are so situated as to make the free use of the knife dangerous. * Fistula— a pipe. 96 ULCERS. Carious Ulcers are those which are connected with caries or necrosis of bony structures. They are often sinuous, but may be seated immediately upon the caries which causes them. The discharge from carious ulcers differs from good pus. It is thinner and fetid, and at last becomes blackish, and often very acrid and irritating. Mr. Bell thought that the fetor of carious ulcers always afforded a sufficient means of diagnosis. The surfaces of carious ulcers are usually softer and more flabby than natural ; and instead of a florid red, they have rather a dark brown with somewhat of a glassy complexion. The granulations generally grow rapidly, but are exuberant and fungoid. Should the orifice heal either by the efforts of na- ture or the appliances of art, the apparent cure is of short dura- tion, for the pent-up matter soon finds another vent and produces another ulcer. When a probe is pushed down to the bottom of a carious ulcer, it generally encounters a roughness of the surface of the bone, which plainly indicates its eroded condition. When obstinate sinuses are observed in the gums, discharging fetid matter, and containing fungus 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 attending caries, the treatment of it must always be secondary to that of the disease which produces it. The removal of the carious or necrosed part and the employment of the means which will best prevent a return of it, are to be regarded as the proper means of curing the carious ulcer. When the caries is seated in the can- cellated structure of bone, it can only be thoroughly eradicated by the terrible energy of fire, and the actual cautery must sweep over the diseased surface and rouse it to the exertion Of its vitality. When a tooth is the subject of caries, no such frightful treatment is necessary. The tooth being passive in the matter, and being acted on by chemical agents only, all that is required is to remove the caries and interpose between the fluids of the mouth and the parts of the tooth thus exposed, a barrier which must be impenetrable to the action of the fluids which caused so much mischief. The only substance by which a cavity in a tooth can ULCERS. 97 be successfully filled is gold, as it only, of all the metals, pos- sesses 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 exceeding deleterious, both locally and constitutionally, and ought never to be used as dental fillings. The Cancerous Ulcer. — Cancer, or Carcinoma. This terrible affection occurs under two forms, called occult and open, or schirrus and ulcerative. The former variety generally, though not always, precedes the latter, and presents itself in the form of a hard, dense 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 schirrus as from a centre. As the disease progresses, the skin adheres 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 irritable. It discharges a thin fetid ichor, sometimes very excoriating. Its edges are hard and irregular, reversed and contorted. Its surface is generally irregular, showing depressions or excavations. The sore manifests no tendency to form healthy granulations, but spreads among the surrounding tissues which successively harden and ulcerate, and become cancerous. The lymphatics propagate the disease to the nearest glands, which are found swollen and indurated, and often ulcerated. The pain of cancer is a burning or scalding sensation, and generally exhausts and destroys the patient long before the devastation of parts can interfere seriously with the functions of life. As blood vessels are destroyed in the progress of the disease, bleeding, more or less profuse, occurs. Cancer, however, presents various appearances. We have seen it occur without preceding schirrus, present an equal smooth sur- face with little secretion; and many other appearances of this ulcer have been observed, as it has been modified by accidental circumstances. The characteristics of cancer may be considered to be an irregular, phagedenic sore, with hard reversed edges, exceedingly irritable under all common dressings, and causing a burning pain. When such a sore has resisted the treatment which is found to be successful in ordinary irritable ulcers, and especially when it is seated in a glandular part and follows schirrus, there can be no doubt of its malignant character. Cancer, in all its stages, is altogether intractable to any treat- ment which has yet been devised, and all but the most soothing applications are found to accelerate its progress and add to the intolerable acuteness of its pain. The only mode of cure now attempted is thorough extirpation, and this is confided almost entirely to the latent or schirrus state. The open cancerous sore rarely yields even to surgical remedies. It is even a mooted question whether the removal of schirrus tumors is advantageous. Some surgeons contend that where true schirrus is removed, cancer 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 endured in hope of cure. It is not by any means easy to settle this question. Surgeons are in the habit of removing all chronic tumors which are hard and painful, whether they present decidedly carcinomatous symp- toms 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 schirrus 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. 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, there- fore, 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 constitutional disease, manifesting itself in local changes of the kind described ; that it is, therefore, use-- less 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 argu- ments brought to bear upon this subject, we will content our- selves with suggesting the practical inference which seems most rational upon the whole ; which is, that eradication of schirrus may be attempted with good hope, though not with certainty of success; that the excision of open cancer will be an experiment very doubtful, yet if the reports of surgeons are to be believed, not absolutely hopeless; and finally, that under all circumstances the operator must be prepared for a recurrence of the disease. Many specifics have been suggested for the cure of cancer, and many nostrums are yet vended for the purpose of curing these sores. All of them are useless, and most of them very hurtful. The medicine commonly resorted to by empirics for the purpose of corroding or " eating out" a cancer, is arsenic ; an application which adds terribly to the suffering and violence of the disease, and probably often produces most serious constitutional effects. We attribute to the improper application of this poison, the sudden death of one young lady, who, having a sore, probably of an ordinary kind, upon her leg, was induced through excessive modesty, to subject it to the treament of a famous female empiric. Although arsenic is useful in certain obstinate cutaneous affec- tions, it does not control cancer when given internally. When externally applied to a surface so irritable as that of cancer, it necessarily does great mischief. Cancer sometimes attacks the tongue. 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 pre- sented a jagged edge, which gave out sanious matter. The whole 100 ULCERS. body of the organ was schirrus, and the neighboring glands manifested a similar condition. A cause so slight as the retention in the mouth of a broken or eroded tooth, seems, in this case, 10 have been sufficient 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 vascular 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 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 syphilis we have nothing to do, but as the secondary or constitutional 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 eruptions, swelling of glands and disease of the periosteum, fascia and bones. The ulcers vary considerably. Generally they are remarkable for their hardened base, feeling like cartilage under the skin ; the borders are red and sharp, the bottom greyish, 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 ton- sils are not much enlarged ; for when the venereal inflammation attacks these parts, it appears to be always upon the surface, and it very soon terminates in an ulcer. ULCERS. 101 These ulcers of the throat are to be carefully distinguished from all others of the same parts. The disease in the throat is uniformly ulcerative; this being the first appearance of disease in that part.* The syphilitic ulcer always begins superficially, and is not pre- ceded by observable, or at least, by any notable degree of inflam- mation. This fact will be sufficient to distinguish these sores from the ordinary open abscess of the suppurating tonsil. There is also an indolent swelling of the tonsil accompanied by an exudation of lymph, which at first sight might be mistaken for an ulcer, and indeed such exudations, when they accompany scar- let 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 sur- face of the parts, becoming very broad and sometimes foul, having a regular termination, but never going deep into the surface of the parts. Mr. Hunter says that there is no part of the inside of the mouth exempted from this ulcerous 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 com- monly very foul, having thick white matter adhering to it like a slough, which cannot be washed away." These ulcers never heal spontaneously, and generally spread rapidly. When the sores are seated upon the pharynx, they produce great distress in deglutition, cough and puriform expectoration, rapid sloughing of the soft parts, exposing the bones and destroying them even as far as the vertebra by caries. The palate is frequently destroyed, throwing the nose and mouth into one cavity, preventing distinct speech, and causing great discomfort and distress. The dentist will often be required to supply this serious loss of bone by an artificial substitute. "At other times, especially in cases of long standing, these sores extend not by sloughing, but by rapid ulceration. The * Hunter on the Venereal Disease. 10 102 ULCERS. 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 yellow 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 w r ith extraordinary rapidity. The substance of the part seems to melt away under the ulceration, and the greater part or the whole of the soft palate, is often de- stroyed before it can be arrested, though no distinct slough can be seen to separate through the whole of its course."* Phagedenic venereal ulcers, like cancerous sores, have thick- ened edges; a characteristic rather of the unhealthy character and spreading tendency, than of any specific quality of the sore itself. There are several kinds of venereal affections observed in the bones. The periosteum may be thickened and inflamed. This is a very painful affection, the pain being greater at night ; and may be mistaken for rheumatism, when the bone is so deeply seated as to prevent the distinct feeling of the swelling. This periosteal disease generally ends in permanent enlargement of the bony structure from deposition of bony matter. Sometimes the periosteum suppurates and causes exfoliation of the bone. Caries of the bone frequently commences in the cancellous structure, and gradually perforates the external plate, and then appears as a soft tumor, which may be seen and felt externally. If this tumor is laid open, a glairy fluid is evacuated ; the peri- osteum is found to be somewhat thickened, and the bone beneath is denuded, and in the centre of the denuded part, is found a small hole which perforates the cortical plate and 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 constitutes the worm eaten caries.f In determining whether a sore in the throat or a caries of the bones be syphilitic, it is absolutely necessary that the observer shall obtain all the collateral information which may aid the * Babington. t Babington. ULCERS. 1 03 diagnosis, for it is often impossible to decide positively 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 certainty all forms of syphilitic eruption; yet, when suspicion is aroused by the appearance of the throat, and corroborated by that of the skin, or vice versa, there must be extraordinary reasons for inferring the cause not to be venereal. Syphilitic eruptions may be tubercular. That is, they may appear in the form of hard lumps, covered by red inflamed skin, and often by dead cuticle. These often ulcerate and leave behind them a peculiar copper colored blotch. Another form of syphilitic eruption, is that of small red accu- mulated pimples, sometimes scattered regularly over the surface, at others arrayed in groups. Scaly eruptions are also common, and sometimes a pustular affection attended with a large hard conical scab or crust (rupia) is observed. These may all be due to other causes, but when occurring together with a suspicious sore throat, they very much strengthen the probability of venereal origin. Mr. Hunter says, when syphilis attacks the tongue, it 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 generally dif- fused, as to produce the remote symptoms observed by the Dentist, the life of the patient is in imminent peril. There has been much controversy as to the means of curing syphilis, one party contending for the use of mercurial means, and the other denying the necessity of these medicines. Wiiliout 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 uncommon cases, where it exists in a kind of combination with scrofula; and 104 ULCERS. secondly, that mercury will do this without injury to the patient, and generally with as little inconvenience as can attend the use of less certain remedies. Without 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 general rule, however, we prefer the proto-chloride or calomel 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 dento-chloride (corrosive sublimate.) Our com- mon practice is to give a grain of calomel, to which is added one-twelfth of a grain of opium, night and morning, until the ulcer disappears or the gums get sore. It is rarely necessary to produce salivation — a mere tenderness of the mouth will generally indicate the predominance of mercurialization in the system, and be attended by healing of the venereal sores, and disappearing of other symptoms of that disorder. Corrosive Sublimate in the dose of a twelfth part of a grain three times a day will often succeed ; and in secondary syphilis, is thought by some to be superior to calomel. When calomel acts too freely upon the bowels, as it sometimes does, even when administered together with as much opium, as it is prudent to give, corrosive sublimate or blue pill may be tried. Should these purge also, resort must be had to inunction; the patient being rubbed with mercurial ointment until his mouth begins to acknowledge the mercurial influence. When scrofula exists in union with syphilis, the iodide of mercury may be used. Scorbutic Ulcers. — Scorbutus is a barbarous half Latin name, given by medical writers to scurvy, a constitutional affection de- pending upon privation of vegetable food, under circumstances calculated to weaken the energies of the system, and which was long a terrible scourge to seamen, soldiers and the inmates of prisons. It has frequently been confounded with other affections a mistake which has led to serious consequences. In the year 1700, the celebrated Boerhave treated with mercury four hundred soldiers thus affected and killed them all. ULCERS. 105 The term scurvy, is applied to sponginess and ulceration of the gums from any cause, but this is 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 become known, it is rarely seen now even in these places. As it would be of little use to our readers, we will not intro- duce here a full discussion of this subject, which has ceased to be of much interest, even to the general practitioner; but will content 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 Cyclopaedia of Practical Medi- cine, written by Mr. Kerr. Scurvy is a general disease characterized by debility, foetor of the breath, sponginess and turgidity of the gums, livid sub-cuta- neous spots, particularly of the roots of the hairs, echymoses, spontaneous hemorrhages and frequent contraction of the limbs- The face becomes bloated early in the disease, and the lips are of a pale greenish hue. The countenance looks sad; the patient complains of extraordinary lassitude and becomes breathless after slight exertion. The gums soon become swollen, itch and bleed upon touch ; they are deep red, soft and spongy: soon fungus and putrid. Bleeding occurs frequently 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 subja- cent 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 fungus appearance characteristic of scorbutic ulcers. The hemorrhage becomes more profuse and general; the increasing dyspnea is accompanied in some cases * Cyclop. Prac. Med. 10* 1 06 ULCERS. with pain under the sternum, but more frequently in one of the sides. In others, however, without any complaint of pain, the respiration becomes suddenly quick and laborious, and death unexpectedly puts a period to the disease. The prevention and cure of scurvy consist simply in providing a proper vegetable diet, and keeping the patient warm and dry. Where this cannot be done, as is the case at sea, the purpose can be effected by administering lemon juice freely, and making the men as comfortable as possible. Medicine has little to do in the matter, though it may render occasional aid. It is always important to distinguish the symptoms of scurvy from those of other diseases ; fortunately there is no longer much danger of mistakes in this respect. The subject does not belong to prac- tical dentistry, though the disease of the gums connected with it make 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 meaning of a word which is continually misused by dentists by applying it to a local fungus affection. Scrofulous Ulcer. — Scrofula. This word is derived from the Latin word Scrofa, a hog — why, it is not easy to perceive; but it is singular that the corresponding Greek word is also derived from a word (x u( p0 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 Strumons 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 oi all the ills that flesh is heir to. ULCERS. 107 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 frequently the parts which first manifest the local influence of the constitutional vice. Very 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 scrofula, yet those who possess what is called the lymphatic temperament, are much more liable to it than others; and as this system is pre- dominant 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 considerable accu- racy, 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, and soft and flabby flesh. Persons presenting these external appearances are generally amiable, and oflen very sprightly and intelligent, and among them are found the loveliest and most attractive of the female sex. The strumous diathesis is exhibited, in another class of persons, very differently. In these the complexion is dark, the skin harsh and the habit indolent ; the countenance is swollen and pasty, and # Phthisis, from >po£,wax. 118 TUMORS. 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, lame- lated, &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 distension or separation of their parts, the disease is not at all similar to the dense tumor produced by the presence of an unnatural quantity of bony substance. Thickening of the periosteum sometimes occasions an apparent enlargement of the bone, when in fact the osseous matter is not at all increased or distended. Sir Astley Cooper described exostosis as having two different seats, viz : between the external surface of the bone and the periosteum, constituting periosteal exostosis; and in the medullary membrane and cancellated structure, forming medullary exostosis. Sometimes he found the production of bone preceded by car- tilage, in which it was deposited ; at other times connected with a fungus of a malignant character, 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 irregularity of ultimate nutrition, a process which cannot be comprehended. The structure and consistence of exostosis present great dif- ferences. 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. Some- times the tumor is entirely cellular, and formed of a few broad laminal intercepting extensive spaces, which are filled with mat- ter, different from the medulla, and of various quality. This case is denominated the laminated exostosis. * Eg out of 05-raov — a bone. TUMORS. 119 portion of bone makes a sort of hollow sphere, with thick, hard walls, the cavity of which is filled with fungus granulations, more or less extensive and indolent. According to Boyer, this variety of the disease differs essentially from osteo sarcoma, not- withstanding external appearances. The case here alluded to, Mr. S. Cooper considers the same as that which Sir Astley has named, cartilaginous exostosis of the medullary membrane.* In this last described form of exostosis, Sir Astley Cooper says that the original shell is absorbed and a new one deposited, and within the ossified cavity thus produced, a very large mass of elastic, firm and fibrous cartilage is formed. This form of disease is not malignant, but often ends in very extensive disease. A true exostosis, consisting of dense bony matter, and of mode- rate size, may exist without much inconvenience to the surround- ing 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 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 consequences. The action of the flexor muscles of the leg has been seriously interfered with by an exostosis in the neighborhood of the knee. An exostosis of the orbit has displaced 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 radial artery by pressing upon the subclavian, and in another a cartila- ginous exostosis of the medullary membrane of the lower jaw extended so far back, that it pressed the epiglotis down upon the rima glottidis, and destroyed the patient.f 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 can- not by any means be considered the ordinary, or indeed a fre- quent cause of other forms of exostosis. * Cooper Surg. Die. + Surgical Essays. 120 TUMORS. In some individuals there is an unusual tendency to the irregular deposit of bony matter, and provocations, otherwise trivial, will often determine local osseous enlargements. Sometimes these provocations are perceived, as when they consist in some form of external force, as blows, pressure, &c; more frequently the determining cause is as obscure as the constitutional vice. Exostosis is always very hard, sometimes painful, often insen- sible. The firm resistance of the tumor, and its adhesion to a bone, will generally enable us to distinguish it from other tumors. Exostosis is commonly gradual and slow in its growth, but the fungus, or medullary swelling of the bones, is often rapid in its development. The latter form of disease is attended with very severe pain, and often with much constitutional irritation. Exostosis of the Teeth. The fangs of the teeth are more frequently the seat of exosto- sis 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 symmetri- cal enlargement. Mr. Thomas Bell says that the substance thus added, differs from the natural bone, being harder, yellowish, and slightly trans- parent. As the swelling progresses, the pressure on the alveolus causes the latter to be absorbed, and thus, as the growth is very slow, room is continually made for the enlarged fang. The wasting, however, being propagated to the tooth, soon exposes the cavity to the action of external agents, and tooth-ache leads to extraction. Mr. Bell says that the continued irritation some- times occasions thickening of the periosteum and suppuration, and the case becomes one of simple alveolar abscess. Exostosis of the fangs, sometimes occasions neuralgic suffering of a very serious grade and long duration, the cause of which is rarely discovered by an ordinary observer. Sometimes the TUMORS. 121 adjacent parts become functionally disturbed, and multiply the points of suffering. Mr. Fox relates the case of a young lady, who had suffered long with this affection of the fangs, which her medical attendants had entirely overlooked. The eyelid of one eye had not been opened for two months, and the secretion of saliva was so abundant from the irritation that it flowed out whenever the mouth was opened. Professor C. A. Harris has recorded the following case :* Mr. S., of Baltimore, having suffered from pain in the left superior bicuspis, applied to a dentist in 1843, for the purpose of having this tooth removed. In the operation the root was frac- tured, 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, how- ever, 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 spoonsful of black matter, resembling thin tar, was evacuated. Upon farther examination, the outer wall of the antrum, immedi- ately 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 exos- tosed. The patient recovered completely in a few weeks. A great number of cases, illustrating the variety and extent of mischief occasionally resulting from exostosis of the teeth, are recorded by writers upon the subject. The dentist when con- sulted for the relief of pain in the teeth or jaws, especially if of long Continuance and obstinate persistence, should always seek * Dictionary of Dental Science, article Exostosis. 122 TUMORS. carefully for evidence of bony enlargement of the fang. It is a very common disease, and in some individuals affects many, or even all their teeth simultaneously. Sometimes exoslosis unites several teeth together. In a specimen presented to the Baltimore College of Dental Surgery, by Dr. G. R. Hawes, of New York, the three superior molar teeth of one side, are thus united. In another specimen, presented by Dr. Blandin, of Columbia, S. C, two upper molars are united ; and in a third, presented by Dr. Ware, of Wilmington, N. C, there is a deposition of bone on the roots of a first superior molaris, as large as a hickory nut. Simi- lar 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 necessary 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 liber- ate the root. TUMORS OCCASIONED BY ENLARGEMENT OF BLOOD-VESSELS. 1. Jlneurismal* Tumors. A tumor caused by the distension of the walls of an artery, or of the heart, is called a true aneurism ; if the swelling be due to the rupture of an artery and the extravasation of blood in the surrounding tissue, it is called a false aneurism. An aneurismal tumor may generally be detected by the throb- ing or pulsating sensation which it communicates to the hand upon pressure. Sometimes, however, when an abscess happens to be seated over an artery the pulsation of the latter will be communicated to the former. The pulse often indicates the ex- istence 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. 1 ' 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, does not come properly within the scope of the present work. * Avevpsvvtiv — to dilate. CHAPTER IX. DISEASES OF THE TEETH AND FACE DEPENDENT UPON MORBID 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, unless 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 distinction be- tween neuralgia and other pains, is that in the case of the former the nerves are concerned primarily rather than as instruments ; or in other words, they transmit intelligence of their own suffer- ing, (for such is pain) not that which is only shared by them with adjacent parts. We must not expect philosophical definitions in medicine. The term neuralgia is not precise, but it is sufficient for practical distinction. The superficial nerves being by far the most sensitive, and withal, the most exposed to injury, are very much more frequently affected with neuralgia than those which are deeply seated. It is not certain whether the seat of the disease is in the neurilemma or the nervous pulp. In fact the ultimate nature of the nerves is too little known to permit us to hazard an opinion upon this subject. Neuralgia is a very acute pain which generally commences suddenly, and occupies a single spot, from which as the attack progresses in violence, it radiates by pangs or flashes to the sur- rounding nerves. The pain is generally sharp and darting or burning, and maybe distinguished, among other characteristics, by this, that in its radiations it follows the threads of the nerves with- out extending to the adjacent structures. There is no heat, red- * Nft^ov a nerve and aXyogpain. 124 NEURALGIA. ness nor swelling, the absence of which are sufficient to distin- guish 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 persons, 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 in- fluence, 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 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 understand. The reason will be seen in the sequel. Neuralgia faciei is sometimes called tic doloureux. The word tic means a sudden twitching or convulsive movement, and as this NEURALGIA. 125 is sometimes noticed in the faces of persons suffering with neuralgia of that part, the term tic doloureux 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 com- monly its seat. The pain is therefore most frequently suffered over the orbit, in the cheek, mouth, lower jaw and lower teeth. It will be perceived at once that the dentist must often be called upon to discriminate between this disease and ordinary tooth-ache, 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 ex- tracted tooth after tooth, and have at last relinquished the patient to his aggravated suffering. The diagnosis of this malady is not difficult. From all acute inflammatory conditions it may be readily distinguished by the absence of all the other symptoms of inflammation except pain, and by the peculiar character and direction of the pain. The fact that it subsides, disappears and returns, will also serve to distinguish it from the continued pain of inflammation. From tooth-ache depending upon exposed nerves, it may be diagnosed by the evident centralizing of the pain in a certain tooth, by the aggravation of it when the tooth in fault is struck and by the positive evidence of a cavity in it, with an ex- quisitely sensitive pulp exposed. The treatment of pure neuralgia faciei is palliative and curative. 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 experience 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 allay- 126 NEURALGIA. ing 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 laudanum, and in some severe cases, or when the patient has become accustomed to the effects of the drug, this dose will require increase or repetition. The curative treatment of pure neuralgia will be modified by circumstances. If the patient be plethoric with a red face and active pulse, even general and local bleeding may be premised. Such, however, is rarely the case, and when it is we have reason, to believe that the disease is rather rheumatic than neuralgic. If the digestion be bad, which is often the case, correctives must be directed to the organs involved. But in most cases the restoration of healthy digestion will not be sufficient to procure permanent relief. Generally, neuralgia is a disease of debility, and is found in the cold, pale and feeble, and in persons of evidently broken health. In such cases the tonic medicines offer most advantage, and of these none are found to be so useful as the salts of iron. There are several preparations of this medicine. The carbon- ate, if properly prepared, is a good form for administering iron, but by far the most valuable preparation is the sulphate. This has also the advantage of being generally good as found in the shops, and of benig always readily procured. It is much more certain and efficient than the other ferruginous preparations. It may be given in doses of a grain two or three times a day, and must be continued for several weeks. Under its use the patient will generally improve in strength and color, and with the invigoration of the general system, the neuralgic affection will frequently disappear. If this medicine should disagree with the patient or if it should fail after a fair trial, recourse may be had to other medicines of the tonic class, of which there are many, mineral and vegetable. * Narcotics from vxpxou I stupify. f Anodyne from * privative ofuvr] pain. NEURALGIA. 127 It is a very common thing for authors and practitioners to con- found the pure and intermittent neuralgias, through want of dis- criminating periodicity from a tendency to return upon slight provocation. Yet the distinction is plain and very important, for upon proper diagnosis of the form of the disorder depends the rational treatment of it. In pure neuralgia the nerve after the subsidence of a paroxysm is left in an exceedingly irritable state, so that it will be excited to another by causes of irritation in themselves exceedingly slight. But this return is merely accidental and occasional, and of course, obeys no law of regular occurrence. In some instances the exciting cause may be so trivial as to escape notice, but after long and painful experience, the patient learns to perceive potent agents for evil in things which previously eluded observation altogether. Periodicity, is the regular return of paroxysms in accordance with a law of the disease and independently of provocation. It generally observes fixed periods of return and departure, and when irregular as to the common law which governs the type to which it belongs, it obeys some regulation of its own, by which some well defined proportion of paroxysm to intermission is pre- served. It does not follow then, that because the neuralgic pain abates either of itself or under narcotics and recurs in a few hours or days, that consequently it is periodical and must be treated by quinine. Intermittent Neuralgia. — In order to understand the character and treatment of this disease, it is necessary to have a correct knowledge of a particular, class of fevers which present very curious phenomena. These fevers belong to the class which we have designated as idiopathic; and to the family of malarious or marsh fevers. They are commonly known as agues, from the fact that each paroxysm is preceded by a chill. Hence, also they are known popularly as chills and fevers. The cause of these affections is always malaria, no other agent or combination of circumstances produces them, and this is so true that the fact of exposure to malaria is most important in deciding upon the character of the disease in mooted cases. 128 NEURALGIA. Malarious neuralgia always assumes the intermittent, never, as far as I know, the remittent type. It may appear as a quotidian, tertian or quarter, or it may be irregular in its periods. Its paroxysms are rarely preceded by chill, accompanied by fever, or perceptibly finished by a sweeting stage. Though evidently depending upon the same cause as intermittent fever, it has no phenomena in common with the former, except its paroxysmal character, periodicity and curability by certain specific means. In endeavoring to ascertain the cause of violent intermitting pains in the face, it is all important to learn whether the patient has previously been exposed to malarious influence. If it shall appear in any instance that he has not been out of the central part of a large city, known to be free, at least in such part of it, from all emanations of a malarious kind, this fact is abundant evidence that the patient has not intermittent neuralgia, however strong appearances may be to the contrary of this opinion. On the other hand, if he lives in a marshy or malarious country, or if he has visited such a locality during the latter part of the preceding summer or early part of the fall, and especially if the patient has had well marked ague previously to the facial suffering, then the presumption will be very strong in favor of the malarious origin of the disease. Besides this historical kind of evidence, the attending circum- stances will shed much light on the case. If there be no ap- parent cause in the condition of the teeth of the affected jaw for so much suffering, if no other disease can be detected in the bones or soft parts, if the pain intermits perfectly and returns periodi- cally, or even if not with entire regularity, yet obviously with some obedience to the law of type, and without provocation, all these circumstances taken together will leave little doubt as to the nature of the malady. Cure. — This distressing malady, which, if misunderstood, is one of the severest and most difficult to alleviate or endure, is when properly diagnosed a very manageable affection and often yields to the very first dose of well directed medicine. We have previously remarked that the pathological cause of intermittent febrile phenomena was not known ; fortunately for NEURALGIA. 129 the world, experience has not waited for pathology but has pointed out the means of relief and the mode of applying it. Certain medicines are known to be positive antidotes to inter- mittent malarious fevers of all kinds. These agents if exhibited freely during the intermission, rarely fail to prevent the return of the paroxysm. Owing to the fact that most of these medicines possess tonic or roborant qualities, it has been supposed that they check intermittents, through this quality. Hence, tonics are said to cure ague. We are convinced, however, that the supposition which at- tributes the prevention of intermittent paroxysms to the common roborant quality of tonics is a mistake, and a mistake which pro- bably has led to unfortunate consequences in practice. The medicines which possess in the greatest degree the anti- dotal power to intermittents, are not those which are the best tonics ; while the best of all roborant medicines have but little, if any power, to check intermittent paroxysms. Cinchona, or Peruvian bark, is by far the best anti-intermittent remedy we have, yet as a pure tonic it certainly is vastly inferior to iron, and hardly equal to some of the vegetable bitters; while arsenic, which, next to cinchona, is the most powerful anti-par- oxysmal medicine of which we have any knowledge, has no tonic property at all. The anti-intermittent quality is therefore obscure, and the medicines under consideration are prescribed for the cure of these diseases, simply because experience has clearly proved their preventing quality, and not because we perceive any rational relation between the physiological effect of the medicine and the pathological condition to be removed. In the treatment of intermittent neuralgia, we must rely upon the medicines named, or, if these fail, upon others of the same class. Generally, however, if cinchona and arsenic have failed, we must look to some other quarter than to this class of means for an efficient remedy. The best mode of administering cinchona, is in the form of the sulphate of quinine, because the dose is very much smaller, and sits better upon the stomach, and because, moreover, the cinchona 12* 1 30 NEURALGIA. in bulk is uncertain in strength. The best form of administering the quinine, is in solution, although pills of it are often given. In order to dissolve it perfectly in water, it is necessary to add a few drops of sulphuric acid or elix. vit. The dose varies very much with the circumstances of the case. Thus if the intermission be long, a considerable time is afforded between the paroxysms, for the introduction of the antidote, and small doses, frequently given, are preferable ; if, however, but little intermission is afforded, the dose of the medicines must be proportionally greater. The dose, also, must vary with the urgency of the case, and the condition of the patient. If he has already suffered long, has been much reduced, and has but little power of resistance left, the dose should be very decided. There is also considerable difference of opinion among practi- tioners upon this subject. Some prefer giving large single doses, or at least rarely repeated ; others, small doses, frequently re- peated. Generally speaking, either mode will effect the desired result ; but as it is plain that we should give the least quantity of medi- cine that will be sufficient, I am in the habit of prescribing moderate doses of quinine, and have never found them to fail except when the stomach refused to bear them; in which cases larger doses would have been yet more objectionable. The prescription of quinine which I generally give, is a solu- tion of ten grains of quinine, dissolved in an ounce of water. A teaspoonful, containing a grain and a quarter of quinine, being given as a dose to an adult. This quantity is given every two hours, if there be an inter- mission of considerable duration, or every hour if the time for administering be short. In very serious cases of intermittent, involving great danger to the patient, and when the powers of life were low, I have very much exceeded the quantity above named. Some practitioners always give it in doses of ten or twenty grains ; but this quantity is unnecessary, and hardly safe ; for though many patients would bear it without inconvenience, some would suffer from its action upon the brain. NEURALGIA. 131 The dose of quinine to young children, must always be very small, as their nervous system is more excitable, and their brain more easily disturbed, than is the case with adults. Next to quinine, arsenic is our most certain antidote to inter- mittent affections. It is given in the form of the arsenias potass, or Fowler's mineral solution, in which form it is manageable, and in proper doses entirely safe. The virulently poisonous character of arsenic, renders it improper to attempt its administration in any but a diluted form. There are many cases in which the arsenic appears to exercise the anti-intermittent power quite as efficiently as cinchona, and the small bulk of the dose, and the readiness with which its flavor may be covered, make it far preferable for administration to children. It may be given very advantageously in alternate doses with quinine. After it has been persevered in for a long time, it is apt to produce oedema, which readily subsides when the medicine is withdrawn. The dose of Fowler's solution, to an adult, is eight or ten drops, every one, two, or three hours, or alternating every four hours with quinine. Sometimes it produces nausea and irri- tation of the bowels. In such cases the dose should be lessened. There are many other remedies, which are more or less effica- cious in the prevention of intermittent paroxysms, but it is not necessary to mention them here. The quinine and arsenic should be given only during the inter- mission; though if this be very short, the administration of rem- edies, and especially of the arsenic, may be recommenced before the fever has entirely subsided. In the treatment of intermittent neuralgias, as in other inter- mittent affections, the prevention of a paroxysm will be more certain, if a full dose of opium be given an hour before the ex- pected return. In cases of intermittent neuralgia, where the patient has been exposed to malaria for successive years, and has suffered much from the diseases attributed to this cause, the liver and other abdominal viscera, are generally deranged, and the neuralgia cannot be permanently relieved until these visceral obstructions are overcome. 132 NEURALGIA. The purgative preparations of mercury, are very useful in such cases. Of course, no permanent cure can be expected, while the patient shall continue to reside in the unhealthy location, as he musl, of necessity, be exposed to continual renewal of the dis- ease. Unfortunately the advice of medical men, is rarely of much avail in directing the choice of residence. This is deter- mined, for the most part, by considerations entirely independent of health ; and there is great difficulty in persuading a man that it is unsafe for him to live where it is most profitable or pleasant, and that his own property is situated where nobody ought to live. CHAPTER X. MORBID SECRETIONS OF THE MOUTH. Six glands, the parotid, submaxillary, and sublingual of each side, pour their secretions into the cavity of the mouth. The mucous membrane, which lines the organ, also contains upon its surface a great number of crypts, or follicles, which prepare and pour mucus into the mouth. The secretions from the glands and mucous membrane, form saliva, which lubricates the facial cavity, and in mastication is thoroughly mixed with the food, the subsequent digestion of which it materially aids. The mucous membrane of the mouth, is continuous with that which lines the pharynx, aesophagus, stomach, and intestines, and sympathizes greatly with any diseased condition which affects those organs. Hence the furred tongue in fever, the red tongue of intestinal irritation, &c. The fluids of the mouth, are readily changed from their nor- mal condition, when the digestive organs are feeble, and perform their functions badly. When such is the case, the secretion of the stomach and its appendages are so changed as to unfit them for the perfect performance of their work ; they become, to a certain extent, foreign matters, and are capable of exciting irri- tation, and also by mixing with alimentary matters, converting them into deleterious agents. Generally the change produced upon the fluids of the stomach, &c, under such circumstances, renders them more acid. Corresponding changes often take place in the fluids of the mouth. They also become acid, and in such cases corrode the dental structures, and cause great devastation of the teeth. They are also liable to be produced in excess, and to be very abundant in salts, which are collected, mixed with viscid mucus, about the teeth, especially of the lower jaw, forming the several varieties of tartar. 134 MORBID SECRETIONS OF THE MOUTH. The saliva of healthy persons, is only sufficient for comfort- able lubrication of the mouth, and being passed into the stomach as fast as it forms, it does not collect in the mouth, or require to be frequently excreted. When healthy, it is light, frothy, and but little viscid, without odor, floats upon, and mingles readily with water. In this condition it is slightly alkaline. The saliva is acid in dyspepsia, and consequently caries is apt to prey upon the teeth of persons suffering with indigestion. Nor may the dentist expect to arrest the devastation, unless he can remove the cause that is continually decomposing the bony struc- tures of the teeth. That the saliva is acid in certain diseases, is abundantly shown by Mr. Donne, of Paris, — who was so struck with the changes in the chemical character of the fluids of the mouth, as responding to disordered slates of the stomach, that he suggested the use of this fact, as the best means of deciding upon doubtful cases of such disorders. M. M. Tiedemann and Gmelin,had previously found the saliva to be alkaline in man, and all other animals whose secretions they had examined. Magendie, with his usual carelessness of facts, and boldness of theory, taught that the saliva was sometimes strongly alkaline, sometimes neutral, and sometimes acid : when the stomach is empty, the fluids of the mouth, according to this writer, are acid; during mastication, alkaline ; the acidity dis- appearing sometimes at the presence of the fust mouthful. The latter part of this opinion, is, of course, mere nonsense. According to M. Donne, who seems to have investigated this matter with great carefulness, with the hope to find in it some semeiological fact, which might lead to great practical results, the saliva is constantly alkaline when the stomach is in a healthy condition. This, then, he considers the normal or natural quality of the fluids of the mouth, and all deviations from it, he considers unhealthy, and indicative of gastric disease. M. Donne declares that he has never found the saliva acid, when the stomach has performed its functions well. The only testing means used by this gentleman in his many ex- periments upon the saliva, were slips of litmus paper. The saliva, if acid, will redden the paper: lor test of alkalescence the MORBID SECRETIONS OP THE MOUTH. 135 paper should first be reddened by an acid and then subjected to the action of the saliva. M. Donne narrates a number of cases of various forms of disease, in all of which the stomach was deranged and the saliva acid. We will quote a few of them. A young woman was admitted into the hospital of La Charite, laboring- under severe bronchitis, attended with great tenderness of the abdomen, excessive irritability of the stomach, diarrhoea, ardent thirst, &c. The saliva was strongly acid. The disease assumed in its progress a marked typhoid character, the tongue was parched and coated with a brown crust, the abdomen was always very tender; delirium and coma supervened and the patient died on the tenth day after admission. The saliva was acid during the whole course of the illness. Dissection showed extensive disease of the mucus membrane of the stomach and in- testines. A young man was received into La Charite, as a fever patient. All the symptoms of ataxic fever soon developed themselves. The saliva during the first days was only slightly acid but later it became more strongly so; he died comatose. The saliva re- mained acid to the end. Dissection showed a fifth part of the mucous membrane of the stomach diseased. A young man was admitted into the hospital as a fever patient. The symptoms were not serious, there was a yellow hue of the skin; the epigastrium was rather tender on pressure, there were, however, neither vomiting nor diarrhoea present, the tongue was white and the saliva was alkaline. During the progress of the case the saliva became acid, continued to be so for three days, then became neutral, and as the patient recovered, gradually re- sumed its alkalinity. In the case of a young man who exhibited the symptoms of gastritis, namely, great tenderness of the epigastrium, thirst, tongue red and parched, &.c. the saliva was found to be decidedly acid. By repeated leechings of the abdomen, and the use of demulcent and refrigerant drinks, the symptoms were speedily relieved, and in a few days the saliva was quite neutral, having no effect either on the simple litmus paper, or on that which 136 MORBID SECRETIONS OF THE MOUTH. had been previously reddened by an acid. It soon regained its alkalinity. This patient had two relapses of his complaint, and on both occasions the saliva was acid at first, and became neutral, and then alkaline, as the symptoms disappeared. From these and similar facts, M. Donne inferred that acidity of the saliva was always attendant upon gastric disorders of a febrile character. Professor Harris informs me that repeated experiments have satisfied him that the acidity is confined to the mucous secretions of the mouth ; the secretions from the salivary glands never red- dening the litmus held to the mouth of their ducts. Schill observes that "carious teeth indicate long-continued irregularities of digestion. The teeth become very sensible (sensitive) in many nervous diseases, and in consequence of the presence of acid in the stomach. They are sometimes covered with a whitish or grey mucus: this occurs chiefly in catarrhs, and inflammations of the digestive and respiratory organs."* When we remember the extreme susceptibility of the teeth to be decomposed by the action of acids, (see page 31,) we may well understand why caries is so general, and so hard to arrest. Providence has made the saliva alkaline, in order to protect the important organs it bathes, from injury by acid matters taken into the mouth, and also to moderate the acidity of the gastric fluids. But under many morbid conditions, especially those most com- mon to artificial life, the protecting fluid itself becomes the assailant, and the teeth exposed at once to the attacks of acid aliments and drinks, and to the more constant action of acidulent saliva, soon yield to those corrosive agents. This acid state of the saliva may accompany a vitiated condi- tion of the fluids of the stomach, when no gastric suffering has attracted the attention of the patient, and the existence of any disorder in that organ has not been suspected. In such a condition of things, however, the dentist can afford only temporary relief, unless, perceiving the evil himself, he suggests such remedies as may relieve the patient of it. * Schill's Semeiology, MORBID SECRETIONS OF THE MOUTH. 137 The practitioner of dentistry should, therefore, be always pre- pared to test the quality of a patient's saliva, as regards acidity or alkalescence ; and he should also be prepared to give such advice as may be necessary, in consequence of any discoveries he may make. When diseases of an acute character exist there will be no demand for the services of the Dental Surgeon, unless his me- chanical assistance be required. It is not necessary, therefore, for us to treat of such affections. But it often will happen, that a patient will apply for operations upon the mouth, who may be affected with some sub-acute or chronic disease of his stomach, for which he is not under medical treatment. If the disorder be not very trifling, the dentist ought, in such cases, always to advise application to a judicious physician. But it will often happen, that the patient cannot conveniently procure such attention, or that the dentist may not have such confidence in the skill of the medical practitioner who could be procured, as to authorize him, as a conscientious man to devolve the case upon another. He must therefore give the necessary advice himself.; In calling the attention of the dental student to the considera- tion of dyspepsia,* as a common name for chronic diseases of the stomach particularly characterized by indigestion, we do not think we are in any degree leading our readers away from the studies proper to them. Dyspepsia or indigestion, representing any derangement of the function by which the aliment, after having been received into the stomach, is converted into chyle, must necessarily present a number of appearances, more or less characteristic of the particu- lar trouble they represent, and the degree of its violence. It is therefore impossible to furnish a description sufficiently accurate and comprehensive to cover all the conditions of defective diges- tion which are included under the common name dyspepsia. Sev- eral complicated organs are concerned in the process of digestion. These are connected together by the natural dependence of recip- rocal necessity, and by powerful sympathies ; and any of them, when diseased, may interrupt the functions of the others. To * Dyspepsia — Avs with difficulty, and IIswtw — I digest. 13 138 MORBID SECRETIONS OF THE MOUTH. understand this subject well, it will therefore be necessary to have a complete knowledge of all the morbid conditions of all the organs of digestion, and of all the means likely, under any circumstances, to be useful in restoring them to healthy action. Of course, it is not our purpose to discuss this subject in all its fulness of detail. It will be sufficient to impart such practical information, as may be easily remembered, and readily made availing by the dental practitioner. The symptoms of dyspepsia vary much with the duration and nature of the affection, the constitution of the patient, his mode of life, &c. Generally the appetite is capricious, sometimes very feeble. Heartburn, a sense of weight or distension in the stomach after eating, incapacity of digesting certain substances, such as oily matters, pastry, &c, costiveness, abdominal pains, weakness, depression of spirits, &c. are most prominent. From the extensive sympathies existing between the stomach and brain, head-ache is a very common attendant upon dyspepsia. This is often very violent, and attended by nausea and vomiting. The patient soon learns by experience that he cannot take certain articles of food or drink with impunity, and every deviation from the diet suitable for him, is attended by renewal of symptoms, and aggravated suffering. Dyspepsia may be variously classified for the purpose of description and treatment, but the simple, plain and practical dis- tinction laid down by Dr. Eberle seems preferable for our pur- pose to any of the more accurate, yet more complicated arrange- ments presented by other writers upon this subject. According to Dr. Eberle, dyspepsia may depend upon two distinct morbid conditions of the digestive organs, viz : 1. On functional debility of the stomach from deficient or vitiated secretion of the gastric fluid, and muscular inactivity, independent of vascular irritation or inflammation. 2dly. On deficient or vitiated secretion of the gastric fluid with vascular irritation or chronic inflammation of the mucous membrane of the stomach and duodenum, and a mor- bidly increased peristaltic action of these organs. The characteristic symptoms of the former grade of indiges- tion, are weak appetite : tongue covered with white fur : absence MORBID SECRETIONS OF THE MOUTH. 139 of epigastric tenderness, except after a paroxysm of colic from flatulent distension; costiveness ; acid and fetid eructations; absence of habitual tension and febrile irritations of the pulse ; and the ability of bearing lean and tender animal food better than vegetable and farinaceous articles of diet. The phenomena which characterize the second or inflamma- tory grade of the disease, are tenderness to pressure of the epi- gastrium, and particularly about the region of the pylorus and duodenum ; a red, chopped, granulated or glossy appearance of the tongue; a firm, tense, small and somewhat accelerated pulse, with slight manifestations of febrile exacerbations towards even- ing; emaciation; irregular action of the bowels, with frequent attacks of mucus, bilious or watery diarrhoea ; violent protracted pain in the lower part of the epigastrium during the process of digestion; fullness about the edge of the false ribs on the right side ; an anxious and discontented expression of the counte- nance; and inability, without great suffering, to endure animal food and stimulants. It appears that the irritative or chronic inflammation of such cases is seated in the mucous membrane of the pyloric extremity of the stomach, and of the doudenum, con- nected usually with a congested state of the liver and often with foecal accumulations in the colon.* The causes of dyspepsia are : 1st. Hereditary predisposition. Some families inherit from their parents some peculiarities in the intimate organization of the stomach which inevitably result in dyspepsia of protracted and aggravated character, which makes its appearance about or soon after puberty, and continues with more or less intermission for years. This predisposition, however, is not of very frequent occurrence. 2d. Mental and moral causes, such as exaggerated passions ; gloomy habits of thought ; depression of spirits ; over anxiety of mind. The influence of the feelings over the stomach is well known. Grief destroys the appetite, so do joy and ardent anticipation. Fasting is a natural exponent of sorrow. 3d. Irregular living, especially the artificial life of the fashion- * Eberle's Prac. of Medicine. 140 MORBID SECRETIONS OF THE MOUTH. able world, which turns night into day and day into night; rob- bing the body of sleep when most disposed to and best prepared for it, and forcing the stomach, at unnatural hours, to eat heartily of the most indigestible and irritating kinds of food, if such ingesta can thus be called without impropriety. 4th. Luxurious and excessive eating and drinking, both of water and intoxicating drinks. 5th. Sedentary living without sufficient exercise. 6th. Unwholesome and insufficient diet. The use of pickles in excess, especially by delicate females. 7th. Want of healthful and sufficiently laborious occupation. It is owing to this, together with the adjuvant action of other causes which we have mentioned, that so many of the young women of our country are feeble, diseased, useless and short- lived. 8th. The abuse of medicines, especially those of a purgative character. People have a wonderful disposition to be actively purged. Millions of pills, containing irritating and powerful cathartics, such as jalap, scammony, aloes, calomel, gamboge and croton oil, are annually sold to persons whose only disease is too frequent purgation. The result often is chronic and incurable dyspepsia. 9th. Eating too fast, so that the gastric juice does not mingle with the food as rapidly as it is taken. Imperfect mastication, generally because of carious teeth. 10th. Extensive disease of the teeth, occasioning frequent and severe tooth-ache, vitiating the secretions of the mouth, and thus furnishing to the stomach saliva of a bad quality. We have just seen that imperfect mastication may cause dyspepsia. Exten- sive caries interferes much with mastication. Moreover, pain disturbs digestion, and frequent tooth-ache not only produces the common effects of pain, but from the position of the suffering, interferes with insalivation and regular eating. 11th. To all these causes may be added every thing which tends to exhaust the vital energies, as every kind of excess necessarily does. The treatment of dyspepsia consists first, in removing as far as possible all the causes of it. It will be useless to make an MORBID SECRETIONS OP THE MOUTH. 141 attempt to cure, unless the patient will make patient and self- denying efforts. The patient must he contented to subsist upon such food as he can readily digest. The diet should be as dry as possible, for all drinks dilute the gastric juice, and when this is vitiated or deficient, dilution renders it still less efficient. As to the character of food, it is exceedingly difficult to lay down a bill of fare which will suit all cases. The stomach, in dyspepsia, is very capricious. Some patients will eat with impu- nity what others cannot digest at all. I once had a dyspeptic female patient whose stomach revolted at the most simple and digestible substances, yet retained and digested comfortably, apple pie and milk. Generally, the patient has learned, by- repeated experiments, what food agrees best with him, and to this he should be confined. In general, when the disease is simply one of debility without gastric inflammation, animal food answers better than vegetable. In selecting the particular kinds of animal food, we should avoid young meats. Veal, lamb, and young pork are very indigestible by weak stomachs. The mode of preparation also is important. Soups of all kinds are pernicious, as they present the food to the stomach very much diluted and mixed with oily matters. Oils in all forms must be avoided, hence fried food, melted butter, gravies, most kinds of fish, &c, are inadmissible. All acid fruits, and the whole family of nuts, come under similar condemnation. Sugar is very apt to sour upon the stomach, especially if it be dissolved in warm water, as in the form of sweetened tea and coffee. In these cases of debility of the stomach, a little brandy taken at dinner is often very serviceable. The remedy, however, is a dangerous one, and no prospect of advantage from it should induce us to advise it to one who has at some previous time been intemperate in its use. It is better for a man to be a dys- peptic than to be a sot; and reformed inebriates have seldom a choice between abstinence and excess. Indeed, every patient who may be advised by his physician to use ardent spirits, should be faithfully warned against the danger of acquiring an intemperate love of alcoholic excitement. 13* 142 MORBID SECRETIONS OF THE MOUTH. The medicinal treatment of such cases consists in the employ- ment of such occasional purgatives as may be necessary to pro- cure regular alvine evacuations ; in the proper use of mild mer- curial means to an extent sufficient to remove torpor of the liver; in the administration of alkalies, if the patient be troubled with an excess of acid ; and finally, in the use of suitable tonics. All pur- gative medicines are not by any means equally well suited for the purpose we have indicated. Those of them which are very harsh and irritating, and those which produce watery and exhaust- ing discharges would be very injurious to dyspeptics. Indeed, we have enumerated the abuse of these cathartics among the common causes of the disease. Rhubarb, from its aromatic and tonic quality, and its mildness, is one of the best medicines for habitual use, under these circum- stances. Aloes is somewhat stimulating to the torpid intestine and generally acts very gently upon the lower bowels. Blue pill mixed with either of the medicines above named, will often prove very advantageous, and calomel given occasionally in a decided dose will be very serviceable when the liver is indolent, and its secretions deficient either in quantity or quality. Of the vegetable tonics, the pure bitters, such as quassia and gentian are the best. But the preparations of iron are more likely to be decidedly advantageous. We must not, however, expect a great deal from medicine in the relief of dyspepsia. At most it is a secondary means of cure. The removal of the causes and the rigid adherence to regimen, will, in most cases, ultimately procure relief. It is very important that the teeth of dyspeptic persons be care- fully examined, for often the cause or at least a cause of the disease may be found in the diseased and defective condition of these organs, and a speedy cure be obtained by their removal. As to the form of dyspepsia attended by sub-inflammatory con- dition of the lining membrane of the stomach, its cure must be devised upon the principles which govern in the treatment of similar conditions elsewhere. Moderate antiphlogistic means and mild farinaceous diet, will generally be attended with perma- nent relief, nevertheless the gastric surfaces, as the mucous mem- branes elsewhere, after having been inflamed remain subsequently MORBID SECRETIONS OF THE MOUTH. 143 very susceptible to renewal of the disease, and the patient when relieved must be very careful not to presume upon the comforta- ble feeling of his stomach, and introduce into it stimulating meats, condiments or liquors. All dyspeptic persons should be advised to eat slowly and chew their food well. If the absence or bad condition of the teeth interfere with mastication as they will often be found to do, the skill of the dentist must supply the deficiency or repair the injury of those important organs. Dyspepsia or indigestion, expresses only the mal-performance of an act which is the result of the combined effects of various organs. Therefore, as failure of function in any one will inter- rupt the healthy completion of the great common purpose, dyspepsia must be a general term comprising several disorders. Being immediately connected with the digesting apparatus, and in fact forming an important part of that great and complicated system by which aliment is received and prepared for assimila- tion, the dental apparatus can hardly escape injury when the other organs of this system are involved in suffering. Indeed, the mucous membrane, which in the stomach and intestine is the seat of the digesting process, and in the mouth is continually pouring out important fluids from its surface and glands, is so intimately connected with the dental arch as to unite it in close sympathy with the more important organs of alimentation. A healthy state of the fluids of the mouth is necessary for the safety of the. teeth, and the secretions of the mouth will not be healthy when the functions of the intestinal canal membrane are disturbed. It is a hopeless task to save the teeth from caries while the patient suffers unmitigated dyspepsia. Syphilis, also, by vitiating the general glandular and secreting systems, may produce a state of the buccal fluids very inimical to the structure of the teeth. This will only be the case in those secondary or constitutional forms of lues of which we have already written sufficiently when treating of ulcers. Rickets very much delays dentition, and so impairs the struc- ture of the teeth that when protruded they are very liable to decay. 144 MORBID SECRETIONS OF THE MOUTH. The enamel of teeth formed under the influence of this constitu- tional vice, is often craggy and worm eaten in appearance, though sufficiently hard. The fang during the progress of the disease, has been found somewhat softer than natural. The exanthemalous febrile affections, which commonly occur in childhood, interrupt the regular deposit of bony matter in the growing teeth, and cause permanent defects which are sometimes discernible in the external appearance of the organs. Measles, for instance, often leaves evidences of its visit upon the enamel of the teeth, in the pitted appearance which they present. As fever of all kinds is always attended with vitiation of the secretions of the mouth, we may readily perceive how any pro- tracted disease of this kind may injure the teeth. All serious diseases of the antrum must involve the dental arch. Inflammation may be propagated, nutrition impeded, caries com- municated and the arch actually broken up in the course of those often fatal diseases which have their seat in this geographically important cavity. The surgeon dentist should be well acquainted with the various disorders and morbid growths which may be developed in the antrum. Early detection is often necessary to cure, and none is so likely to have the opportunity of early discovering the hidden mischief, as the dentist. The first symptoms of the disorder are often felt in the teeth, and unless the dentist who may be con- sulted shall be able to point out the true nature of the evil, delay may be occasioned, and delay may be fatal. Mercurial salivation, (ptyalism) has often caused extensive devastation in the dental arch. Mercury, like all other of hea- ven's boons has been shamefully abused, and serious and even fatal injuries have resulted from the reckless administration of this most useful medicine. Unhappily, the occurrence of such calamitous accidents, has induced such general and unreasonable prejudice against the use of mercurial medicines, that vastly more evil is now suffered by society from the improperly with- holding, than injudiciously using them. The feeling against mercury has been the common hobby-horse of charlatans and un- principled physicians, and it needs no little firmness to enable a MORBID SECRETIONS OF THE MOUTH. 145 physician to deal honestly with his patient in the use of this drug. From the fact that salivation is injurious to the teeth, dentists have been led to comment severely on the use of calomel, and thus have done much to spread abroad terrible notions of the evils inseparable from the employment of this and other mercu- rial preparations. Some of these censorious gentlemen have seen evidences of mercurial devastation in every form of disorder and variety of decay ; and to them calomel is the one thing to be avoided by all who live to eat, or eat to live. Doubtless salivation, especially if profuse, must be destructive to the teeth, fortunately it is at length understood that ptyalism is not, by any means necessary to the attainment of all the benefit of mercury. Salivation is an accident always to be dreaded, and as far as possible to be avoided. Yet even at the risk of it mer- curial remedies are indispensable, inasmuch as life is more im- portant than teeth. There is no reason to believe that the use of mercury is injurious to the teeth, when salivation is not induced ; yet caries of these organs is very often attributed to it. People are exceedingly apt to confound the post hoc with the propter hoc,* and dentists are as liable as other men to fall into the error. A patient who has escaped a severe attack of fever, finds his teeth rapidly decaying; in great alarm he applies to the dentist. The latter glances at the mouth and with a look of boding sagacity, inquires if the patient has not been taking calomel. The patient replies that he has been taking more or less, and then the man of science, as he is presumed to be, launches forth for the hundredth time into a bitter diatribe against mercury as the origin of all evil. And why might not the lamented caries be as justly charged upon the tartar emetic or magnesia, which the patient may have taken simultaneously with the calomel? or why does not the dentist seek for the all sufficient cause of devastation in the fact that the teeth in question had been bathed in the acid saliva of a fevered mouth for weeks consecutively ? Why transfer the blame to the remedy by which the fever was subdued, and cast * To consider whatever occurs subsequently, to be consequent upon what has been observed to precede it. 146 MORBID SECRETIONS OF THE MOUTH. implied and serious censure upon the physician, whose judicious employment of the villified drug has, perhaps, saved the patient's life? Until we have other information than we now possess, we cannot believe that the proper employment of mercury is injurious, and while we reprobate its abuse and would think the physician unpardonable, who would be careless or reckless in the use of a medicine capable of doing so much harm, we cannot but regard that man as the author of greater evil, who by silly declamation against an important remedy, fetters the physician in his contest with the most formidable diseases. Scrofula, to which we have already called attention, interferes with assimilation, and consequently with the completeness of nutrition and growth. Being often inherited and developing its mischievous nature very early in life, it influences the teeth during the important process of formation, and by preventing their per- fect organization renders them feeble to resist the influence of morbific causes. This evil consequence is, however, generally conterbalanced by the thinnesss and deficiency of mucous and salivary fluid, and the difficulty with which the fluids of the mouth of strumous persons become acid. Pregnancy is supposed to be fraught with danger to the teeth. Indeed, this opinion has been sufficiently general to have become condensed in the adage — "for every child a tooth" — meaning that the mother may expect to lose a tooth as the result of each pregnancy. Pregnancy is not disease, it is a physiological condition, and we cannot believe that it is per se, and naturally a cause of disease any where, especially in organs distant and not immedi- ately dependent upon the uterus. But in pregnancy the nervous system is irritable, and the sympathies of the body are in more lively play. The vascular action is also greater and the blood is more highly charged with fibrine. It therefore happens that there is more liability to pain then than at other times, and less patience to endure it. Consequently, if the woman has any dis- eased teeth, previously neglected, they will be apt to ache, and when aching, the pain to her irritable nerves is intolerable. Be- MORBID SECRETIONS OP THE MOUTH. 147 sides this, there is occasionally a sympathetic tooth ache, which though it cannot be directly traced to the uterus, certainly depends upon its gravid condition and not upon disease of the tooth itself. The dentist should be aware of this; it is readily alleviated by an anodyne. It also happens very frequently that the artificial life and the absurd habits of our young females, induce a constitution but little capable of sustaining child-bearing, although to the woman of good health and vigorous frame, parturition is fraught with no disadvantage to health or shortening of life. These pallid, soft and delicate girls, when become pregnant, begin rapidly to break down, and the rapid caries which destroys their teeth is but the first manifestation of the premature decay of the whole body. This is a subject upon which we could and would willingly write much, but it would be useless. Fashion, custom, inclination will bear sway over reason and moral obligation, — years of comfort will be sacrificed for hours of mirth, — showy dress and ball room vigils will continue to feed the insatiable tomb with the loveliest of our race. CHAPTER XT. MORBID EFFECTS OF CONDITIONS OF THE TEETH, AND THE PARTS IMMEDIATELY CONNECTED WITH THEM, UPON THE GENERAL SYSTEM. Having considered the several forms of disease in other parts, or of the general system, which morbidly affect the teeth, we proceed to inquire what effect these latter organs, in their varied states, whether physiological or pathological, may induce in other parts, and what changes they may cause in the more general phenomena of vital action. As the body is a unit, knit by the closest bonds, pervaded by one system of blood-vessels and nerves, directed by one intelli- gence, and kept in a continual relation of function and expression by an all pervading law of reciprocal re-action and sympathy; as diseases of other parts, and those which in distinction to well defined and limited affections we call general, are capable of affecting the teeth, it might be apparent, if we had no particular facts in evidence, that the morbid condition of the teeth may pro- duce corresponding evils in other parts, and may even involve the whole system in troubled and morbid action. It might also be evident that severe and long continued pain, located in the immediate vicinity of the brain, and in parts little accessible to soothing appliances, cannot be less dangerous to health than pain in other organs situated at greater distance from the nervous centres and more easy of access. It might also be perceived that sensitive organs, in imme- diate contact with the great lining membrane of the thoracic and abdominal cavities, and intimately connected with it by function, cannot be less capable of propagating disorder to it than parts located far from it, and having no immediate rela- tion to it. Yet natural as these inferences seem to be, they have been, 14 150 MOEBID EFFECTS OF THE TEETH, ETC. until lately, almost entirely overlooked, and even now the medical profession are by no means awake to the facts and the importance of the morbid relation actually existing between the teeth and other parts. It is exceedingly uncommon to hear that a physician, in search- ing for obscure causes of protracted ill-health, has paid any atten- tion to the state of the teeth, though often their terribly diseased condition cannot escape involuntary recognition by more of his senses than one. The matter is never alluded to in lectures delivered to medical classes, and, in fact, is hardly recognized at all as a subject for pathological or hygienic consideration. Within a few years, however, several writers upon dentistry have urged the medical profession to turn their attention to the diseased conditions of the teeth in connection with other dis- orders, and they have supported their appeals with such an array of well observed and clearly narrated cases as must impress the mind of all reflecting readers with the fact of the morbid rela- tions in question. Unfortunately, these writings are not read by the general practitioner, and it is to be feared that a long time must elapse before physicians become properly informed upon this subject. In the meantime it is the more important that every dentist be able to perceive these sympathetic conditions and call the atten- tion of the patient and physician to them. The teeth, while in a physiological condition, are capable of inducing great local distress, and constitutional disorder even of a fatal kind. During their evolution and passage through the gum, the pressure even of a sound tooth upon a sound gum may be attended by irregular phenomena of the most alarming kind : it would be strange indeed if the action of a diseased tooth upon the diseased gum should be attended with no evil consequences. That the process of dentition happens in infancy, causes cer- tainly a modification of effect in accordance with the peculiari- ties of the infantile constitution ; but, the action of morbid teeth upon the less mobile nerves of the adult may be as certain, though less rapid and ostentatious. The question, however, like other medical questions, is one of fact, not of inference. And we would leave the truth to be deduced from a fair examination of subjected cases. CHAPTER XIL MORBID EFFECTS OF FIRST DENTITION. Dentition is not, in itself, a morbid process, but a healthy- physiological act. It would be strange, therefore, if it neces- sarily involved disorder of function and serious consequences to the subject. The truth is, that when naturally performed, under the favor- able circumstances of sound constitution and good health on the part of the child, the cutting of the teeth is performed without pain or any collateral evil, these organs appearing in their place, without any previous unpleasant sensations to attract attention to their progress through the gum. It is thus that the domestic animals perform dentition, and many children complete theirs with no more perceptible inconvenience. More generally, however, the child experiences, at least with some of its teeth, more or less suffering of a local kind, and in many cases the pain is attended by sympathetic irritation of a grave and not unfrequently of a fatal character. It is important to know that, however large may be the pro- portion of painful, in comparison with natural dentition, the former are nevertheless to be regarded as accidental modifications of the regular and healthy process. Starting with this knowledge, we will, of course, be led to enquire into the causes, so general and so potent, which effect the changes in question, and to devise means and management most proper for escaping or annulling them. Does painful dentition depend upon the pressure exercised by the tooth upon the gums ? If it did, all children would experience suffering and more or less collateral morbid effects. For although the difference of natural sensibility in different children would occasion differences in the degree of trouble arising from this cause, yet this compara- 152 MORBID EFFECTS OF FIRST DENTITION. tive sensitiveness, being merely natural and healthy, could not account for the extreme contrasts exhibited between easy and simple, and complicated and dangerous dentition. Nor is it all likely that extreme sensibility would escape mor- bid manifestation during the rapid evolution of infantile life, until awakened from its passivity by the evolution of organs, them- selves not sensitive, (in their healthy state,) passing through structures not by any means remarkable for this quality, and per- forming their eruption so gradually as to make no sudden de- mands upon the nervous and vascular system, so as to disturb the equilibrium of nervous and vascular distribution. Nor is it consistent with the facts observed in the history of dentition that the cause of the suffering is the pressure of the fangs of the teeth upon the periosteum of the alveoli. Those who adopt this explanation have not considered that the shooting of the teeth, characterized by the enlargement of the alveolar walls, and the distension of the gums occasioned by the forma- tion of the body or of the crown of the teeth is an epoch often more dangerous than that of the organization of the roots ; which besides would do much more harm in compressing and binding the soft and pulpy part of the tooth than the serous membrane, which performs the function of a periosteum and lines the interior of the gum and proper cavity of the teeth* The truth seems to be, that a great number of children are born into the world so feebly or disproportionably constituted that they are not capable of maturing. Most of these necessarily perish during childhood, by some of the many forms of disease common to that period. Many others, though born with suf- ficient vigor, are reduced by bad diet and defective management to a condition which readily yields to irregular or morbid agents. A child may be very feebly organized, and yet may appear for a time plump and healthy, but when the vital powers come to be tested either by accidental or physiological demands upon its energies, the natural feebleness is ascertained by the development of various morbid phenomena indicating the particular location and kind of disability. * Baumes on First Dentition. MORBID EFFECTS OF FIRST DENTITION. 153 Again, children born healthy are often subjected to privations or to injudicious diet and regimen which rapidly alter their fluids and tissues, and lay the foundation for serious accidents. Dentition demands a certain amount of constitutional energy to accomplish it. The rapid development of any organ does this. The changes which take place at puberty, and the evil conse- quences, to the feeble, of the developments then completed, are illustrative of this fact. This demand is the severest test of functional and organic completeness in the child, and many will not bear it. • The development of the teeth determines an unusual flow of blood to the head. This happens at a time when the brain is proportionately large, and undergoing rapid evolution. Indepen- dently of dentition, this period of life is attended by a strong tendency to cerebral affections, and to pulmonary and abdominal complications. The nervous and vascular systems are, in the child of this age, remarkably active. The several organs have to perform not only their functions and the preservation of their entireness, but also rapid growth. Animal life is therefore ex- alted with all its qualities. Among these are sensibility and sympathy : the capacity to be impressed and to propagate im- pression. Hence a slight cause may produce great local or con- stitutional effect, and disease of any kind may induce sympathetic or constitutional disorder apparently much out of proportion to its own intensity or importance. In the older child the relation of secondary to primary affec- tions is more equable, and the second dentition is performed without the occurrence of those serious constitutional affections Which so frequently attend the first. Any unnatural obstacle or impediment to the eruption of the first teeth, will tend very materially to augment the probability of morbid consequences. A disproportion between the teeth and the jaw, or the unusual hardness and impenetrability of the gum, are of this nature, and sometimes provoke local and sympathetic disturbance. The appearance of several teeth at once may make a larger demand upon the system than it can readily meet, and hence cause embarrassment, or if their dentition be painful, the amount of 14* 154 MORBID EFFECTS OF FIRST DENTITION. suffering may be too great for the sensitive and sympathetic na- ture of the child, especially if it be constitutionally feeble. The natural symptoms of healthy dentition, are not remarka- ble. An increased flow of saliva is usually noticed, though this perhaps, is not as certainly the consequence of dentition as is generally supposed. The mouth of infants is generally well supplied with fluids, which, there being no teeth to prevent it, will escape more or less from the mouth. The child also carries its fingers to the mouth more frequently, and seems pleased to press a resisting substance between its gums. Gentle friction of the gum also seems to be agreeable. The gums are noticed to be hot, and the child takes the breast frequently. The bowels are generally looser than usual, and the child ordinarily mani- fests some little restlessnes and sleeps less profoundly than pre- viously. These symptoms precede the eruption of the teeth by several weeks, and seem to depend upon the rapid ossification and growth of the teeth. After a few days, they often subside, to be renewed when the teeth are pressing forward and about to pene- trate the gum. It is common to alleviate these little inconveniences, by giving the child a coral, crust of bread, or other hard substance, to press upon with its gums. Nature is generally a very correct guide as to her own wants, and as it is natural thus to allay the sensation of the gums at this period it must be right. A priori, however, we might have feared that the continual pressure would condense and harden the gum and make it more impenetrable. Inasmuch as nature has not indicated the precise degree of resistance proper for the purpose, it would be well to use sub- stances which do not possess this quality in an unnecessary degree. The French use a stick of marsh mallows, or liquorice root dipped in honey, or a sweetened decoction of barley — the Ger- mans, a small bag filled with sugar and spices. It is doubtful, however, whether the success of this invention for quieting the child may not induce the nurse or mother to neglect it, and withhold the breast which it would take eagerly and frequently. Nothing so soothes the infant as the frequent lubrication of MORBID EFFECTS OF FIRST DENTITION. 155 the mouth with the mother's milk and where nothing in the state of the mother's health or the condition of her breast forbids this indulgence, it is cruel and unnatural to deny it. It may be, too, that the constant use of sweet and condimental substances would disorder the stomach of the child: an accident to be studiously avoided during teething. The bowels are generally loose during dentition, and even when the purging is very frequent we must not consider it ex- cessive while the child nurses freely, and especially while it does not emaciate. Costiveness is much more to be feared under such circum- stances than purging. It is unnatural, and unless overcome by proper treatment will result in irritations, local, and perhaps sympathetic, which may not easily be remedied. It is always important to restrict a teething child to proper aliment. The bowels may very readily be irritated, and the system is so liable to violent excitement at this time that all irri- tation should be dreaded, especially irritation of the abdomen, for this is the most important part of a child, being the centre of the very active processes of nutrition and augmentation every where going on. This is no time to try experiments upon the stomach. Nutritious and easily digested food, and that which is tree from acidity, is to be given, and in such quantities as the child is willing to take. Unless, indeed, it has been habitually over-crammed and taught to eat an unnatural quantity. When the mother has milk, this is, of course, the best food for the infant, but it will generally happen that the child will require more nourishment than it can obtain from this source. In selecting food for it, regard must be had to the condition of the child. If delicate and thin, animal food will often be indis- pensable. Beef, mutton, and occasionally a little salt meat may be given with advantage. Young meats are gelatinous and less digestible and should be avoided. If the child, on the contrary, be too fat, if it has been over- crammed with milk until it presents an appearance similar to that of the show calves, stuffed and swollen for exhibition at a fair, it should have diet of a far less nutritious kind. Farinaceous articles well diluted with water will be more suitable. 156 MORBID EFFECTS OF FIRST DENTITION. Milk, if fresh and sweet, generally agrees well with children ; but the milk of the cow is more nutritious than that of the mo- ther, and should be diluted. Cream freely diluted with water generally agrees better than milk. It is common among the rich to thicken the child's milk with arrow root, Ions les mois, or other concentrated farinaceous food. The consequence generally is that the parents are enabled to rejoice over fat babies, and soon to sorrow over sick ones. In- stead of making the milk of the cow more nutritious, it should be rendered less so than natural. It is rarely that articles of this kind, even when they are what they are represented to be, are fit for children. But this is rarely the case. Most of the arrow root, &c. of the shops is potato starch.* Some parents are in the habit of refusing children flesh of all kinds, and indulging them freely in milk and potatoes. The result generally is to fatten the children excessively, without providing them with a proportionate amount of muscular fibre. The child should have as much exercise in the open air as the circumstances of the parent will admit. All kinds of exercise seem to do it good. It is seldom fatigued even by very long rides, and rarely fails to acknowledge in its altered appearance the good effect of even an hour's exercise in the fields. Frequent bathing is of great use to children of all ages, but even this means requires to be administered with judgment. The cold bath is a powerful remedy, and cannot be used with equal safety and advantage upon all children. Those who are ruddy and robust will bear it well ; while others who are pallid and of cold skins may suffer serious injury from it. If after the bath the child shivers for a considerable time, and remains cool, and if it contracts a dread of the water, the temperature should be elevated to meet the condition of its sensibilities. Of course, in cold weather, the water should always be warmed in proportion to the necessities of the case. When dentition becomes complicated with morbid conditions, directly or indirectly connected with it, the management of it requires far more care and skill. The local symptoms are to be * If the milk require the addition of any farinaceous substance, I prefer rice flour. MORBID EFFECTS OF FIRST DENTITION. 157 allayed, serious symptomatic affections are- to be relieved, and the strength of the child to be supported through a tedious pro- cess, in which the powers of the system are taxed to their utmost capacity. A single mistake here will often prove fatal, and it is easy under such circumstances to make mistakes. The diseases of dentition are local, those which affect the teeth, gums and mouth — or sympathetic, those which manifest themselves in other organs. The local diseases of dentition are, first, inflammation of the gums. These are swollen, hot, redder than common and very sensitive. The child will not permit them to be touched, and incessantly craves the breast, or cold liquids. The condition of the gum is almost always attended with more or less fever and irritation of the intestinal canal. There is also an evident deter- mination of blood to the head. The face is flushed, the head hot, the eyes red and watery, the flow of saliva profuse, and some- times the salivary glands are swollen and tender. Aphthous exu- dations are often noticed, and it is said, though this must be very uncommon, that abscesses sometimes occur at the root of the tongue. The fever is generally ardent, and increases and subsides with remarkable suddenness. The thirst attending it is very great, and a strong tendency to irregular muscular contractions or convulsion is generally observed. The sleep of the child is uneasy and frequently interrupted. It frequently starts and screams, and when awake is usually fretful and stupid by turns. These symptoms are often very suddenly and effectually allayed by freely incising the gum and capsule down to the tooth or teeth, and liberating them from their investments. This ex- pedient is generally resorted to whenever the gum is elevated and distended , sometimes, however, it is of no avail, either be- cause it is not effectually done, or because the symptoms to be relieved do not in fact depend upon the mere mechanical pres- sure. The French writers make a formidable matter of this little operation; and indeed, as practised by some of them, it is no trifle, for they make a crucial incision upon the tooth and dis- sect up the flaps of the gum, or else, with a bistony, completely cut off the top of the gum. 158 MORBID EFFECTS OF FIRST DENTITION. There is no necessity for such painful and protracted opera- tions ; a free incision, until the lancet grates upon the tooth, is all that is necessary for the incisors; and when the double teeth are in question, a cross incision may be added. The lancet should be carried down to the tooth, or else no good will be done. The bleeding which results is trifling and salutary; tending to relieve the inflamed and swollen gum. It has been objected to this operation, that unless the tooth should be very near the surface, the incision would heal and the cicatrix would offer more resistance than the original structure of the gum. The fact is, however, that if such a cicatrix should occur, and the symptoms return, it would be very easy to divide the gum again ; moreover, a cicatrix is always a feeble tissue, which is far less resistant than the natural part whose loss it represents. Conjointly with the use of the gum-lancet, attention must be paid to the bowels of the child. If it be costive, the torpor of the bowels must be relieved by the administration of proper purgatives. Of these, calomel is for several reasons by far the most useful, and is equally safe, for occasional administration, with the most innocent of the class. In these conditions the abdominal secretions are always vicious, and we have no means so powerful as calomel for the restoration of impeded or altered secerning function. To a child of a year old, four, and to one of two years, eight grains should be given at a single dose ; and, if necessary, its cathartic effect insured by the subsequent administration of castor oil or magnesia. Small doses of calomel are ineffectual, and, if frequently re- peated, are dangerous. Should the bowels be too loose, and the passages thin and white, the same medicine similarly administered, or joined to a little rhubarb or chalk, will generally check the diarrhoea. In these cases, as where constipation exists, the fault seems to be in the deficit or altered secretion of the liver, which calomel restores. The fever will generally abate in proportion as the bowels are put right. Should it continue ardent, however, and especially if MORBID EFFECTS OF FIRST DENTITION. 159 the cerebral plethora should increase or remain unabated, a few leeches behind the ears will often prove serviceable. The cold bath, or sponging with cold water, will also allay the fever and restlessness. The warm bath may sometimes be preferable, and will be equally serviceable. Above all, country air, and exercise out of doors, are the best means of combating the disorders of dentition. " Very different," says Mr. Jay,* " was the practice of our forefathers, who, misled by the fanciful doctrine of signatures, were in the habit of applying to the gums specific ointments made of the brains of hares, or of the combs of cocks, which, as old Hartman would have us believe, ' cause the production of teeth without difficulty, and free from accidents."' It is questionable Whether we have much right to laugh at the metaphysical medicine of our ancestors : certainly our poster- ity will find abundant occasion to ridicule our own. We have yet to learn that any ancient theory or practice of cure was more utterly absurd than Homoeopathy or the cold water treatment. The doctrine of signatures is quite as philo- sophical as mesmerism, and the combs of cocks and brains of hares are certainly as efficacious as Hahneman's dilutions. Among the local diseases of complicated dentition we must enumerate caries of the tooth and abscess of the gum. When from any cause, local or constitutional, caries of the tooth takes place, it engenders inflammation of the periosteum, which soon extends to the gum. This becomes painful, swollen and tender ; an effusion of fluid takes place between the fang and its investing membrane, which thus becomes a sort of cyst or sac. Finally pus is formed, an abscess appears, and the matter is voided, either by a spontaneous or artificial opening. The continuance of the carious tooth as an irritant will, of course, prevent the proper healing of the ulcer, and the fungus, so common in carious ulcers, will shoot up. " In other cases the pressure of the abscess having produced absorption of a portion of the alveolar process at its lower part, it effuses its contents through the aperture thus formed, and the matter insinuates itself along the surface of the lower jaw, and * Cyclop, of Prac- Med., Art. Dentition. 160 MORBID EFFECTS OF FIRST DENTITION. forms an internal tumor near its base. This tumor is at first hard and discolored, but in the course of time it ultimately inflames, and bursting or being opened, leaves a puckering in the integu- ment, which, adhering to the bone, remains a permanent blem- ish. When the diseased tooth, which is the cause of the mis- chief, is removed before external redness takes place, the tumor ultimately retires, and leaves the skin unblemished."* A spongy condition of the gums, in which they bleed freely at the slightest touch, is sometimes observed in dentition. Ulcera- tion sometimes attends this condition. Weakened digestion and consequent imperfect preparation of chyle and insufficient nutri- tion, may be considered the cause of this affection. Treatment. — Inflammation of the gum may be very much abated by the application of a leech to it. In order to do this with facility, a thread may be passed by a needle through the ex- tremity of the animal, and it then may be enclosed in a glass tube. When the inflammation has subsided, the carious tooth should be extracted. Should an abscess occur from a similar cause, extraction must also be resorted to. Sponginess and ulceration of the gums, depending upon a de- praved digestion, must be met by such means as will restore the alimentary canal to the regular and complete performance of its functions. Mild astringent lotions, such as myrrhine and aluminous solu- tions, may be simultaneously employed. * Coleys' Diseases of Children. CHAPTER XIII. SYMPATHETIC DISEASES OF DENTITION. A vast number of diseases have been described by different authors, as the results of dentition. The recapitulation of them would show a crowded list of formidable complaints, from which it would seem that no child could escape. Dentition appears in this exhibition as the Pandora's box from which all manner of evils are successively let loose to worry and destroy the devoted infant. Without pretending to enumerate the forms of disorder attributed to teething, we offer the following as a specimen: Vomiting, anorexia, diarrhoea, cholera, costiveness, increased or diminished urine, urethral or vaginal discharge, with painful micturition ; dry cough, dyspnoea, catarrh, pneumonia, spasmo- dic affections of the face, limbs, glottis, &c., insomnia, agitation, and fright on awaking; epilepsy, somnolence, stertor, coma, tran- sient palsy of the arms and legs, ophthalmia, hydrocephalus, ma- rasmus, eruptions, especially about the head and face, swelling of the hands and feet, enlargement of the cervical, femoral and me- senteric glands, and other scrofulous affections. Although any of these disorders may, and all of them do occur during dentition, it does not by any means follow that teething is the cause of them. The mucous membranes of chil- dren are very liable to inflammatory affections, and their brain is very liable to sympathize with these and other disorders. Moreover, the process of dentition would certainly afford an awk- ward complication to any of these forms of disorder occurring simultaneously with it, or provoked by accident during the pro- gress of teething. No doubt also, dentition itself, especially if obstructed, or otherwise irregular or morbid, may become the exciting cause of any disorder to which the child may at the time happen to be most prone. 15 162 SYMPATHETIC DISEASES OF DENTITION. Should inflammatory affections of mucous membranes occur during dentition, the treatment should be regulated by the nature of the particular case, and the judgment of the physician. It would always be well, however, to examine the gums carefully, and to incise them freely if they be at all swollen. This can do no harm, and sometimes will result very happily. Very often, perhaps most frequently, the mucous affections are not inflammatory, but consist in a kind of morbidly increased sensi- bility, which we call irritation. The irritability of the stomach, the vomiting and purging are frequently of this kind, and would only be aggravated by antiphlogistic treatment. Proper purgatives, especially calomel : proper food, and suf- ficient exercise will be found to accomplish all or nearly all that art can do for the relief of such conditions. The cough which accompanies dentition is also due to the irritability of the mucous membrane, and need no special treat- ment. The inexperienced practitioner must be careful, however, not to confound this condition with proper catarrh or pneumonia. Children are liable to severe pulmonary disorders, which require the most prompt and vigorous treatment, and which it would always be serious and often fatal to neglect. The febrile disturbance, the quick, short respiration, the dis- tended nostril, and the indescribable, yet intelligible appearance of the little patient, will render mistake entirely unnecessary. The most serious complication of dentition is undoubtedly a gastro intestinal disorder, which has acquired the name of Cholera Infantum. This disease occurs only in hot weather, and is almost peculiar to cities. Occasional cases of it, however, occurring in warm, unsheltered places in the country, are sufficient to show that its urban character is dependent simply upon the heat of cities, which especially at night is very much greater than is experi- enced in rural situations, unless very unfavorably circumstanced. This disease seems closely connected with dentition, for al- though very young infants may be attacked by it, they are by no means so liable as those who have completed their first year. Hence the familiar danger of the child's " second summer." SYMPATHETIC DISEASES OF DENTITION. 163 The disorder usually commences by purging ; frequently as the immediate consequence of some indigestible substance taken into the stomach, but often without any known exciting cause. The matters passed at first are light green — presenting somewhat the appearance of chopped grass, and gradually becoming paler until they are of an extremely pale yellow or absolutely white. Vomiting, especially after swallowing liquids, generally attends the diarrhoea, and commonly fever of a fickle fluctuating charac- ter also occurs. The child emaciates very rapidly, and in a few weeks or days will be reduced to a mere skeleton, and be too feeble to stand alone. The brain and nervous system become torpid, the muscles relaxed, the child somnolent and stupid, and death, from cerebral congestion or convulsions, closes the scene, i The disease is sometimes acute and rapid in its development and progress, at other times chronic. The only medicinal agent which is uniformly beneficial in this disease is calomel. The nature of the alvine discharges evinces a deficiency or entire absence of bilious matter. A full purgative dose of calomel rarely fails to restore this secretion, and all the symptoms are alleviated by it. From the fact that this medicine can be given in small bulk, that it is almost tasteless, and that it will remain in the stomach which rejects all other drugs, it is peculiarly adapted to the con- dition in question. As this adaptation makes it the most availa- ble, it is exceedingly fortunate that its medical qualities make it by far the most efficient of remedies in this disease. Some writers recommend it to be given in small doses, fre- quently repeated, but while there is no advantage to be gained by this procedure, there is risk incurred of mercurializing the child ; which would generally be fatal to it. It is true that this rarely occurs; but some children have a peculiar constitutional sucepti- bility to mercurial action, and it is better to risk nothing unne- cessarily inr this respect. The dose which experience leads me to employ, is from five to ten grains, according to the age of the child and the con- dition of its sensibility. It may be repeated several times within a week or less, if necessary. 164 SYMPATHETIC DISEASES OF DENTITION. Alkaline medicines, soda, potassa, magnesia and chalk, are also useful in neutralizing acid, and, perhaps, also in correcting the disordered condition of the mucous membranes. A cautious, yet bold use of opium, will often render service which no other treatment will afford. It quiets the stomach, soothes irritation, checks the diarrhoea, and gives refreshing sleep. The great difficulty in the treatment of this disease arises from the fact that it is the result of causes which continue to act: so that the disorder is constantly reproduced. These causes are heat and dentition ; and it is often impossible to cure the child while the causes continue to act. In large well ventilated rooms it is often possible, even in cities, to procure for the child a temperature which is salutary ; but even under these circumstances it is not always possible to do so. When, therefore, the little patient is the child of poverty, imprisoned in the small room of a small house, shut up in a court or alley, it is almost impossible to rescue it from death. The most certain of all remedies is to take the child to the country. There proper medical treatment will rarely, or never, fail to cure the disease. Children in apparently the last degree of prostration are sometimes revived as by miracle, by the cool air of the country. But when we say country, we do not mean a hot room near the roof of an unshaded tavern fronting on a turnpike road, where numbers of sick children are shut up together, in a temperature perhaps higher than that of the spacious city mansions from which they have been hastily removed. Shade and green grass are essential. There must be no bare surface to reflect the heat, and there must be shade where the child may be exercised, and where it may be conveyed in the middle of the day, when coun- try houses are as warm, and often, from their size and construc- tion, warmer than city dwellings. Convulsions very frequently occur during dentition. They are of an epileptic character. The symptoms are a fixed stare and often distortion of the eyes, insensibility and frequent irregu- lar contraction and expansion of the muscles, generally of the SYMPATHETIC DISEASES OF DENTITION. 165 limbs and face. The jaws are firmly clenched, and the saliva is ejected in froth from the lips. This is a very frightful and generally very alarming affection, though not very often fatal. Convulsions during dentition may be excited by several causes. The first and the most common is the eating of crude and indi- gestible matters ; secondly, fever ; and thirdly, the irritation of the teeth themselves : often two, and sometimes all three of these causes act together. The convulsion generally passes off in a few minutes, but another will occur unless the cause be removed. Sometimes it will continue with little or no mitigation for hours, and some- times it continues until the death of the patient. In order to relieve the spasms, it is generally sufficient to put the extremi- ties in warm water and pour cold water on the head : if this do not speedily accomplish the end, more active means must be used, and such as look to the removal of the cause. If spontaneously, or by use of the bath, the convulsion sub- sides, we should carefully enquire into the cause of it. If the child has eaten anything, it should be immediately vomited, and indeed this can rarely be amiss, for it is often impossible to elicit the necessary information, until the presence of the ejected matters exhibits the cause of irritation. If the child have fever, it should be bled, in order to relieve the brain, which is suffering from the rapid circulation of blood through it. This may be done either by the lancet or by leeches. If the gum be swollen and tense, and the child seems to be suffering from this cause, a free incision will often relieve the tendency to spasm, by allaying the local, and with it the cerebral irritation. Finally, if the child be costive, its bowels should be imme- diately opened by injection, and subsequently by a purgative dose of calomel. Dr. Underwood describes a peculiar swelling of the hands and feet as a casual attendant upon dentition. He considered it, however, as rather beneficial than otherwise, as it ceased spon- taneously with the appearance of the teeth. 166 SYMPATHETIC DISEASES OF DENTITION. Cutaneous eruptions frequently occur during dentition, but they are of little consequence, as they spontaneously disappear, and, in some instances, may be considered as a salutary diversion made by nature for the relief of the brain. Sometimes, how- ever, they are so disagreeable, that some efforts are demanded for their relief. Most, or perhaps all of them, occur indepen- dently of dentition, and as a description of them would be tedious and, without plates, unsatisfactory, and as they are all fully described in works specially upon this subject, it will only be necessary to name them here ; so that the student may seek fur- ther information from writers upon cutaneous disease. The principal varieties are, an erythematous efflorescence behind the ears, called, in medical language, intertrigo : crusta lactea ; the several varieties of strophulus ; small phlyctenae, or blisters, and evanescent red spots. Although these eruptions occur frequently during dentition, they are by no means peculiar to this period, and it is difficult to show that they are necessarily connected with the cutting of the teeth. Intertrigo. This is a kind of erythemic or superficial inflammation of the skin, generally attended with some exudation of a semi- purulent matter, occurring behind the ears. When the two excoriated surfaces rub upon each other, the result is frequently a very ugly superficial ulcer. The disease can be readily cured by the use of absorbent or " drying" powders. All moist appli- cations do harm. A most valuable prescription for this and similar conditions of the skin is a powder composed of two parts of lapis calaminaris and one part of calomel rubbed together in a mortar. This is to be freely dusted upon the sore by means of a little raw cotton, several times a day. It will rarely fail of success. There is an opinion very prevalent that it is hazardous to dry up these eruptions, but there is no ground for this sup- position. SYMPATHETIC DISEASES OF DENTITION. 167 Crusta Lactea or Milk Crust, (Porrigo Larvalis.) This eruption appears with" white vesicles, speedily passing into dark-colored scabs, itching and ichorous, and frequently covering a large part of the face, head, and sometimes other parts. The eruption is very ugly and unpleasant, but is rarely inju- rious to the child. The little patient is generally plump and hearty. Indeed, the disease seems rather to depend upon a ple- thoric state, than upon any morbid condition of an important na- ture. The teething is not impeded by it. Crusta Lactea is often obstinate and of some months' duration. The only serious attendant upon the disease is the itching, which is sometimes so annoying to the child as to cause it to fall away, and become sallow, &c. No treatment is required, or, rather, none does it much good. The bowels should be kept free, and the itching allayed by warm bathing, lotions of weak spirit and water, and solutions of Sul. Zinc. Where there is much discharge from beneath the scabs, the drying powder already mentioned is a good application. As a general rule, the less we do to cure this affection the better. Time will certainly restore the child its natural skin; medicine might, and if persevered in, would destroy its appetite, tease its stomach, enfeeble its health, and, after all, produce no effect upon the eruption, except, perhaps, to make it worse. Strophulus, Tooth Rash, Red Gum. This is an eruption very common to nursing children. It consists of red or white and itchy papulae evolved upon the face and lower limbs, disappearing and returning, and ending generally in the throwing off of a kind of powdery desquamation. The papula; present differences in size and appearance, which have given origin to different designations. When vividly red, prominent, scattered over the cheeks, face, arms, and dorsal aspect of the hands, and intermingled with erythematous patches of varying extent, it is called Strophulus Intcrtinctus, (Rayer.) 168 SYMPATHETIC DISEASES OF DENTITION. When the papulae are white," large, and without surrounding redness of the base, the affection is called Strophulus Candidus, (Willan.) When the papulas are very thick, smaller and confluent, Wil- lan calls it Strophulus Confertus ; and, finally, S. Volaticits, when it occurs in circular patches, or clusters, here and there, on the surface. All these forms of strophulus may affect the child at the same time. It is not by any means a serious affection, though it sometimes torments the child by the itching it causes. To allay this, we may use the cold or warm bath, purgatives, and cool dressing ; for the sufferings of the child may be very unnecessarily aggra- vated by warm clothing, especially at night. The disease spontaneously declines, in a few days or weeks, leaving behind it no traces of its previous existence. Phlyclence, are vesications or blisters of different sizes, resem- bling scalds or burns. They soon disappear, and require no spe- cial treatment. There are a number of rashes seen during dentition, which it is not necessary for us to describe particularly. Scrofulous children are subject, during dentition, to the lymphatic disorders peculiar to their constitution, such as is manifested by the swelling of the cervical, inguinal and mesenteric glands. The treatment of these, and kindred affections, must turn upon the means of invigoration previously referred to when consider- ing the constitutional vice upon which they depend. Proper nutriment, exercise, clothing, &.c, will do all that can be expect- ed from external agents. Second Dentition. The cutting of the second set of teeth is commonly accom- plished without inconvenience, either of a local or constitutional character, with the exception of the wisdom teeth, which being often crowded, not unfrequently occasion a great deal of suffer- ing, such as acute local pain, inflammation of the gums and adja- cent tissues, fever, violent headach, ophthalmia, &c. This suffering has often been mistaken for that accompanying other SYMPATHETIC DISEASES OF DENTITION. 169 affections, such as neuralgia, intermittent fever, and rheumatism. Abscesses near the angle of the jaw may occur under these circumstances. Of course the treatment, under such circumstances, would be to liberate the impeded tooth by a free incision, or even, under certain conditions, to extract it. The inflammation of the soft parts must be combated, if necessary, by antiphlogistic means. Third Dentition. A number of well authenticated cases of partial and even com- plete dentition, occurring in very old persons, are recorded in the books. In one instance recorded in the Edinburgh Medi- cal Com., vol. iii. the subject of this late teething suffered very severely. The patient, in this instance, was sixty years old, and entirely toothless. At this time he experienced very severe pain in his gums and jaws, which at length amounted to excruciating tor- ture; but at the end of twenty-one days from the beginning of his sufferings, he was compensated by the appearance of a complete new set of teeth. With regard to the constitutional effects of this abnormal den- tition, Prof. Harris, who relates two cases of this kind as having occurred under his own observation, remarks : " It would seem that the efforts made by nature for the production of a third com- plete set of teeth, are usually so great, that they exhaust the remaining energies of the system ; for occurrences of this kind are generally soon followed by death." CHAPTER XIV. EFFECTS OF DISEASED TEETH AND GUMS UPON THE GENERAL HEALTH. That diseased conditions of the teeth and the structures ad- jacent to them, do exert a most pernicious influence upon the general health, is a fact as well established as any other medical observation ; yet the medical profession are, as yet, with very few exceptions, entirely unaware of it. We are not apprised that the subject is ever alluded to by lecturers on the practice of physic, when recapitulating to their classes the causes of functional disturbance and constitutional suffering; it is not noticed in the many text-books on practice; and, certainly, however frequently the physician may look into the mouths of his patients, it is very rarely that his comprehen- sive glance perceives any thing worthy of note in the decaying organs of mastication. It is full time that practitioners of medicine should perceive the importance of the teeth and of their diseases; but, until they do so, it is the more important that the dentist should be able to point out the causes of obscure disease, which the physician has in vain endeavored to discover, simply because he has sought for it every where but in the right place. It might be granted, a priori, that if physiological conditions of the teeth, owing to their peculiar position, association, and history, may exercise powerful influence upon the health of other organs, pathological conditions of these same teeth cannot be entirely harmless. Again, if we would examine the structure of a tooth, and perceive how completely its sensitive part is enclosed in an un- yielding bony case, we might readily infer from the consequences of compression in other parts, that the swollen and inflamed pulp, &c., would be exceedingly painful. If, too, we would regard EFFECTS OF DISEASED TEETH AND GUMS. 171 the close connection existing between the teeth, the rapidity with which the flash of sympathetic pain darts along the nervous cords which vitalize them, and the intolerable and protracted suffering which ensues, upon even trifling irritation of these sensitive fila- ments, and remember that pain itself is fully capable of derang- ing the whole economy, and inducing serious and fatal disorder, we might, without the aid of much reflection, adopt the very ra- tional conclusion that the diseases of the teeth must be of con- siderable consequence to the entire organization. We might, also, with similar propriety, conclude that the teeth were not made merely for ornament, and that mastication and insalivation are something more than mere forms of introduction to the sto- mach ; that they are important to digestion, which is important to the entireness of organs and the performance of function, and that if mastication, and the insalivation accompanying it, be im- perfectly performed, some corresponding imperfection of diges- tion must result. We might also infer, from the known con- sequences of long-continued morbid influences, however unim- portant in their immediate action, that disturbance of digestion, constantly repeated, must, in time, develope evils of a serious character. The old pathological maxim, "ubi irritatio ibi fluxus,"* is fraught with a valuable lesson to the medical practitioner. It is true that the nervous, and to a certain degree, even the vascular forces hurry to the part which throws out the signal of distress, and all the floating energies of the system are directed to the re- lief of the suffering. If it can be readily accomplished, the equilibrium of the system is soon restored and no perceptible in- convenience results. But if from the impracticable nature of the tissue or organ affected, but little relief can be given, and if the efforts of nature to accomplish cure or removal of the part, end only in accumulating about it an uncommon amount of sensibility, increasing the irritation and demanding yet more of constitutional effort to combat it, the consequence must be such a diversion of nervous influences from other parts as to weaken their force of action, and to embarrass their functions. • "Where there is irritation, to thai pari will l>o iru> flow." 172 EFFECTS OF DISEASED TEETH AND GUMS. In short, it is easy to understand that when the first movement towards constitutional derangement has been made, if the cause continue to act, each accession of morbid condition must aggra- vate and extend the evil, and hence it is that causes in them- selves very slight may, if long continued, from the influence of sympathy and the accident of relations, induce morbid conditions of the most serious character. The remarks of Mr. Koecker upon this point are so sensible and so well expressed, that no apology will be necessary for in- troducing them here at some length. Mr. Koecker observes that, " to form a more distinct concep- tion of the very powerful morbific influence which the diseases of the teeth and their contiguous parts must unavoidably pro- duce upon the general constitution, it is necessary to consider the peculiarity of the structure and functions of these parts. " The extremely hard and dense structure of the bony parts of the teelh, and the great arterial activity and nervous irritability of their lining membranes, which can so powerfully, and for so long a time, defend the teeth against general local and morbid in- fluences, are also causes of their producing very extensive morbid effects upon the whole system. The functions of the teeth as well as of the gums, when in a healthy state, act as powerful stimuli towards their preservation, but when these parts are dis- eased or affected with disorder of any kind, they become con- stant causes of irritation upon them as well as upon the general health. The bony structure of the teeth, however, having in itself but little self-restoring power, and their peculiar func- tions being much less favorable to this natural process than those of any other part of the body, and the teeth and their gums, periostea and sockets, being altogether dependent upon each other, this power is much more constantly and in a much higher degree required, and seems to be much more exerted by these than by any other structures, and the more these powerful efforts are incapable of curing the dental diseases, and resisted in their efforts to remove their causes, the more active is the constitution in its attempts to resist the progress of such diseases, whilst at the same time a considerable portion of general health and strength is consumed in the struggle. EFFECTS OF DISEASED TEETH AND GUMS. 173 " Diseases in the bony structure, and indeed of the teeth and gums generally, when yet in their incipient stage and without being influenced by any other causes than the local disorder itself, produce no greater constitutional effects than other local maladies; but with this difference, that their self-curative action is exerted in a proportion corresponding to the peculiar struc- ture, functions and relations of these parts, and therefore com- paratively much greater and longer continued than that produced by diseases of other parts or bones. In this state they proceed very slowly, and their morbid effects can only be detected by the most minute attention. " The genera] system, however, in the meantime being often disturbed, the caries will be found to proceed much faster to- wards the cavity of the teeth, and the inflammation of the gums to increase. In that event, any constitutional disorder is competent to aggravate the local one, whilst the latter, also, in its turn, greatly excites and augments the former. At this period it may be still taken as a general rule, that the morbid influences of general disease upon the dental maladies are more powerful than those of the teeth upon the general system. " The teeth having been deprived of their vitality by the de- struction of their lining membranes, are not only rendered use- less, but are converted into lifeless incumbrances upon the sys- tem, which produce, by their mechanical and chemical irritation, an action similar to that effected by gangrene or mortification in other bones, by means of which, nature attempts to throw off the dead part. " The parts surrounding such dead teeth, viz : gums, periostea, sockets and maxillary bones, are thus involved in serious disease, inflammation gradually extends over the whole of these parts, and a strong effort appears to be made to effect the expulsion of the decayed teeth, now become dead and offending bodies. But although nature might succeed in thus removing almost any other soft or hard part of the body of equal dimensions, in a few weeks or months, a space of from five to ten years, and some- times a much longer period is required for the removal, by the same natural power, of a dead tooth. "As long as the primary diseases are principally confined to the 174 EFFECTS OF DISEASED TEETH AND GUMS. teeth themselves, and in these instances where they are the prox- imate local causes of diseases of the mouth without supposing the existence of many dead stumps of teeth, so long may we look for those acute symptoms and effects which have been stated, and see them change alternately from one form of disease into another, but after that period, or when the local maladies having origi- nally commenced in the gums, periostea, alveoli and maxillary bones, shall have extended to a certain degree, a total transition into a permanent chronic state of the disease takes place. " In such a state of disease nature seems exclusively and actively engaged by producing inflammation and suppuration in extricating the mouth from all the morbid causes effecting the diseased parts, such as dead roots and stumps, tartar, and teeth which are loose or irregularly situated. The sanative power of nature, being however, very rarely competent to effect such a cure, the various diseases of the gums, periostea, alveoli, and maxillary bones are exasperated, and for the most part terminate in a state of suppuration and mortification." * When the chronic condition here described has been fairly reached in the progress of disease, the sensibility of the parts is much diminished ; the gums and periostea are thickened and callous, and ihe continual discharge sufficiently depletes the ves- sels, to relieve them of the suffering incident to inflammatory engorgement. All resistance to devastation of the dental arch, seems to cease, and the parts are abandoned to rapid destruction. In the meantime the patient congratulates himself that his teeth have ceased to ache, and consequently gives himself no trouble about them. Inflammation, suppuration and caries now spread along the dental arch until every tooth is broken down and every root has become a permanent irritant, provoking a constant puru- lent discharge from the soft parts about it. The food is no longer chewed, and everything which passes through the mouth is mixed with a vitiated compound of saliva, mucous, pus and blood, which descends to the stomach to mingle with the gastric juice and deteriorate the quality of that most important fluid. * Koecker, Princ. Dental Surgery. EFFECTS OF DISEASED TEETH AND GUMS. 175 The absorbents, too, are constantly at work, and the dissolved fragments of carious bone, &c, are constantly thrown into the current of the blood. The alveoli cannot escape the general ruin. Involved in the all-pervading inflammation, they also suppurate and break down, and not unfrequently the maxillary bones and the antrum are also involved in disease. Dyspeptic symptoms, marasmus, cough and other pectoral symptoms, violent neuralgic affections of the face, great nervous depression, hysterics or hypochondriasis, may be expected to attend such conditions of the teeth. The dyspepsia is easily accounted for. In the first place, the food is badly prepared for the stomach ; 2d, the fluids of the mouth, constantly trickling into the stomach, impair its tone and vitiate its solvent secretion ; and 3d, the continual demand made upon the system by the vain efforts which nature makes to cure the diseases of the teeth, and also by the frequent and severe pain, diminishes the nervous influence which the stomach re- ceives, and impairs its powers. Every one is aware that when the stomach is full, there takes place in that organ such a concentration of nervous energy as is sensibly felt by its loss, in other parts of the body. Hence the drowsiness and the indisposition to mental and physical effort experienced after a hearty meal. It is also well known that anything which attracts from the stomach this accumulated nervous power, impairs appetite and digestion. Extraordinary emotions, powerful intellectual efforts, venereal excesses, &c, all act in this way upon the digestive apparatus. Pain, also, wherever located, produces a similar effect, and the impairment from this cause will be important in proportion to the frequency and continuance of the suffering. In these several facts we have sufficient reasons for the indi- gestion which so frequently attends extensive diseases of the teeth. Marasmus, or gradual emaciation, is but a consequence of the insufficient nutrition attending dyspepsia. Cough and other pectoral symptoms, may result as the conse- quence of any prolonged irritation, especially if digestion be 176 EFFECTS OF DISEASED TEETH AND GUMS. impaired. The mucous membrane, of the larynx, trachea and lungs sympathizing with similar structures and participating in the common defect of nutrition. Neuralgic affections of the face, head and neck are occasioned by the continual irritation of the extremities of the dental nerves and the propagation of it to the trunk and branches of the great fifth pair or trifacial nerve. Depression of spirits, hysterics and hypochondriasis result from continual nervous irritation, and the debility of nerve which results from long-continued over-action. Indigestion also is a powerful cause of the melancholy or hysterical condition so often observed in these cases. Epilepsy and other affections not enumerated above, sometimes occur as the result of dental irritation, as will be shown by the following cases narrated by Dr. Rush (Med. Repos. vol. 6, 285 :) Case 1. " Some time in the month of October, 1801," says Dr. Rush, " I attended Miss O. C. with a rheumatism in her hip joint, which yielded for a while fo the several remedies for that disease. In the month of November it returned with great vio- lence, accompanied with a severe tooth-ache. Suspecting the rheumatic affection, was excited by the pain in her tooth, I di- rected it to be extracted. The rheumatism immediately left her hip, and she recovered in a [ew days. She has continued ever since to be free from it. " Soon after this I was consulted by Mrs. T. R., who had been affected for several weeks with dyspepsia and tooth ache. Her tooth, though no mark of decay appeared in it, was drawn by my advice. The next day she was relieved from her dis- tressing stomach complaints, and has continued ever since to enjoy good health : from the soundness of the external part of the tooth, and the adjoining gums, there was no reason to sus- pect a discharge of matter from it had produced the disease in the stomach." (Doubtless it was due to the irritation and the consequent deviation of nervous influence to the suffering parts.) Case 2. (Dr. Rush.) Some time in the year 1801, I was consulted by the father of a young gentleman in Baltimore, who had been affected with epilepsy. I inquired into the state of his teeth, (an enquiry which is even yet very unusual in such cases, EFFECTS OF DISEASED TEETH AND GUMS. 177 but which serves to shew the superiority of Dr. R. in judgment and comprehensiveness of thought,) and was informed that sev- eral of them in his upper jaw were very much decayed. I directed them to be extracted, and advised him afterwards to lose a few ounces of blood at any time when he felt the premonitory symptoms of a recurrence of his fits. He followed my advice, in consequence of which I had lately the pleasure of hearing from his brother that he was perfectly cured. In commenting upon these cases, Dr. Rush remarks : " I have been made happy by discovering that I have only added to the observations of other physicians in pointing out a connection between the extraction of decayed and diseased teeth, and the cure of general disease. Several cases of the ef- ficiency of that remedy in relieving headache and vertigo, are mentioned by Dr. Darwin. Dr. Gater relates that M. Petit, a celebrated French surgeon, had often cured intermittent fevers which had resisted the bark for months and even years, by this prescription." (These cases must have been merely irritative fever, appearing, as it generally does, with exacerbations depend- ing upon constantly recurring circumstances, such as the stimulus of light, food, exercise, &c. They were not true intermittents.) He also quotes from the work of Petit, two cases ; the one of consumption (apparently) the other of vertigo, both of long con- tinuance, which were suddenly cured by the extraction of two decayed teeth in the former, and of two supernumerary teeth in the latter case. In the second number of a late work entitled " Bibliotheque Germanique Medico Chirurgicale," there is an account by Dr. Seibold of a young woman who had been affected for several months with great inflammation, pain and ulcers in her right up- per and lower jaws, at the usual time of the appearance of the catamenia, which were always deficient in quantity. Upon in- specting the seats of these morbid affections, the doctor discov- ered several of the molares in both jaws to be decayed. He. directed them to be drawn, in consequence of which the woman was relieved of the monthly disease in her mouth, and after- wards had a regular discharge of her catamenia. These facts, continues Dr. Rush, though but little attended to, 17 178 EFFECTS OF DISEASED TEETH AND GUMS. should not surprise us, when we recollect how often the most distressing general diseases are brought on by very inconsiderate inlets of morbid excitement into the system. A small tumor concealed in the fleshy part of the leg, has been known to bring on epilepsy. A trifling wound with a splinter, or a nail, even after it has healed, has often induced a fatal tetanus. Worms in the bowels have produced internal dropsy of the brain, and a stone in the kidney has excited the most violent commotions in every part of the system. Many hundred facts of a similar nature are to be met with in the records of medicine.* When we consider how often the teeth, when decayed, are exposed to irritation from hot and cold drinks and aliments, from pressure, by mortification, and from the cold air, and how inti- mate the connection of the mouth is with the whole system, I am disposed to believe they are often unsuspected causes of general, and particularly of nervous, diseases. When we add to the list of these diseases the morbid effects of the acrid and putrid mat- ters which are sometimes discharged from carious teeth, or from ulcers in the gums, created by them; also the influence which both have in preventing perfect mastication, and the connection of that animal function with good health, I cannot help thinking that our success in the treatment of all chronic diseases would be very much promoted by directing our inquiries into the state of teeth in sick people, and by advising their extraction in every case in which they are decayed. It is not necessary that they should be attended with pain, in order to produce disease ; for splinters, tumors, and other irritants before mentioned, often bring * I met with a remarkable case of this kind a year ago. A wagoner between 40 and 50 years of age, a very athletic man, had been engaged on the day previous in lifting some logs of wood, and perceived a little blood upon his finger, though no wound could be seen. Early the next morn- ing he drove his wagon to the city, nine miles distant. On the road he suffered with intense pain in the finger, and when he reached the city, he was chilly, pale, and evidently laboring under great constitutional irrita- tion. The finger showed no wound. The pain increasing, he with con- siderable difficulty reached home. Erysipelas appeared, and he died in a few days. The season of the year, being winter, precludes the possibility of his hav- ing been bitten by a serpent. He was not intemperate in his habits. EFFECTS OF DISEASED TEETH AND GUMS. 179 on disease and death, when they give no pain, and are unsus- pected as causes of them. This translation of sensation and mo- tion to parts remote from the place where impressions are made, appears, in many instances, and seems to depend upon an original law of the animal economy." Tissot, who wrote nearly a century ago, had become aware, from observation, of the great importance of diseases of the teeth to the general health. He describes toothache as resulting from gout and rheumatism, as connected with disordered sto- mach, and as the result of the presence of noxious matters in the blood, which, according to the pathology of his day, was the mode of expressing what we mean by constitutional yices or disorders. He also mentions intermittent toothache, which he cured with Peruvian bark ; and neuralgic toothache, which was arrested by generous diet and wine. Modern medicine, or rather, medical writers, have retrogra- ded in some respects, however much they may congratulate themselves upon their progress in others. Microscopic soma- tology but poorly compensates for that close observation of liv- ing disease upon which our fathers deservedly laid so much stress. In the Dublin Medical Free Press, I find the following case recorded : — Case 3. Painful affection of the eye cured by extracting a tooth. — Dr. Emmeuch relates a case of this kind. A man con- sulted him on account of a painful affection of one of his eyes, which had lasted fourteen years, and occasioned great suffering. There was considerable vascularity of the conjunctiva and scle- rotica, especially around the cornea, which structure itself was somewhat opaque and spotted. There was a continual flow of tears, with pain, and intolerance of light. All these symptoms were greatly aggravated by any indiscretion in diet and the use of the slightest stimulus, such as a single glass of wine. All kinds of remedies had been tried in vain, at different times, and the affection seemed incurable. On examination of the upper jaw, Dr. E. found a carious tooth in the side corresponding to that of the affected eye. The portion of the jaw around the tooth was painful, and very sensitive to the touch. The patient 180 EFFECTS OF DISEASED TEETH AND GUMS. thought that the affection of the tooth had begun simultaneously with that of the eye. The tooth was drawn, and almost imme- diately afterwards the symptoms relating to the eye began to subside, and soon entirely disappeared. The affection of the eye was evidently the result of sympathy between the second and third branches of the fifth pair of nerves. Dr. Rush (Med. Inq. and Observations on the Diseases of the Mind, p. 33,) observes that " Irritation, from certain foreign matters retained in irritable parts of the body, is among the causes of insanity. 1 ' He adds, " I once knew some small shot which were lodged in the foot of a school-boy, induce madness, several years after he became a man. It (insanity) has been brought on, in one instance, by decayed teeth, which were not accompanied with pain." Mr. Koecker has published a number of cases, forcibly illus- trating the effect of diseases of the teeth upon the general health. From these we select the following : — Case 4. " Mrs. P., a lady of great respectabilty, under the medical care of Dr. Jule Rucco, of Leicester Square, had, some years since, continually suffered from dyspepsia, as well as from various kinds of nervous attacks of a very annoying and alarming nature. This judicious physician had for a long time suspected the cause, and frequently proposed to consult me. By the wish of the lady, however, the dentist of the family was at last sent for, and three or four teeth and roots were removed, which, ac- cording to the assertion of the dental attendant, were all that could be extracted. The disease, however, was only aggrava- ted by this interference, and the sufferings of the patient in- creased more and more. " About six months after, the doctor again urged a meeting with me on the subject, and at last I was sent for. I found the lady laboring under a complete salivation from an extraordinary sym- pathy of all the glands in any way connected with the teeth. On the previous night, and, indeed, for many nights preceding, she had been suffering such violent fits of convulsion as to alarm the whole family. The face was affected with an acute erysipelatous inflammation, accompanied with headache, as also with consider- able derangement of the digestive functions, such as sickness, EFFECTS OF DISEASED TEETH AND GUMS. 181 vomiting, loss of appetite, &c. By examining the mouth, I found that the previous dental treatment had been but very partial, and I proposed the removal of every tooth and root which produced irritation. " The lady consented immediately to my proposal, and the necessary operations were performed on the 8th of October, 1824, when nine decayed teeth, some of them mere roots, were extracted. The patient was requested to rinse her mouth fre- quently with a diluted astringent lotion. By this simple local treatment, and by the further medical care of Dr. Rucco, she was perfectly cured in about a week after the operation. " Very soon after her recovery, the lady was enabled to fulfil a promise of marriage which for some time had been prevented by her protracted and distressing disease. Since that period, she has enjoyed perfectly good health. The farther treatment of the case has, however, been delayed, on the accomplishment of which, of course, the permanency of the cure will depend." Case 5. A literary gentleman in the neighborhood of Lon- don had been for some years under the medical care of Mr. J. Derbyshire, of Greek Street, Soho, on account of a constant state of derangement of his digestion. Much sedentary occupation, and some excessive grief, had of late greatly augmented the distressing symptoms generally ac- companying this cruel disorder. His disease had assumed the character of hypochondriasis. His spirits were so dejected, and the state of his bodily health was so low, that he was no longer capable of attending to his ordinary business. Having had some conversations with Mr. Derbyshire on thje influence of disease of the teeth upon the general health, that gentleman was induced, at his next visit, to inquire into the state of his patient's teeth, and learning that they were in a very de- plorable condition, he proposed a consultation with me on the subject. After a particular examination, I found every tooth in the patient's mouth more or less carious, or dead, and all the gums and sockets in a very diseased state. On the 27th of May, 1824, twenty-one teeth and roots were extracted, all of which were more or less in a state of putrefac- 182 EFFECTS OF DISEASED TEETH AND GUMS. tion — three large grinders only excepted, which were either suffering from complicated caries, or producing morbid irritation upon the other parts, from some other causes. The mouth was restored to perfect health in the course of about six weeks. During the progress of treatment of the dis- eases of the mouth, the general health improved very surpris- ingly; and after the restoration of perfect health to all the re- maining teeth, and their relative parts, the patient enjoyed unin- terrupted good health, and returned to his ordinary professional avocations. Case. 6. The following is a letter which was handed to me (Mr. Koecker) hy Miss B., Manchester Street, London, in the beginning of the month of May, 1825. The history it gives is, perhaps, one of the most distressing cases of its kind, concern- ing a lady of great respectability and rank in Scotland, of about thirty-eight years of age. Its contents, indeed, are not less re- markable for the manner in which they display the uncommon fortitude of the unhappy sufferer, than for the striking confirma- tion which they give of the facts which I have detailed, as well as the description I have given, respecting the present state of dental surgery. Considering this evidence as most useful and important, I beg to submit to the reader the whole of the fair sufferer's most interesting and affecting communication. " My Dear I have been so ill since I wrote you last, that I have not been able to answer your kind letter. As I can express myself to you easier than to a stranger, I shall endeavor to give you some idea of my present state, and you can give my letter to Mr. Koecker. Constant faint gnawing pains in my gums, membrane of my mouth and cheeks, accompanied with considerable swelling of the latter, which are always blotched, inflamed and irritated, just in the way some people's faces are affected when suffering toothache ; my very nose is swelled and inflamed, and the muscles of the under part of my face so con- tracted and drawn upwards, that I cannot swallow any thing but liquids. My mouth is contracted and full of slimy saliva. In bed I have constant twitches in my gums, like what I could figure electricity. Sometimes my gums and face burn like fire, EFFECTS OF DISEASED TEETH AND GUMS. 183 and sometimes feel as if every nerve and blood-vessel were filled with ice, and the sheets near my mouth are wet with saliva. All these sensations often run down behind my ears, to my neck and arms; and at these times I have a great hurry and agitation of spirits, and aching across the breast and heart. To me, one of my greatest tortures is the extraordinary inflation of gums, particularly towards the roof of my mouth. They feel as if they absolutely tore from the bone, hove up, as it were, with the wind, and my jaws feel twice too large for my mouth, the pres- sure against my face is such. The same sensation often proceeds to my cheek bones, which increases the swelling of the muscles and the dragging up of the under jaw. " I must now go back in my history, that Mr. Koecker may know the progress of the last five years of my continued misery. But, unluckily, I fear it is impossible to make any one under- stand my sufferings, they are so various and complicated. You know I always blamed my teeth as the cause of all my sufferings; but I am now convinced that the disease is in my gums and remains of the alveolar processes; and as I was told that was a part of his profession Mr. Koecker was supposed to be very skilful in, it makes me very anxious to have his opinion. You will remember how long (many months) the sockets of my large molar teeth stood open, and even when they did heal up, the gums were full of morbid sensibility. When I last saw you, I had only about five front teeth remaining, and eight below. About 1818 they began to ache a little, and, as usual, to irritate and inflame my cheeks. The five upper ones began to spoil ; but I fought on with them until the winter of 1819, when the inflammation, and the various sensations I have mentioned before as now suffering, increasing, and the teeth themselves aching, I had them pulled. The gums swelled and inflamed most dread- fully, the horrid sensations in the roof of my mouth increased, and my face was as bad as ever. In about a month the wounds healed, but the gums remained swelled and became a hard white gristle. After suffering for many months, I had the gums opened. They were so hard and thick, the dentist said they were like bone. The sockets were not the least absorbed ; of course, rough, and in some parts exfoliated. 184 EFFECTS OF DISEASED TEETH AND GUMS. " The gums were kept open near a month, and caustic applied to excite absorption. In the course of this process the point of a tooth was discovered in one of the sockets, and extracted. It was a full grown eye-tooth, which, for want of room, had never made its way down. I was easier as long as the gums were open; but just where I was, when they healed up and resumed their state. " Some months after this, my under jaw became affected; the teeth were not spoiled, but became so painful to the touch, that I could bear nothing in my mouth to touch them. My lips be- came very tremulous, and my hands trembled so that I could neither feed nor dress myself. When warm in bed they ceased ; but from the moment I rose and began to speak, or let the air into my mouth, I never ceased trembling, and the dry wretchings (which you remember how tortured I used to be with) increased so as to bring on vomiting. I suffered in this way for eleven weeks, when, in despair, I had all my remaining teeth pulled. The tremblings and wretchings quickly abated, and in a few weeks completely left me, and I have never had them since. My under gums, even before the teeth were pulled, were a hard gristle, and almost as white as the teeth. My gums have been often opened to give me relief, but as nothing will induce them to suppurate, I get no advantage, the wounding only increas- ing the hardness. " These gums seem to me to act as levers, pressing on the nerves and blood-vessels, and keeping up a constant irritation and in- flammation in my mouth and face. " Under an idea that my complaint proceeded from neuralgia, I was advised to have the mental nerves divided at the chin, which did no good, and has created such hard tumors on these places, that I think their pressure on the side of the jaw is the cause of the twitching pain of my under lip, and the contraction of the muscles. " I would take it as a great favor if Mr. Koecker would say whether he thinks he could be of any use to me here, until I am able (which, alas ! I fear I am not,) to come to London ; or if he could give me any advice which I might desire to be done here ; and if he will be so very good as to mention what are the EFFECTS OF DISEASED TEETH AND GUMS. 185 different kinds of diseases he has ever met with in the gums or alveolar processes, and his mode of treatment. There seems to be an idea here that if the sockets are not carious, there can be no disease there ; but I think Fox mentions otherwise. " My upper gums had not been touched for four years, until a week ago, when a part was opened that was very troubl esome and much swelled. The bone was full of points and inequalities, and rough ; sounding gritty, like sand. There was a great deal of thick slime, like the white of egg, mixed with blood. Some nitrous acid was put upon the wound, to try to keep it open a little, but in vain. It is already covered with a new gum, and the old thick parts gaping open. I am sure if these old swelled gums could be got away, I should suffer less. " I should think there is about the eighth of an inch of the socket remaining. The ridge of the under jaw is as sharp as a knife, and so painful to the touch, when I press it, that it makes my face, ears, and neck burn. My lips are painful, and are drawn in. I was advised to try false teeth, but they increased my sufferings ten-fold, which is very hard, as the clinching of my jaws adds much to my sufferings. My eyes are beginning to be much affected, which must plead my apology to Mr. Koecker for this sad scrawl, which I think you will need to help him to decipher. " There are various opinions about my complaint. One says it is a nervous complaint at the origin of the nerves, affecting the extremities of these nerves ; others say it is a nervous affection of the dental nerves and their ramifications on the face ; and others are of opinion it is an affection of the covering of the bone. I am satisfied it is some disease of the antrum. Could it injure me to have the antrum opened to ease my mind ? There is one place where I think there is part of a fang of a tooth, which I am certain was broken, as the dentist burnt the tooth without letting me see it; perhaps that may torment me." Mr. Koecker gives no opinion upon this case; but the lady seems to me to have had more discernment than her professional advisers. The disease was probably seated in the antrum, and very likely the fragment of fang was the irritating cause. 18 186 EFFECTS OF DISEASED TEETH AND GUMS. The following cases are reported by Dr. C. A. Harris : — Case 7. "In September, 1830, I was consulted by Mr. , at that time a resident of New York. Before I examined his teeth, he informed me that his general health had been very bad for four or five years past, and that he had applied to some of the most eminent physicians of New York, Troy, and Albany, but had not obtained any permanent relief from his sufferings. " The character of the symptoms that prevailed at this time was very peculiar. His digestive organs were so much de- ranged, that he was obliged to observe the strictest regimen, and confine himself to the simplest kind of vegetable food. Besides the dyspeptic affection with which he was troubled, he had severe paroxysms of headache and vomiting, that recurred at regular intervals of from four to five weeks. These were always preceded by numbness, which commenced in his tongue and ex- tended thence throughout the whole system. This sensation con- tinued usually for about two hours, when it was succeeded by a violent pain in the head and partial vertigo, from which, in about ten hours, he was relieved by vomiting. The effects of these paroxysms lasted about ten days, and the other symptoms had continued, without much mitigation, for three years. " On examining his mouth, I gave it as my opinion that the dis- eased state of his teeth 'was the cause of his affliction. This idea, though entirely novel to him, he was disposed to believe correct, and therefore readily consented to the treatment I prescribed. Many of his teeth were much decayed, and nearly all of them covered with tartar. The roots of some were de- nuded of the gums, the alveolar processes more or less absorbed, the gums turgescent, fungoid, bleeding on the slightest touch, and of a dark red color. The secretions of the mouth were viscid, and their exhalations exceedingly offensive. " Such of his teeth as could not be perfectly restored were ex- tracted, and as much tartar was taken away as could be con- veniently removed at one time, and the rest at subsequent sittings. His gums were freely scarified, and a tonic astringent and deter- gent wash directed to be used three or four times every day. Under this treatment the local affection of the mouth rapidly dis- appeared, and in about four or five weeks his teeth and gums EFFECTS OF DISEASED TEETH AND GUMS. 187 became perfectly healthy. His general health also began to im- prove, and in about two months it was perfectly restored, and has so continued." Dr. S , a distinguished surgeon and physician of Virginia, reports the two cases following: — Case 8. " Mrs. S , a lady of thirty or thirty-five years of age, with several children, in easy circumstances, rather delicate and of sedentary habits, complained of derangement in the func- tions of the digestive organs, with much nervous disorder, and a painful sensation about the head, as if there were a pound weight on the top of it, with an occasional tightening of the scalp. This last sensation, she compared to that which might be expected from having the scalp forcibly drawn together on the vertex by the clawing of some animal with talons, as a hawk. Her friends, at first, thought but little of her complaints, and from their eccen- tricity were inclined to believe them, for the most part, imaginary. The affection of the head, however, and the sensitiveness of the nervous system, evidently increased, until they became so harass- ing and acute, that they deprived her of rest and made manifest inroads upon her healthful appearance. M Medical advice having been now obtained, a regular and care- fully directed course of purgatives was prescribed, but with little or no advantage. The cathartics having been discontinued, the Rub. Ferri, Bark, Valerian, Mineral Acids, Zinc, Assafcetida, &.c, were next tried, to which were added frictions and tepid salt baths, but still without any material amendment. " She now began to have evident exacerbations of fever towards evening, which passed off with copious and debilitating sweats that much reduced her, and caused her countenance to assume a sickly aspect. She visited the watering places in Virginia, but though her strength was somewhat recruited, the distressing symptoms, with some slight modifications, still continued. She was occasionally confined to the house, but generally was able to take some slight exercise in the open air. " This state of things had continued for eighteen months, when the attention of her physician was called to an abscess formed near the root of one of her incisor teeth. This brought about an in- quiry into the general state of the teeth, of which the following is the result : 188 EFFECTS OF DISEASED TEETH AND GUMS. " Mrs. S , at. an early period had bad teeth, which, since her marriage, had been gradually growing worse. A few years before the time of which 1 speak, two of the incisors of the upper jaw were clipped off" close to the sockets, and artificial teeth were inserted on the fangs. Much pain, irritation, and swelling of the gums and lips followed the operation, and similar symp- toms occasionally occurred for a year or two afterwards, and were frequently attended with alveolar abscesses. The remaining in- cisors of the upper jaw and several of the inferior and superior molar teeth were found to be in a dilapidated state. The alveolar processes of several of the inferior molars were partially de- stroyed, and one or two of their roots were turned on one side and clung" to the alveoli by the remaining integuments. " The situation of the mouth rendered it quite probable that the ill health of the patient arose from the irritation produced by the bad state of her teeth ; the more so, as her nervous system was exceedingly sensitive. She was persuaded to have the carious incisors and the worst of the molars removed, and, a short time after this was done, her health began to improve. The affection of the head and scalp soon ceased, the nervous symptoms van- ished, and she is now in good health and has a set of teeth deci- dedly more ornamental than those given her by nature ever were. The speedy restoration of her health after the removal of her diseased teeth, justifies the conclusion that her bad health depended on the bad state in which these organs were found." The following case, related by the same gentleman, is particu- larly worthy of attention as showing the terrible consequences which may result from ignorance of the effects which disease of the teeth, or even of a single tooth, is capable of producing in subjects of certain constitutions : Case 9. " Miss W , a maiden lady of about fifty years of age, in comfortable circumstances, and for the most part sedentary of habit, had suffered much from pain in the right cheek. For some time it was not considered of much moment, but, on its continuance, a physician was consulted. " He found but a single tooth, one of the second molars, in the superior maxillary of the affected side, and that was in a semi- decayed state. The gums above the teeth, and for half an inch EFFECTS OF DISEASED TEETH AND GUMS. 189 on each side of it, were much swollen and of a livid redness. The tumor seemed spongoid and puffy to the touch, but there was neither fluctuation nor abscess. The patient's health had not sensibly deteriorated. She said the tumor on the gums had existed for many weeks, but had not been attended with any remarkable pain until the occurrence of that of which she com- plained. She described it as being deep in the cheek and gen- erally dull, but now and then, for an instant, sharp and lancinating. She said the tooth for several years past, had been accustomed to ache occasionally, but that, notwithstanding its decayed state it was very useful, and she had therefore declined having it extracted. " The immediate extraction of the tooth was, however, thought advisable, and with her consent, it was effected. A week after- wards the spongy tumor of the gum continued, without any abatement of the pain in the cheek. The tumor was now laid open with a lancet. It contained no matter, but was filled with those shaggy or shreddy fungi which are often seen to occupy tumors or diseased bones. An abscess or some other affection of the antrum was suspected. A perforation was therefore made in its cavity and about a table-spoonful of very dark brown matter discharged, which gave the silver spoon into which it was re- ceived a thin coat of the blackest pigment, and, on account of its offensive smell, was almost insupportable. There was a difficulty in reaching the disease with remedies, and it was thought advisable to enlarge the communication with the antrum. The crown of a small trephine was accordingly applied to the alveolar portion of the superior maxillary, the soft parts having been first dissected up, and a corresponding portion of the bone was removed. The end of the little finger could now be introduced into the antrum, the inner surface of which, it was easy to perceive, had, at several points, been denuded of the pituitary membrane and of the periosteum. " The disease was now fairly exposed, and nothing could ex- ceed the offensiveness of its fetor when not corrected by suitable dressings. The usual anti-scptics and detergents were locally applied, while tonics and a generous diet were prescribed to sus- tain the patient's general health, and every effort was made to 190 EFFECTS OF DISEASED TEETH AND GUMS. substitute a healthy purulent secretion for the ill-conditioned and offensive discharge from the antrum, but without any effect. " An irremediable necrosis seemed to have taken possession of the superior maxillary of the affected side, which soon began to come away by piece-meal. In the meantime the soft parts about it were laid waste by the phagedenic character of the ulceration, and the eye of the same side became seriously affected. The disease now progressed rapidly. The perforation of the antrum was made on the 11th of March, 1821, and on the 26th of May following, the patient was found in a perfect state of apoplexy, the disease having penetrated the basis of the cranium and seized upon the brain itself. On the 30th of the same month she ex- pired, and was thus released by death from the most horrible disease that can be conceived, but which had its origin in nothing more extraordinary than a neglected carious tooth." Phthisis Pulmonalis induced by Dental Irritation. Dr. M , an eminent practitioner of this State, reports the following extraordinary case : Case 10. " In the summer of 1834, I was called to visit Mr. D. M , who had come into this neighborhood to obtain the benefit of the country air, having resided in Baltimore from his earliest youth. When I saw him he was in the last stage of phthisis pulmonalis. He gave me the following history of his case : " About eight years previous he felt a soreness and tumefaction in his gum at the posterior part of his mouth, and as he had never cut the dentes sapienliae, he thought the disquietude was occa- sioned by the progress of one of these teeth, and in consequence gave it no attention until the soreness and inflammation had ex- tended themselves over the whole surface of his mouth and fauces. The tooth not having protruded through the gum, he consulted his family physician, who advised immediate extrac- tion. " In conformity with this advice, he called on an eminent dentist of Baltimore, but the tooth not having presented itself and the cause of his suffering being doubted, the operation was deferred. EFFECTS OF DISEASED TEETH AND GUMS. 191 His sufferings, however, having become intolerable and the irrita- tion having extended itself to the lungs, producing considerable uneasiness, he determined, if it were at all possible, to have the tooth removed. A few days after, he stated his determination to the dentist. The gum was freely split, and after considerable pain and difficulty, the tooth extracted. The inflammation in his mouth and fauces immediately subsided, his appetite returned, and his general health soon became as good as formerly. " About three years subsequent to this, his mouth and fauces, under similar circumstances, and from the same cause, became very sore and painful. The inflammation soon reached the lungs and established a confirmed phthisis pulmonalis. He died a few weeks after my first visit." The subject of this case was doubtless the victim of tubercu- lar disease of the lungs. The tubercles were latent until the dental irritation was propagated to them, when inflammation and softening rapidly ensued. The teeth, though they did not, strictly speaking, cause the consumption, evidently precipitated it and perhaps anticipated the fatal development by many years. The same physician, to whom we are indebted for the preceding case, has recorded another, in which the fatal result was more directly attributable to dental suffering. He says : Case 11. "My friend, Dr. L , of Frederick, Md., was called to visit a young gentleman who labored under violent pain of the face and inferior maxillary, with very great tumefaction of the gums. His sufferings were traced to the roots of one of his molar teeth, which had been broken in an attempt to extract it. His gums and the glands of his throat became so much enlarged, that it was impossible to remove the offending portion of the tooth. The inflammation, notwithstanding the skilful exertions of the physician, rapidly increased, high and intractable fever super- vened, deglutition became totally obstructed, and, in a few days, he died." Case 12. A case very similar to the last, though more for- tunate in its results, came within my knowledge lately. A den- tist was applied to to extract a molar tooth, which he did. He told the patient that the tooth had come out entire; and dismissed him. Violent inflammation ensued, a large abscess formed, and 192 EFFECTS OF DISEASED TEETH AND GUMS. the life of the man was brought into imminent jeopardy. His physician called in a surgeon, and both being baffled, an eminent dentist was consulted. He suspected that a fragment of the root had been left , and after great difficulty, owing to the swel- ling of the parts, he succeeded in extracting it, and saving the life of the patient. Dr. Fitch, in his " System of Dental Surgery," narrates a number of cases of constitutional disease, evidently caused by the protracted irritation incident to diseased conditions of the teeth and gums, from which I select the following : — Case 13. "In February, 1827, Dr. Samuel Jackson called and requested me to see Mrs. It , living in Tenth above Walnut street, who, he said, was laboring under every symptom of confirmed phthisis pulmonalis, and also appeared to suffer greatly from a diseased state, of her mouth. I, accordingly, called on Mrs. R . The following were her symptoms. Great emaciation, hectic fever, almost constant cough, nearly a total loss of voice, articulation being extremely difficult, the voice as if speaking through a trumpet. Dr. Jackson said that in the practice of seven years in the hospital, almshouse, and private practice, he had never seen a person recover from the symptoms under which Mrs. R labored. " The following was the condition of Mrs. R 's mouth. About two years before she had the upper wisdom-tooth of the left side plugged, and the plug was pounded in by a mallet and punch. The fangs of the tooth converged together so as to form a fang of a conical shape. In hammering in the plug the socket was much injured. A chronic inflammation took place, which passed back over the palate, half arches, and some distance down the aesophagus, also over the glottis, epiglottis, and larynx. It then traveled forwards on the right side of the under jaw, and caused to inflame and slough away all the sockets and teeth of the lower jaw but one, which was the left dens sapientias. When I first saw Mrs. R the process of inflammation, sloughing, and gangrene was at its height. Extensive exfoliations of the jaw were taking place. Dr. Jackson and myself concluded that the patient could not live more than four weeks. EFFECTS OF DISEASED TEETH AND GUMS. 193 " Treatment. I at once removed all the teeth that were loose, and whose sockets were in a state of gangrene and exfoliation. I likewise, as fast as possible, removed all the dead bone, and directed the patient to wash her mouth constantly with a strong infusion of powdered galls. In about eighteen days her mouth was perfectly well. The amendment of her general health was surprisingly rapid. In five weeks she was able to take long walks in the street, and in six months she was restored to perfect health. Nearly six years have passed away, and she still con- tinues perfectly well." As a corollary to this case, Dr. Fitch very properly observes : I I think we may safely infer, although diseased teeth do not, in every instance, excite general diseases of the system and of the lungs, yet, like an insidious enemy, they are ever ready to unite with or exasperate other causes, so as finally to undermine the powers of the system. I would earnestly solicit the atten- tion of the medical faculty in general to a critical inquiry into the state of the teeth in all cases of pulmonary affection, and there is hardly a doubt that their inquiries would result in the general conclusion that a diseased state of the teeth and gums do very frequently excite pulmonary affections, especially in per- sons predisposed to them, and always aggravate these com- plaints, let them be excited by whatever cause they may." Professor Chapman, of the University of Pennsylvania, in his lectures related the following case : — Case 14. " Some years since a lady came from a distant part of the country to this city, in pursuit of medical aid, and placed herself under the care of Dr. Chapman. He found her laboring under every symptom of obstinate dyspepsia, by which her health and strength were greatly impaired. His correct and well known acumen in the pathology of disease immediately led him to inquire into the state of her gums and teeth. He found her gums in a high state of inflammation, and many of her teeth loose and diseased. By the direction of Dr. Chapman she applied to one of our most respectable dentists, and had her mouth and teeth placed in a healthy condition, and with the return of health in her teeth, gums, &c, every dyspeptic symp- tom left her, and she became quite well. 10 194 EFFECTS OF DISEASED TEETH AND GUMS. " After some time had elapsed, and the lady's health seemed confirmed, she had a few artificial teeth placed in her mouth to supply some which she had lost, which, either from not being well adapted and properly inserted in her mouth, or from some peculiarity in the lady's constitution, proved a source of irrita- tion, and brought on a return of the distressing dyspeptic symp- toms, which compelled her to dispense entirely with the artifi- cial teeth, when her health was again completely restored." The celebrated Baglivi observes that " Persons whose teeth are in an unclean and viscid state, though daily washed, have universally a weak stomach, bad digestion, and offensive breath, headache after meals, generally bad health and low spirits. If engaged in business or study they are irritable and impatient, and are often seized with dizziness. From weakness of the stomach they are naturally somnolent, scarcely wakeful in the morning, and never satisfied with sleep." Hufeland enumerates sound teeth among the signs of long life. " For good digestion," he says, " good teeth are extremely necessary, and one, therefore, may consider them among the essential properties requisite for long life : and in two points of view — First, good and strong teeth are always a sign of a sound, strong constitution and good juices. Those who lose their teeth early, have, in a certain measure, taken possession of the other world, with a part of their bodies. Secondly, the teeth are a great help to digestion, and, consequently, to restoration." Mr. Liston observes :* " From the presence of carious teeth, or decayed portions of teeth, many evils, both local and general, ensue, besides inflammation and abscess. They are frequently the cause, and the sole cause, of violent and continued head- aches; of glandular swellings in the neck, terminating in, or combined with, abscess; of enlargement and inflammation of the tonsils, either chronic or acute; of ulcerations of the tongue and lips, often assuming a malignant action from continued irritation ; of painful feelings in the face, tic-doloureux, pains in the tongue, jaws, &c; of disordered stomach from affection of the nerves, or *Liston's Surgery. EFFECTS OF DISEASED TEETH AND GUMS. 195 from imperfect mastication ; of continued constitutional irritation, which may give rise to serious diseases." Case 15. (Dr. Fitch.) "Mrs. S , aged about 38 years, was sent to me, by one of our most eminent physicians, with a" request that I would examine her teeth, and perform such opera- tions upon them as I judged proper, to render them and the gums healthy. The state of this lady's health was miserable ; she was harassed by the most distressing symptoms of dyspepsia. Her digestion was very imperfect, the stomach irritated, loss of appe- tite, and a most melancholy depression of spirits. When she first called it was necessary for her to repose herself for some time, before she could have her mouth examined. ; ' Upon examining her teeth and gums, I found nearly all the former in a state of disease, and the latter were in a state of sup- puration, much inflamed and swollen. A considerable deposit of tartar was formed around the necks of the teeth; in several in- stances their fangs were denuded of the gum by the deposit of tartar, and, in fine, her mouth was in a general state of disease. I need not detail the several operations by which her mouth and teeth were rendered healthy. Suffice it to say, that in about four weeks her mouth was perfectly well. The amendment of the general health, after the first operations were performed on her teeth, was almost surprising, and would have been entirely so to any person not acquainted with the immense sympathy be- tween the mouth, gums, &c, and the stomach. " Within five weeks after I saw her, every vestige of disease in her digestive organs left her, and she was apparently in per- fect health." Case 16. Neuralgia from diseased teeth. — (Prof. Harris.) " The following is one of the many cases of tic-douloureux or neuralgia faciei, produced by disordered teeth, that have come under my own observation. " The subject of it was a lady about forty years, of sedentary habits, and naturally of rather a nervous temperament. For sev- eral years she had been alllicted at times with a most distressing and painful affection of her face, which was pronounced by her physician to be tic-douloureux. The pain was sometimes so acute and lancinating that it almost deprived her of reason. It 196 EFFECTS OF DISEASED TEETH AND GUMS. generally commenced near or a little anterior to the angle of the superior maxillary bone, thence it darted across the face to the alee of the nose and then to the temple, forehead and angle of the eye, accompanied with frequent and sudden transitions from one side to the other, twitching and tremors of the muscles of the affected parts and with a preternatural flow of saliva. Her face, and sometimes the whole of her head, were rendered so sore by these paroxysms, that the slightest touch would produce pain. " These paroxysms, although they were generally of short dura- tion, frequently recurred as often as ten or fifteen times in twenty- four hours, and sometimes lasted ten, sixteen, and even twenty days, after which they would gradually subside, having subjected her during their continuance to the greatest misery and leaving after their subsidence a dull, heavy pain in one or both jaws. A sensation similar to this was always (especially in the right side of the upper jaw) experienced several days before one of these attacks, which often enabled her physician to ward them off, and finally led to the detection of their cause. These spasms were more severe and occurred more frequently in cold, damp and wet than in warm and dry weather. " Bark, quinine, carb. ferri, stramonium, belladonna, and vari- ous other tonics and antispasmodics were prescribed, but without any apparent beneficial effect. Leeching, sinapisms and epispas- tics were also of no avail. As a last resort, it was determined to divide the affected nerve, but before the operation the physi- cian was induced by the pain in the jaws, always preceding these paroxysms, to examine the condition of the patient's teeth. The examination showed them to be in a very unhealthy state. The molares generally, and especially those on the right side, were involved in complicated caries. The gums were much tumefied and inflamed, and the gums sensitive. " Her teeth and gums, from the diseased condition in which they were found, were immediately supposed to have some agency in producing the affection of the face. A consultation with me was therefore proposed, and I was requested to visit her. " On examining her teeth, I found that eleven were so much decayed as to render their restoration impracticable. It was therefore determined to remove them immediately, but it was not EFFECTS OF DISEASED TEETH AND GUiMS. 197 thought proper, owing to her extreme debility and the state of her nervous system, that more • than two or three should be extracted at one time. " So great was her agitation at the mere thought of the opera- tion, that notwithstanding the agony she suffered, she could not, on my first visit, be persuaded to have even a single tooth ex- tracted, but requested me to call on the next day, when she promised she would submit to the removal of as many as she possibly could. " I accordingly called on the following day, and to the aston- ishment of her friends, she allowed all her jaw teeth that were carious, eleven in number, to be at once extracted. The opera- tion at once revealed the cause of her disease. The roots of three of these teeth were very much enlarged by bony deposi- tions. One of the fangs, was, at its extremity, about the size of a pea. Those of the other two were not quite so large, but a disposition to exostosis was manifested by all. With the removal of these teeth, all symptoms of pain entirely vanished, nor have they, to my knowledge, returned since." Case 17. Death caused by the extraction of a tooth. — (Jour- dain.) " A citizen having submitted to the extraction of a tooth, the gums became gangrenous ; the gangrene reached the brain and caused death." The same author reports a case of Case 18. " Convulsions and death caused by the shortening of a tooth longer than the others. A nun of Padua having had a tooth shortened in order to get rid of the deformity, died imme- diately in an epileptic convulsion. A small fragment of nerve was discovered in the section of the tooth." This case and others which fortunately have not terminated so seriously, should be a warning to all operators upon the teeth, not to inflict sudden and violent pangs. Experience shows us that a great amount of pain can be endured, if slowly and gradually inflicted, while instinct teaches us all to dread sudden pangs, even of more moderate intensity. Even in extracting a tooth, it is better to operate gradually rather than to wrench it out with a sudden and violent effort. If pain be gradually in- flicted, the nervous system, conscious of the coming trial, sum- mons up all its powers of endurance ; but when taken by surprise, 198 EFFECTS OF DISEASED TEETH AND GUMS. the shock is severely felt and the consequences may even be fatal, as in the case just quoted. Pain is a great evil. It should never be inflicted unnecessarily, and when necessity occurs, the inflictor should use all possible means to render the suffering as tolerable as possible. Moreover, there is great difference in individuals as to the tolerance of pain; even as to the perception of it. Many persons will suffer terribly from operations which would not cause serious pain to others. The same persons will suffer much more at one time than an- other. All these considerations are well worthy the attention of the dentist. Very severe headache of the neuralgic kind, is frequently caused by diseases of the teeth and by the irritation produced by the presence of dead roots in the jaw. In illustration of this, I will quote a few from many cases : Case 19. " Inveterate headache cured by the extraction of many roots of cariotis teeth. — (Fabricus Hildanus.) A lady was afflicted with a very severe continued pain in the left side of her head. The violence of the pain was chiefly experienced in cold damp weather. By the advice of her physicians, she had tried a great many remedies, internal and external, but without success. Finally, I was called to see her. I carefully examined all the causes of her malady. I learned from her that for six months she was afflicted with an agonizing pain in the teeth of the left jaw. After this, the pain somewhat abated, but left a similar one in the corresponding side of the head. I conjectured from that the headache was caused by the roots of dead teeth. Upon examin- ing the upper jaw, I found four carious teeth whose roots were deeply planted. I advised her to have them extracted, to which she cheerfully consented. I then purged her freely and applied cups to her neck and shoulders, and an aposeme to be taken dur- ing four days in the morning. On the fifth, while fasting, I ex- tirpated the roots." After other treatment of a kind then in vogue, but of no utility, the lady recovered. Case 20. Headache dependent upon the teeth. — (M. Petit.) " The late Princess of Conde recommended to her physicians one of her proteges, to be cured of a headache of five years duration. She had been bled twenty times, and finally Mr. Petit EFFECTS OF DISEASED TEETH AND GUMS. 19 was requested to bleed her in the throat. This surgeon having examined the patient, was led from her complaint of a pain and weight in the lower jaw, to look into her mouth. He found some irregularity in the teeth, and upon close inspection ascertained that the patient had an unnatural number of them, there being eighteen in the lower jaw. The second molar on each side appearing to be most crowded, he took them out, and in twenty- four hours the lady was cured of a headache of five years continuance." Case 21. Ophthalmia and loss of an eye by abscess upon the teeth. — (Fab. Hil.) " A lady of Cologne was for a long time tor- mented with inflammation upon the last molar of the left side, which was carious. By the advice of physicians, she was fre- quently purged, and cupped between the shoulders, but as she refused to have the tooth extracted, the continued irritation of the gums occasioned inflammation of the eye on the same side, which finally destroyed the sight." Case 22. Ear-ache cured by extracting a tooth. — (Jourdain.) " A lady had long suffered with severe pain in the right ear. All the ordinary remedies were used without effect. At length she was asked if she had any carious teeth. She replied that she had not : that all her teeth were good and never gave her any inconvenience. Nevertheless, her mouth was carefully exam- ined. At first sight all seemed right, but a close inspection showed external caries of the dens sapientiae. As the pain of the ear extended to the angle of the jaw, and even a little along its base, I persuaded the lady to permit me to extract this tooth, which I suspected to be the real cause of the mischief. Three days afterwards, the lady was perfectly and permanently re- lieved." A similar case is reported by Mr. Koecker. Dr. Darwin relates several cases of serious disorder produced in adjacent parts and in the general system by diseased teeth. The following are very remarkable : Case 23. " Mrs. , about thirty years of age, was seized with great pain about the middle of the right parietal bone, which had continued a whole day before I saw her, and was so violent as to threaten convulsions. Not being able to detect a decaying 200 EFFECTS OF DISEASED TEETH AND GUMS. tooth or a tender one, by examination with my eye or by striking them with a teaspoon, and fearing bad consequences from her tendency to convulsions, I advised her to extract the last tooth of the under jaw on the affected side, which was done without any good effect. She was then directed to lose blood and to take a brisk cathartic, and after that had operated, about sixty drops of laudanum were given her, with large doses of bark, by which the pain was removed. " In about a fortnight she took a cathartic by ill advice, and the pain returned with greater violence in the same place, and before I could arrive, she suffered a paralytic stroke, which affected her limbs and her face on one side, and relieved the pain of her head. " About a year afterwards I was again called to see her on account of a pain as violent as before, exactly on the same part of the other parietal bone. On examining the mouth, I found the second molaris of the under jaw, on the side before affected, was now decayed, and concluded that this tooth had occasioned the stroke of the palsy, by the pain and consequent irritation it had caused. On this account I earnestly entreated her to allow the sound molaris of the same jaw, opposite to the decayed one, to be extracted ; which was forthwith done, and the pain of her head immediately ceased. 1 ' Case 24. (Darwin.) Since the above was first published, I have seen two cases which were very similar, and seemed much to confirm the above theory of sympathetic hemicrania, being, perhaps, always owing to the sympathy of the membranes about the cranium with those about diseased teeth. " Lord M. and Mr. B., of Edinburgh, both of them about the middle of life, were afflicted with violent hemicrania for about two years ; in the beginning of which time, they both assured me that' their teeth were perfectly sound, but on inspecting their mouths I found all the molares were now so decayed as to have lost their crowns. After having suffered pain for sixteen or eighteen months, almost incessantly, in different parts of their heads, they had each a hemipegia, from which they gradually recovered as much as paralytic affections generally do recover. All the stumps of their teeth which were useless were directed EFFECTS OF DISEASED TEETH AND GUMS. 201 to be extracted, as the swallowing so much putrid matter from decaying bones, seemed to injure their digestion." Sir Henry Halford, in a paper on tic-douloureux, read before the College of Physicians, related the following cases which came under his own observation : — Case 25. " A lady, forty years of age, suffered under the violent form of tic-douloureux, at Brighton, notwithstanding the careful attention and skill of a very judicious physician there. On returning to town, it was observed that the rending spasms, by which the disease is marked, were frequently preceded by an uneasiness in one particular tooth, which exhibited, however, no signs of unsoundness ; but the constancy of this symptom was enough to justify the extraction of the tooth in this instance; and on its being drawn, a large exostosis was observed at the root of the tooth, and the lady never suffered more than very slight attacks, and these very seldom, afterwards." Case 26. (Sir Henry Halford.) " The late Earl of C. un- derwent martyrdom by this disease, and excited the warmest sympathy of his friends by the agonies he sustained for many years. He submitted to the operation for the division of several branches of the fifth pair of nerves repeatedly, by Sir Everard Home and Mr. Charles Bell, without obtaining more than tem- porary relief. At length he was seized with apoplexy, and lay insensible for some days, and in great peril, from the attack, but finally recovered. After the apoplexy the paroxysms of tic- douloureux became less frequent and less severe, and were ad- ministered so satisfactorily by an ingenious physician, who wrote his inaugural exercise on the disease. For the last year or two of his life his lordship ceased to suffer from the tic-douloureux, and died at an advanced age, without any marked malady. While I attended him he underwent repeated exfoliations of the alveolar process of the teeth, which I thought occasioned his torment." Doubtless, the exfoliations being completed, and the disease of those parts removed, the irritation ceased, and the patient recovered. It is melancholy to think of the protracted suffering which rendered the life of this unfortunate nobleman wretched and comparatively useless, and which might probably have been cured with little difficulty, if such men as Sir Everard Home and JO 202 EFFECTS OF DISEASED TEETH AND GUMS. Mr. Charles Bell had been aware of the sympathetic disorder which may be, and often is, produced by diseased teeth. These eminent gentlemen not only did no good, but they inflicted great additional pain on their unhappy patient; but, doubtless, he would have fared little better in other hands, for the profession, while searching with powerful microscopes for causes of disease, entirely overlook the teeth, though reason and experience, the demonstrations of the anatomist, and the voices of the most dis- cerning of the masters in medicine, are continually pointing them to the important sympathies of these organs. From its relation to the teeth of the upper jaw, the fangs of which frequently perforate its floor, the antrum is often the seat of disease of a serious and sometimes fatal character, resulting from irritation produced by diseased conditions of these highly sensitive organs. Indeed, the teeth are directly or indirectly concerned in most of the diseases of the antrum. Boyer, Des- champs, Harris, and most others who have written upon this subject, give united testimony to this fact. Dr. Harris, in the second edition of his valuable work on Dental Surgery, records several cases in evidence of the facility with which diseased teeth may propagate disorder to the antrum, and the formidable diseases which may result therefrom. I select the following : — Case 27. (Dr. Harris.) " Mrs. L., at twenty-seven or twenty- eight years, of a scrofulous habit, had been at times affected, for more than two years, with a deep-seated pain in the right side of her face, midway between the orbit and the alveolar ridge, and on closing the left nostril, and making a violent expiration through the right, discharged a slightly, yet perceptibly fetid mucous matter which occasionally excoriated the mucous mem- brane lining this cavity of the nose. The pain, from the fact that it was most severe in cold and damp weather, was thought to be rheumatic. General and local bleeding, fomentations, mus- tard plasters, purgatives, anodynes, tonics, and many other reme- dies, had been employed in vain. " A severe paroxysm of toothache, about this time, more than two years since she first felt the deep-seated pain in her cheek, induced her to apply to me. EFFECTS OF DISEASED TEETH AND GUMS. 203 , a vein. % Styptic, from Zrvyeiv, to constringe. WOUNDS OF THE MOUTH AND FACE. 213 directly over an artery, the impulse of the latter may be so sensi- bly communicated to the former as to cause the blood to flow per saltern. Again, in one instance the author found the venous blood of a plethoric patient to be as red as arterial, when issuing from the orifice. This, however, is very rare. The loss from them is therefore much greater than from veins. Moreover, the arteries contract and expand, and force their blood by this process, through their canals in jets or gushes. Hence it is almost impossible for a coagulum to form of sufficient size to resist the force of the propulsion. An artery, unless of very small size, if once divided by a clear incision, will continue to bleed until the patient succombs from exhaustion, unless artificial aid be afforded. The means of arresting arterial hemorrhage are, compression, ligature, laceration and the actual cautery. Compression may be exerted either upon the trunk of the ves- sel at a spot nearer the heart than the wound, and where its superficial position or relation to a bone renders pressure more easy and complete, or upon the lips of the divided vessel. Pressure upon the trunk of the vessel can afford but temporary relief, as the current of blood will soon find its way through an- astamosing branches into the vessel beyond the impeded point; upon the lips of the wound, unless very much favored by position, it can rarely be perfect, as the arteries for the most part lay deep, and the means of compression must be applied at the bottom of the wound. The ligature is by far the most important of the means used for arresting hemorrhage, and the discovery of its adaptedness is the greatest advantage of modern over ancient surgery. The ancients supposed that the arteries contained a mysterious something, which they called the animal spirits, and to prevent the egress of this, they resorted to the actual cautery ; thus add- ing a most painful and dangerous burn to a wound often large and sufficiently serious. An artery is composed of three coats, viz : the outer or fibrous, the middle or muscular, and the inner or serous. When a ligature is tied firmly around the vessel, the outer 214 WOUNDS OF THE MOUTH AND FACE. coat being firm and strong, remains unbroken ; tbe middle and the inner or serous coat, are always lacerated. The effect of the ligature then is : 1st. To rupture the middle and internal coats of the artery. 2d. To bring the lacerated parts into close contact. 3d. To produce adhesive inflammation by the exudation of coagulated lymph. 4th. To cause the forma- tion of a coagulum in the obstructed vessel ; and 5th. To cause ulceration of the outer coat, by which the ligature is liberated and the wound suffered to unite. It appears then that the final closure of the vessel is the result of a most wise and benevolent provision of the Creator which enables us, through the structure and vital properties of the arteries, to procure their obliteration at such point as we may select. This provision would, however, be entirely nugatory unless some means were provided by which parts thus deprived of cir- culation should receive it through other channels. But this means is provided in the facility with which, under these circumstances, the anastamosing branches are enlarged. Through these rapidly expanding canals the current of blood presses towards its desti- nation, and in a few hours the inconvenience resulting from the complete obstruction of such trunks, even as the carotid and external iliac, is permanently remedied. In placing the ligature, which should be of hard twisted silk, around the artery, great care should be had not to enclose in it the nerve or vein which commonly attend the former. Serious and even fatal consequences would follow such a blunder as this. When the external coats of the vessel are so soft as to give way before the ligature, a little of the surrounding cellular tissue or muscular fibre may be enclosed within the thread. The method to be pursued in reaching each particular artery will be found in the works on general surgery. It is not within the design of the present work to describe them. We have mentioned laceration as one of the means of arresting hemorrhages. When an artery is torn, the internal coat is, of course, brought into the condition produced by the ligature, except that the op- posing surfaces are not pressed together. It generally happens, WOUNDS OF THE MOUTH AND FACE. 215 however, that the shock of this kind of injury interrupts the con- traction and expansion of the vessel, and a coagulum is thus per- mitted to form. This mode of operation is only proper when we have to deal with small vessels. Their bleeding may generally be arrested by seizing them with the forceps and twisting them so as to rupture their internal coats. The actual cautery* is a terrible means, which should only be used under peculiar circumstances. We have already said that until within a comparatively short period, searing with a red-hot iron was the means commonly employed to arrest arterial hemorrhage. Stumps, after amputation, were submitted to this dreadful application, adding vastly to the terror and pain of operations which even now seem almost too severe for endurance. The cautery, by disorganizing the extremity of the vessel, and corrugating the animal fibre, is an effectual preventive of hemorrhage, and may be resorted to when there is no other resource. It sometimes happens that an injury is done to a bone, which opens an artery imbedded in it ; the same happens, occasionally, in operating upon these organs. Under such circumstances, it is sometimes impossible to use a ligature. It also happens occasionally that in the extraction of a tooth, a vessel is ruptured which continues to bleed freely for hours, and even days, after the injury; and the hemorrhage is not only exceedingly inconvenient, but sometimes is sufficiently great to be alarming. Under these circumstances, after ineffectually stuffing the socket with lint, &c, medicated by alum, the mineral acids, &c, it becomes necessary to use the actual cautery. Owing to the very small surface to which the heated body is to be applied, this can be done without much pain to the patient, and will, if dexterously accomplished, afford prompt relief. A probe ending in a small button, or some other metallic body of suitable size and form, should be heated to a white heat and *The actual cautery is fire or a heated body, the potential certain chemical substance, which combine with and destroy the tissues, as nit. of silver and pure potass, &c. 216 WOUNDS OF THE MOUTH AND FACE. carried suddenly to the bottom of the socket. Care should, of course, be taken not to touch the tongue or cheeks. The potential cautery will also accomplish the purpose, but the hot iron is more prompt and not more painful. If the hemorrhage from a simple incised wound be merely venous, we need not be concerned about it : it will soon cease, unless the trunk be very large. The treatment of incised wounds, consists in bringing the edges of the wound close together and keeping them in contact. This done, nature performs the cure by throwing out lymph, which cements the adapted edges together, and becoming organized, forms a permanent bound of union. When this is accomplished without suppuration, it is called by surgeons, " the union by the first intention." This mode of union leaves but a very slight cicatrix and occa- sions the least deformity. It is, therefore, especially desirable in all wounds of the face and neck. It also is attended with the least possible contraction of the parts, and is, therefore, as well as for other obvious reasons very desirable in all wounds of the mouth. It will be noticed, that we propose no means for curing wounds. The truth is, we have none, and none are wanted. Nature is abundantly capable of repairing these injuries, if the parts be placed in a proper relation, and be protected from the external air, which is a positive irritant to the internal surfaces. There is no virtue in salves or balsams to heal simple incisions ; but these applications may retard the cure and cause suppuration where none would otherwise have occurred. There are several means for approximating divided surfaces, and keeping them in contact. They are adhesive plasters, sutures and bandages. Of these, adhesive plasters are the most important. They are generally sufficient to approximate the parts closely, and unless very great nicety be required, will generally answer all desirable purposes. The solution of gun cotton in ether, which has recently been introduced into surgical use, promises to supersede sutures to a considerable extent. WOUNDS OP THE MOUTH AND FACE. 217 Stitures or stitches, are threads passed through the lips of the wound and then tied, holding the divided surfaces together. When very muscular and contracted parts are divided, such as the lips or the eyelids ; where it is important to prevent de- formity, and where the wound is too deep to be closed by adhe- sive straps ; where, from the moisture of parts, adhesive plaster would not be available ; or when, as in lacerated wounds^ the parts have been broken into small and irregular fragments, not affording sufficient sound surface upon which to fasten the plasters ; in such cases, sutures are useful. Lacerated wounds bleed less profusely than simple incisions. The injury done to the vessels is commonly of a kind which paralyzes them for the moment, or at least so far enfeebles their function as to prevent active hemorrhage. This is sometimes the case even when large arteries are torn asunder. Cases have been observed where the arm has been torn from the shoulder by machinery, and the arteries left hang- ing out from the wound, yet no serious bleeding ensued. In the experiment of Dr. N. R. Smith, the carotid artery of a horse, when ruptured by a blunt hook passed under it, bled but little. The absence of bleeding in extensive lacerations, though imme- diately convenient, yet indicates an amount of injury to the parts far greater and far more difficult to remedy than that which attends incisions. The parts may be entirely destroyed ; or their vitality may be so far lessened as to make them incapable of resisting the in- flammation which will result, and cause them to mortify. Wounds of this kind do not heal by resolution ; they will sup- purate, and consequently the cicatrix that results is more un- seemly than is left by simple incised wounds. The pain is generally in inverse proportion to the extent of the injury. Small lacerations causing great suffering, while those which are very extensive, so benumbing the sensibilities as to cause but little. A miller, whose arm and scapula were wrenched off by a wheel, did not know what had happened until he saw the arm revolving round it. There was, as usual in cases of this kind, no serious hemorrhage. The indications in lacerations are to cleanse the wound of any foreign substances, such as sand, 22 218 WOUNDS OF THE MOUTH AND FACE. gravel, &c, and to unite the ruptured parts, as nearly as we can, without inflicting serious additional injury. A difference of opinion exists as to the proper application. Inasmuch as the part is at first cold, and the circulation weak, it has been the common practice to apply some stimulating appli- cations, such as turpentine, or some spirituous preparation ; and when inflammation is established, to dress the wound with warm poultices, in order to promote the suppuration. The most eminent surgeons of the present day, however, pre- fer very cold applications, such as ice or ice-water, in order to allay the inflammation, which is sure to occur, and which is apt to be excessive. The probability is that the wound, like an incised wound, does better without any dressing at all, except its own blood, which protects it from the air and forms a soft, well-adjusted cushion between the wound and the bandage, which, of course, should be thrown around it, so as to protect it, but loosely. The author once saw a wound of this description, of an aggravated character, which was treated in the way described, by Dr. N. R. Smith. The patient was a boy whose hand had been caught in an agricultural machine. His fingers were lite- rally crushed : the phalanges splintered, and the flesh torn up and hanging in rags about the broken bones. The joints of the fin- gers were, for the most part, disorganized, and the organ pre- sented so hopeless a condition, that amputation seemed inevita- ble, and Dr. Smith was invited to perform the operation. This experienced and skilful surgeon, while he admitted the appa- rently hopeless condition of the wound, observed, very justly, that it would be time enough to amputate when the parts should become gangrenous or some constitutional symptoms of an im- perative character should supervene : that injuries of the hand were not apt to occasion tetanus ; and that he would advise to let the hand alone, to see what nature would do. A few spiculae of bone were removed, and the hand was, without having been washed, bound up in its own blood. To the surprise and gratification of all concerned, the wounds healed rapidly, and although, from loss of bone and rupture of joints, the fingers remained deformed, stiff, and crooked, the boy finds them very much more useful than a stump would have been. WOUNDS OF THE MOUTH AND FACE. 219 Contused wounds do not differ very materially from lacerations. They, too, require to be let alone, unless the inflammation suc- ceeding be so great as to require the treatment heretofore de- scribed as proper for such conditions. Contused wounds are generally attended by an effusion of blood beneath the skin, which gives the parts a black or deep blue appearance. As the absorbents slowly take up the extrava- sation, the color becomes greenish and yellowish, and finally dis- appears. With regard to both these kinds of wounds we may say, that whatever treatment they require is demanded by the inflamma- tion which follows them, and must be modified to suit the degree and character of it, without regard to the transmatic cause of it. Punctured Wounds. — These are injuries made by a pointed instrument, penetrating to some depth, and characterized by an opening very small in proportion to the extent of the wound. Very often, the instrument by which the wound is inflicted is of a shape, designedly devised, for the purpose of inflicting the greatest possible amount of injury. A bayonet, for instance, is triangular and pyramidical, much broader at the base than the point. Of course, it is forced into the body like a wedge, and bruises and lacerates the parts exceedingly. A punctured wound, other things being equal, is a much more severe injury than a simple incision. It is both a lacerated and contused wound, and of course is fraught with the peculiar dangers attending such injuries. But, moreover, it is inflicted upon deeply seated parts; vital organs may be reached; large vessels and nerves punctured ; even bones penetrated or splin- tered. Wounds of the more deeply seated parts do not heal with the same facility as the skin ; they are more out of reach of dressing and manipulation; they suppurate, and the matter is liable to form sacs or pouches, or to be infiltrated into the ad- jacent parts, acting as an irritant, and spreading inflammation in its course. The constitutional impression also is greater when deep seated parts are wounded, than when superficial injuries, even of greater extent are suffered. 220 WOUNDS OF THE MOUTH AND FACE. The danger of punctured wounds depends upon the extent, situation and character of the injury, and the age, constitution, &c, of the subject. The indications for the treatment of a punctured wound are, 1st. To remove any fragment of the instrument by which the injury has been inflicted ; 2d. To secure any artery which may have been wounded ; 3d. To place the part in the easiest and most relaxed position ; and, I am tempted to say, 4th. To let it alone. I am convinced that much injury is done by attempts to aid nature in her efforts at reparation, when she is abundantly competent to complete the work without active as- sistance. Some surgeons inject stimulating applications, in order to bring about inflammation, which is sure to ensue soon enough if the health of the patient permit. Others advise to lay the w T ound open, and lengthen it so as to convert it into a deep incision. This is often impracticable without doing vast injury, is always painful, and when accomplished will not pre- vent the natural consequences of the laceration already suffered. The object of this practice is to prevent the accumulation of the matter; but generally the matter will escape readily enough, and surely it will be time enough to provide for the evacuation of retained matter, when it shall be ascertained to exist. Sometimes the lips of the wound tend to heal before the more deeply seated parts have established their suppuration. This can be prevented by introducing a pledget of lint, or a "tent," into the wound, and keeping it there until the growth of granu- lations from the bottom and the adhesion of the sides are com- pleted. The tent should be removed every day, and a shorter intro- duced, from time to time, until the cure be completed. Constitutional symptoms are to be treated upon general princi- ples. Before inflammation is established, and while the system is suffering from the pain and shock, opium will be our most im- portant means. Should inflammatory symptoms run high, blood-letting and other antiphlogistic means will be required. Gun-shot Wounds are violent contusions made by dense bodies moving with great momentum. The injuries thus in- WOUNDS OF THE MOUTH AND FACE. 221 dieted are serious in proportion to the extent of the wound and the importance of the parts involved. These wounds generally bleed but little, but even when slight, and penetrating only fleshy parts, they produce a remarkable constitutional shock, manifested by faintness, feeble pulse and muscular weakness. Gun-shot wounds must be treated upon the principles which apply to all other mechanical injuries. If the ball or other projectile can be removed without difficulty, it should be done; if it cannot be readily found and dislodged, it is better to let it alone, as much more injury will be done by groping after it among the lacerated parts, than by its presence. Generally it will come away in the suppuration. Sometimes the wound heals over it, and it may remain for years imbedded in bone or muscle, without causing inconvenience. The notion which prevailed formerly, that lead, when projected by gunpowder, is poisonous to the flesh, is a mistake. This metal does no injury, except by its weight. Burns. — Injuries caused by the action of fire or heated solid bodies are indiscriminately called bums : when the result of contact with heated fluids they are called scalds. Of course injuries from these agents must differ very much according to extent and degree; varying from the slightest perceptible ery- thema to gangrene of the parts, and from a very limited to a very wide spread wound. Indeed, under the common name burn, as under the general term wound, are grouped together a great variety of injuries, alike only in the fact that they are caused by fire or heated bodies. Yet it is common to speak of remedies for burns, as though all of these injuries were alike, and required the same treatment. There is no branch of sur- gery in which empiricism retains its ground as firmly as in the treatment of burns. A great number of applications have been lauded as specific for these conditions, and when, from some terrible accident, a large number of persons are scalded, it is mortifying to notice the want of all agreement among physi- cians as to the proper management of the distressing cases which clamor for relief, and the dogmatic empiricism with which nostrums are insisted upon by professional men, who are unable 22* 222 WOUNDS OP THE MOUTH AND FACE. to give any satisfactory reason for their extraordinary confidence in their own suggestions. Some years ago a steamboat started from the wharf in this city, upon a trial trip, and exploded before she had gone a hun- dred yards. Many persons who thronged her decks were scalded and blown into the water. When taken out, they were chilled and shivering, with feeble pulse, laboring under great constitutional irritation. Under these circumstances, it was painful to notice the modes of treatment adopted, upon opinions of specific virtue in cer- tain agents, without any apparent regard to the probability of good, as inferred from their known qualities, and the condition of parts to which they were applied. Cold water, spirits of turpentine, raw cotton, soot, soap, with many other applications, have been strongly advocated as dressings for burns ; yet certainly it would require an utter dis- regard of rational conduct to apply turpentine to the extended surface of an abraded cutis, or cold water to the shivering skin of a feeble patient, whose whole constitutional effort cannot accomplish reaction. The danger of burns is in proportion to extent rather than degree. A small portion of the body might be burned to complete destruction, with far less danger than a large surface could be reddened and vesicated. ' Scalds, therefore, which are superficial burns, are very dan- gerous, because, from the diffusible nature of their cause, they are generally extensive. The reason is, 1st. Because the pain of burns is the prime cause of the constitutional distress, and of the serious or fatal consequences that ensue, and superficial burns of the skin are generally most painful and most extended; 2d. The skin has powerful sympathies with the mucous membranes of the bowels and lungs, and these are very apt to assume serious inflamma- tion when the skin has been extensively scalded. 3d. The functions of the skin are important, and cannot be extensively interrupted with impunity. From the last two causes, it happens that scalded persons are WOUNDS OF THE MOUTH AND FACE. 223 apt to die of pulmonary engorgement, and not because they have "inhaled steam," as has been so commonly supposed. Where burns or scalds are superficial, the great object is to protect the irritated surfaces from the air, which is most dis- tressing to them. To this end, nothing is better than the raw cotton, which, to prevent its adhesion to the sore, should be moistened with some unctuous substance. Linseed oil and lime water mixed together are commonly used for this purpose, and the mixture answers very well. The cotton thus treated forms a soft, warm, innocent dressing, and is as good a sub- stitute for the skin, (and this is what we want,) as we can pro- cure. Wheat flour or other farinaceous matters sprinkled on until the part is completely covered and protected, will answer a similar purpose. For obvious reasons, the cotton is prefera- ble. A coating of gum arabic, applied in solution, has been used with good results. If there be no blistering or abrasion of the surface, the injury being severe erythema, cold water will give immediate relief. Sometimes the part upon which the burn has been immedi- ately inflicted will be disorganized or nearly so; the surround- ing parts, and those subjacent, partaking of the injury in pro- portion to their propinquity to the place of contact. In such cases, as the vitality of the parts is nearly exhausted, and gangrene likely to take place, the stimulating agents, tur- pentine, &c, may be very properly employed. In short, the treatment of burns, like that of other injuries, must depend upon the judgment of the surgeon, in view of the peculiar condition of the injury. Burns leave large and unseemly scars, which pucker as they contract, and often cause permanent deformity by the shorten- ing of skin and muscles. It is important, in the treatment of these injuries, to guard against this tendency as much as pos- sible, by preventing those positions which, though most easy to the patient, will permit the contraction above mentioned. Care must be taken, too, that two burned surfaces be not brought together and kept in contact. I once saw a child < re rendered entirely useless through neglect of 224 WOUNDS OF THE MOUTH AND FACE. this precaution. The palms had been burned, and the mother bound up the closed fists, and suffered them so to remain until palmar adhesion and permanent muscular contraction rendered the organs entirely useless. Fractures. A fracture is a solution of continuity of a bone, produced by violence, acting either by some external agent, or, occasionally, by the sudden and extraordinary contraction of muscles. A fracture may take place transversely, obliquely, or longi- tudinally. The difficulty of adjustment and reparation will be in accordance with certain circumstances which give character and importance to the injury. Cseteris paribus, a simple division of the bone transversely, or a longitudinal fissure of moderate length, will involve much less suffering from injury to the soft parts, and will be much more likely to heal without deformity, than a fracture which is oblique; because, in the former cases, there will be but little if any displacement of the broken surfaces of the bone, while in the latter the muscles attached to the separated part are apt to draw it out of its position, and cause it to ride upon the fixed portion. The action of the same muscles is of course continually opposing the force us ed to keep the restored fragment in place. Fractures may be comminuted — that is to say, the bone maybe broken into small fragments; they may be compounded, that is, may be associated with injuries, more or less serious, of the soft parts covering or covered by the bone, such as lace- rations of the muscles, skin, protrusion of fragments of bone through the integuments, &c. Fractures are said to be complicated when attended by some accident or condition which materially embarrasses the treat- ment and cure. Thus a large artery may be wounded, an im- portant viscus injured, or a constitutional disease, affecting the vitality of the bones, may exist. Treatment of Fractures. — The general treatment of fractures consists in meeting the following indications: 1st. To restore WOUNDS OP THE MOUTH AND FACE. 225 the displaced pieces of bone to their natural position. 2d. To keep them there; and 3dly. To afford any additional aid which the nature of the injury and the constitutional circum- stances may require. It does not always happen that the frag- ments are displaced. In such cases the duty of the surgeon, so far as the condition of the bone is concerned, requires no more than to support the parts, and place them in such a posi- tion as will best guard against displacement. It will be seen that the surgeon has nothing whatever to do with the produc- tion of bony union. That is entirely the work of nature, and is accomplished by the formation of a hard intermediate sub- stance, which is called callus. Soon after the injury, a swelling is observed around the broken ends of the bone, which gradually hardens until it sur- rounds the fracture with a kind of bony splint, within which the process of reparation goes on. This is called the provisional (Callus, As the cure advances, this hard swelling subsides, though it rarely entirely disappears, and the bone is found to be permanently united by an organized osseous substance, which well subserves all the purposes of the lost bone. According to the experiments of Breschet and Villerni, the following are the principal circumstances remarked during the process of reparation of fracture. 1. Extravasation and coagulation of a small quantity of blood between the ends of the fracture, which blood escapes from torn or ruptured vessels. 2. A fluid, at first of a viscid quality, effused and secreted as it were between the periosteum and the bone, and likewise exuding from the surfaces of the fracture, and from the soft parts. 3. A gradual increase in the quantity and consistency of the preceding substances blended together, forming every day a stronger connection between the parts ; then their change to a red intermediate substance between the fragments and between the bone and periosteum to a substance which is at first soft, but in the end acquires the character of bone. 4. At the fractured parts a reunion of the periosteum and soft parts, which are equally indurated and confused together with the intermediate substance between the fragments. 226 WOUNDS OF THE MOUTH AND FACE. 5. A diminution and then an obliteration of the medullary cavity, at first by a cartilaginous, and then by a bony deposition. 6. Successive ossification of the whole of the swelling com- posing the callus, and of the substance between the fragments, preceded by a fibrous and cartilaginous state. 7. The return of the soft parts around the fracture, and then of the periosteum to their natural state. 8. After the union of the surfaces of the fracture, the medul- lary cavity and texture are gradually re-established, and the swelling formed by the callus always diminishes.* "Whatever may be the process by which callus is formed, it is during the first two or three weeks after the fracture that the fragments undergo the changes which promote their reunion. But it is within the twentieth and thirtieth, and especially be- tween the thirtieth and fiftieth days, that nature labors effectu- ally in consolidating the callus. Hence, at this period, our care to retain the ends of the fracture in exact contact and perfectly at rest, should be redoubled, for though there are a few instances In which deformity really proceeds from irregular ossification, it is a fact that the deformity almost always originates from the fracture being disturbed and not kept properly reduced. f Fractures of the Jaws. — The lower jaw is liable to be frac- tured at any part of its extent, as between the symphysis and the masseter muscle, within the muscle, and between it and the angle. The bone may also be broken in two places simulta- neously. Sometimes, also, the condyles, and less frequently the coronoid processes, are broken off. Fractures of this bone may be perpendicular, oblique or lon- gitudinal. Sometimes a part of the alveolar process with its teeth has been split off. When the fracture is near the symphysis, the submaxillary muscles will draw down the part to which they are attached, while the other fragment, released from the counteraction of those muscles, will be proportionably elevated by those which close the mouth. When fractured in two places, the middle * Cooper's Surg. Die, Art. Fractures. f Boyer. WOUNDS OF THE MOUTH AND FACE. 227 fragment will be drawn downwards and backwards, while the lateral portions will be supported by their muscular attachments. When the fracture occurs within the masseter, little displace- , ment can take place, as the muscle attached to both frag- ments keeps them in their natural position. Fractures of the lower maxillary may generally be detected without much difficulty. If, after a severe blow or fall, there should be severe pain in the jaw, attended with laceration and swelling of the soft parts; if the line of the bone be irregular; if crepitus be felt; if the gums be denuded, and if the level of the teeth be interrupted, there can be no doubt that fracture has occurred. Nor is it necessary that all these appearances shall be present in order to satisfy the observer of the nature of the injury. As the bone can be traced with the finger along its whole length, and its level observed both upon the upper and lower margin, the displacement or crepitation, and the pain or disability of motion, will sufficiently indicate the kind and point of injury. There is little difficulty in replacing the fragments of a frac- tured lower jaw. We have but to push the displaced part up- wards and a little forwards, and press it exactly into a line with the fixed portion — observing that the teeth are also properly level. It is not so easy, however, to keep the parts in their proper place, but the upper jaw being fixed, enables us to sustain the lower one against it. A piece of pasteboard, moistened and softened with vinegar, or, if there be excoriation, with water, is first adapted to the basis of the jaw. A four-tailed bandage is then employed to keep the parts in position. This consists of a piece of muslin or flannel, several inches wide, the centre of which is perforated for the reception of the. chin, and the two ends divided longi- tudinally, so as to make two tails on each side. The anterior of these are carried up the side of the face, and secured to a night-cap posteriorly, and the posterior tails anteriorly. The patient must keep his mouth closed as nearly as possible, re- fraining from talking, and subsisting upon fluid or semi-fluid food. Sometimes a tooth will be splii in the fracture, and must be 228 WOUNDS OF THE MOUTH AND FACE. extracted. It sometimes happens, also, that the teeth are so irregular as to prevent the complete closure of the jaws, in which case a piece of cork may be so placed as to accomplish the purpose of supporting the lower by pressure against the upper jaw. Dr. Rhea Barton, of Philadelphia, devised a bandage for fractures of the jaw, to which many surgeons give a preference. He commences with a roller an inch and a half wide, below the prominence of the occiput, and continues it obliquely over the centre of the parietal bone across the juncture of the coronal and sagittal sutures, over the zygomatic arch, under the chin, and pursuing the same direction on the opposite side, until he arrives at the back of the head; he then passes it obliquely around and parallel to the basis of the lower jaw over the chin, and continues the same course on the other side, until it ends where he commenced, and repeats.* When the condyle is fractured, the external pterygoid mus- cle pulls it forwards, and it is by no means easy to apply such a force to the deeply seated fragment as to bring it in contact with the body of the bone. Our only alternative is to press the lower portion as well as we can to the condyle, by placing a thick compress upon the angle of the jaw, and applying our bandages so as to press upon this part of the bone. Compound fractures of the jaw are to be treated as similar injuries elsewhere. Every attention must be paid to ensure cleanliness, contact and rest of the parts, and constitutional symptoms are to be met by antiphlogistics, anodynes and tonics, as cases may require. Dislocations] or Luxations. The forcing of articular surfaces out of their relative position is called a dislocation or luxation, or familiarly, putting out of place. These injuries require surgical aid, it being rarely pos- sible for the patient to replace the bone by his own efforts. * Reese, Note Cooper's Surg. Diet. f Dis loco — to get out of place. WOUNDS OP THE MOUTH AND FACE. 229 The cause of dislocations is generally external violence, es- pecially falls, but they may be occasioned by the sudden and violent contraction of muscles, and these latter are always more or less concerned both in effecting dislocation and repairing it. Luxations may be complete or incomplete. They are com- plete when the articular surfaces no longer touch; incomplete, when they remain partially in contact. They are necessarily attended with rupture or violent elon- gation of ligaments. The symptoms of dislocation are pain and incapacity of the part, change of position and relation of the bones which form the joint, ascertained by the touch and by the position of the limb or part. Sometimes, also, special symptoms, indicating the pressure of bone upon sensitive or important parts, attest the nature of the injury. Dislocations of the Lower Jaw. — From the latitude of motion enjoyed by the lower maxillary bone, and the necessary loose- ness of its articulation, it is very subject to dislocation, though this can only take place in one direction, forwardly, and not then unless the mouth be wide open and the chin depressed greatly at the moment of the injury. Sometimes when parties are in high altercation, and one of them is vociferating loudly, a blow from the other, falling upon the expanded jaws, will put a stop to the flow of epithets or recital of grievances, by dislocating the submaxillary. Some- times, also, after the jaw has been previously dislocated and the ligaments relaxed, yawning will be sufficient to bring the condyles to slide forward, and the ligaments giving way, to glide beneath the zygoma. The injury has resulted from the use of great force in ex- tracting a tooth, the jaw being much depressed at the same time that great force was exerted upon a posterior tooth, ele- vating and pulling forward the posterior part of the bone. Dislocations of the jaw are very painful, owing to the pres- sure of the condyle's upon the deep scaled temporal nerves, and those which go to the masseter, which nerves pass before the root of the zygomatic processes. — (Boyer.) The mouth is open 23 230 WOUNDS OF THE MOUTH AND FACE. and immovable, the patient speechless, the saliva running from the mouth, and the countenance expressing great distress and anxiety. If the dislocation be long continued, the jaws are more nearly approached than when the injury is recent. The coronoid process forms under the cheek bone a prominence which may be felt through the cheek or from within the mouth.* Upon the whole, it is not easy to mistake the character of the injury. Dentists should be aware of the possibility of such an acci- dent as this when extracting a tooth, and should guard against such a position of the jaw as would be favorable to it. It may happen, however, even in the hands of the most skilful and prudent, and they should be prepared to reduce the dislocation immediately. Mr. Fox dislocated the jaw of a patient on both sides, while endeavoring to extract a tooth for him. The manner of replacement is very simple. The operator must first wrap his thumbs thickly with cloth of some kind, to protect them from injury. He must then place them as far back in his patient's mouth as he can, and while he depresses- the posterior part of the jaw with them, he must elevate the chin with his palms and fingers. This process disengages the condyles from beneath the zygoma, when the muscles draw them into their place with considerable force — enough to lace- rate the thumbs of the surgeon, unless they have been well guarded against such an accident. Sir Astley Cooper placed the patient in a recumbent posture,, placed two corks between his molar teeth, and elevated the jaw* Efforts at reduction may be confined to one side, if one only be dislocated. In order to prevent a redisplacement, the jaw should be sup- ported for several days, by bandages similar to those employed for fracture of the lower jaw, and the patient should be warned against opening his mouth more than absolutely necessary for the reception of soft food. * Cooper's Surg. Diet. CHAPTER XVI. PARTICULAR AFFECTIONS OF THE MOUTH AND ADJACENT PARTS. Diseases of the Gums. Of inflammation of the gums I have already treated, in con- sidering the general subject of inflammation. They are liable to other disorders which are worthy of notice. Among these are tumors, termed epulis* and parulis.f These tumors differ entirely in character. The parulis is an abscess, the result of suppurative inflammation ; the epulis a true tumor or morbid growth, seated upon and involving the structure of the gum. Parulis is therefore a distension of the parts by injected blood and effused matter ; parulis is an addition of organized but un- healthy substance, increasing the solid bulk of the parts. The term epulis is applied to different excrescences seated opon the gum. Some are hard, even scirrhous; others soft and spongy. Some are developed in the gum itself, others have their seat in the membranes of the teeth, periostea, or in the dense structures of the bones. Of course, as they differ in character and seat, they can have no uniformity as to the inconvenience and danger attending them. They are generally caused by carious teeth, whose fangs keep up a continual irritation in the neighboring parts, and are sometimes traceable to neglected parulis or gum boil as their immediate cause. The most common form of epulis is that of a soft, red, spongy mass, which bleeds readily, but is not attended with much pain, * Epulis— mi — upon, ovtov — the gum. t F'arulis — rtapa — near, ovXov — the gum. 232 AFFECTIONS OF THE MOUTH. as it is not very sensitive. It is liable to be reproduced after removal, but, unless improperly treated, is not dangerous. Sometimes, instead of appearing externally, the disease com- mences in the sockets of the teeth, and loosens and displaces them, though they may be perfectly sound. Some swelling of the gums and a discharge of pus accompanies this condition. A smooth, shining, elastic tumor sometimes shows itself upon the gum. It is compressible, but little sensitive, and bleeds freely if cut into. It is not malignant. A scirrhus may be located in the gum, where it will exhibit its distinctive qualities, hardness, acute lancinating pain, and unequal surface. It follows the history of similar tumors else- where, and is much to be dreaded. Another form of carcinomatous affection of the gums is that of a soft, spongy, bleeding fungus, much like the first form of epulis, but accompanied with great sensitiveness and acute pain. When these affections, either in their natural progress or from ill treatment or injury, assume a rapidly progressive form, very terrible phenomena begin to manifest themselves. If previously hard they soften, the bones become carious, a fetid and sanious discharge is poured out, the teeth are loosened, the devastation spreads, the lymphatics swell, hectic supervenes, and after much severe suffering the patient expires, from nervous ex- haustion, hemorrhage or suffocation. When the tumor is of the non-malignant kind, and has not so far progressed as to involve a large mass of bone in caries, and soft parts in ulceration, it may readily be removed, and its return prevented, by the removal of the carious teeth which cause it, if, as is generally the case, it has been induced by this cause. Without removing these irritants, of course no perma- nent cure can be expected. When of the malignant variety, the most prompt and decided means must be resorted to, to prevent fatal conse- quences. Mr. Liston and Prof. Mutter both regard genuine cancer of the gums as a very rare disease ; but they concur in thinking AFFECTIONS OF THE MOUTH. 233 that such affections are degenerations from original character, owing to constitutional causes, neglect or bad treatment. There is, therefore, more encouragement to hope for success in the attempts made to remove these affections, than when they are but the local indications of general disorder. The treatment will of course be modified by circumstances. If the disease be not malignant, but is evidently a mere fungous condition of the gums, depending upon the irritation of a ca- rious tooth, &c, it is only necessary to remove the cause of the trouble, and then to cut away the tumor, and destroy what may remain of it by compression or caustic. If the tumor be of the elastic kind, it must be thoroughly removed. If it hang by a narrow neck, it may be cut off by a ligature. Profuse bleeding is apt to result from incising these tumors, and will generally demand the use of the actual cautery for its suppression. The scirrhous or malignant tumor requires a very thorough exsection. Every tooth and all the bony structures in any way connected with it must be boldly cut away, and the wound seared with the hot iron. The mode of operation preferred by Prof. Mutter, and which he thinks "better adapted to the case," and fraught with less suffering than the use of the mallet and chisel, is thus described by himself.* "Having placed the head of the patient in a good light, and against the chest of an assistant, who stands behind the ope- rating chair, the surgeon makes a perpendicular incision on each side of the tumor, with a pair of strong scissors, or rather cutting forceps, and without stopping to arrest the hemorrhage, at once detaches the mass, by dividing the alveolar process above or below the tumor, as the upper or lower jaw happens to be involved, with cutting forceps, one blade of which is applied to the inner portion of the jaw, and the other to the outer. The raw surface is next carefully examined, and every vestige of the 1 removed with a knife or scissors. If the bone appears • Listen and Matter's Surgery, p. 285. 23* 234 AFFECTIONS OF THE MOUTH. affected, it must be cut away, and often a very good preventive to the return of the disease is the use of the actual cautery. The bleeding may be arrested, either by the cautery, or by placing a pledget of lint, dipped in creosote, in the chasm, over which a slice of cork may be laid, and then closing the jaws, make the sound one act as a compress. To secure the dress- ing, the bandage for fracture of the lower jaw may be applied. The parts should not be examined in the first twenty-four hours; but after this period a daily dressing is required, the nature of which depends on circumstances. If there be no disposition to a return of the disease, it will be sufficient to wash the part with some detergent solution, until cicatrization is completed. But if fungous granulations make their appear- ance, the vegetable caustic, (caustic potassa,) or actual cautery, should be applied, until this disposition in the wound is de- stroyed. "Instead of using the perpendicular cuts with the short forceps, some prefer a thin saw, but the method just described is less painful, and accomplishes the object in a much shorter period. When the tumor is very large, the saw may be required, and should be always at hand, in case the edges of the forceps should turn in making the first cut. "When the tumor is very large, or seated in the side of the bone, or far back, the cheek should be divided, in order to enable us to reach it without difficulty. In such cases I have found great advantage in using a cutting forceps, so curved as to pass readily to the back part of the mouth, and then allow of the blades being passed above the base of the tumor, when the upper jaw is affected, and below it, when the inferior max- illary is the seat of the disease. "After the removal of the diseased mass, the wound of the cheek may be closed, and union by the first intention attempted; and when the dressings are carefully attended to, the deformity resulting from the incision is scarcely perceptible, unless the portio dura is extensively injured, when paralysis,- generally incurable, ensues, often giving rise to a very unpleasant ex- pression of countenance." AFFECTIONS OF THE MOUTH. 235 Of whatever kind these tumors may be, they should be care- fully watched. So long as they cause no inconvenience, they may be let alone, but if, by reason of growth or any other cause, they begin to inflame the surrounding parts, or to become pain- ful during the movements of the jaw or contact with air or food, they should be extirpated. If pendulous and accessible, a liga- ture or the knife may be used; but if broadly based and fully incorporated with the gum, and but small in size, caustic should be used. A number of cases have been collected by Jourdain, and published in his celebrated work on the diseases of the mouth, which show the serious character often assumed by epules. In truth, all forms of tumors may appear upon the gum, and the only difference to be observed in their treatment in this location, grows out of the impossibility of using applications and appli- ances which are found useful and convenient elsewhere. So far as tumors of the gums are concerned, the treatment is very limited indeed. If they contain matter, they must be opened; if connected with carious teeth, these must be removed; if with carious alveoli or maxillary bones, the treatment must be direct- «d to the deep seated cause ; if they are malignant, or if in any way inconvenient, they must be removed, either by cautery, ligature or incision, as the nature of the case may require. Parulis. — Abscess of the gum is so called. It is precisely similar to such tumors in other soft parts, and generally, if not always, depends upon carious teeth. Sometimes the abscess makes its appearance without pre- ceding pain, over the fang of a diseased tooth, and after re- maining for some time will gradually disappear, the matter it contains having been absorbed, or having found vent through an opening in the tooth. More commonly, however, the ab- scess succeeds a violent and protracted tooth-ache, which is the consequence of cold acting upon the irritable nerves of carious teeth and bad conditioned gums. The pain is sometimes very severe, but at all times there is an aching or throbbing sensa- tion, due to the inflamed state of the gum tissue. Sometimes several days and nights of severe suffering will elapse before 236 AFFECTIONS OF THE MOUTH. the abscess is seen to elevate itself from the gum : at other times it will be formed in a few hours. When first perceived, it is a hard circumscribed elevation, either immediately upon the gum or in the cellular tissue between the gum and cheek. After a longer or shorter time, the tumor softens, the pain abates, and fluctuation is perceived in the tumor. If no artificial means be employed to evacuate the matter, an opening will be made and the matter discharged. Sometimes, though very rarely, ulceration will perforate the cheek, and the pus be evacuated on the outside. This is an accident much to be deplored, and therefore, as soon as fluctuation is perceived be- tween the gum and cheek, the pus should be evacuated. During the inflammatory stage of the tumor, before pus is formed, little can be done except to apply leeches to it. This, if applied very early, will sometimes prevent suppuration, and more often limit its extent. After the tumor is fully formed, however, leeching will do no good. We can only soothe the patient by keeping the face warm, applying counter irritants to the cheek, and prescribing anodynes. Unless the diseased tooth be removed, the abscess will be formed again upon the slightest provocation. Generally, after the evacuation of the pus, the abscess is filled with granulations, and the parts return to their natural state. Sometimes, however, the tumor is due to slow suppuration of the fang or alveolus, and in this case the matter continues to trickle through the opening, the edges of which become thick- ened and hard, and a fistula is formed. Of course, the only remedy is to remove the diseased tooth or bone. It not unfrequently happens that abscesses are formed at the roots of teeth which appear sound, and after much pain endured by the patient, fistulous openings evacuate the matter which should have been discharged by extracting the tooth or teeth whose obscure disease produced and perpetuated the trouble. In illustration of this important fact, I will quote some cases reported by Jourdain. "The late Mr. Desjardins, surgeon, requested me to visit with him M. Rose, Place de Greve. AFFECTIONS OF THE MOUTH. 237 "This patient had been suffering for many days such violent pain along the whole extent of his chin, as to prevent him from, sleeping at night or pursuing his business by day. As no disease could be discovered in his teeth, and as they were not at all subject to ache from cold or heat, they were not suspected to cause the suffering. The patient was bled, but without effect, and the pain becoming excessive, I was called in. I first ex- amined the lower incisors, but could discover no signs of dis- ease. The other teeth also appeared sound. The lower part of the gums of the incisors appeared slightly reddened, but without swelling or fluctuation. A little purple exanthema upon the right gum was the only additional alteration that we could perceive, and this was not sufficient to determine the extraction of the tooth. "Thus uncertain how to act, I applied a lighted taper to these two teeth. From the reflection of the light, we satisfied our- selyes that the incisor tooth nearest to the canine was the cause "5th. Urinates without difficulty; bowels moved by injec- tions ; patient entirely free from pain ; pulse natural. "6th. Dressing removed ; the flap is uniting by the first intention along both sides, throughout its entire extent ; the greater part of the pins and stitches removed. "7th. The remainder of the pins and stitches removed; pa- tient perfectly comfortable and cheerful. "10th. Sat up all day by the window. "16th. Walked out to take an airing. "During the whole progress of the cure, there was not the slightest swelling or undue inflammation in the flap or about the neck. The patient was slightly hysterical for the first few days, but never complained of any thing but pain in the shoulder, a slight headache of a few hours duration, and the uneasiness oc- casioned by the retention of urine. The wound on the shoul- der granulated rapidly and skinned over in about six weeks after the operation. It was curious to observe ^hat upor touching the flap after it had healed in the neck, the patient would always refer the sensation to the shoulder or arm from which the flap was taken. "The confinement of the head, and the distortion of the face occasioned by the strictures being now removed, the next step was to relieve, as far as possible, the very. great deformity of the under lip. "The under lip, from being dragged down and greatly stretched by the former projection of the under jaw, was ren- dered greatly too large, so that it pouted out an inch or more further than the upper lip. This, together with a turning out of the mucous membrane on the left side, which extended nearly down to the lower edge of the chin, making the lip too short on that side, was the nature of the deformity yet to be relieved. "To remove this unseemly appearance of the lip, the inverted portion was cut out in a V shape, extending down to the flap in the neck, and sufficiently large to reduce the lip to its proper size. The edges were then brought together, and secured after the manner of a single hare-lip. The wound healed in TUMORS REQUIRING AMPUTATION. 281 the most beautiful manner, and the appearance of the lip was greatly improved; but there yet remained a deep depression or notch in the edge, sufficiently large to keep exposed the tops of two or three teeth, besides preventing the coming together of the lips on that side. "I now determined to raise, if possible, this depressed por- tion of the lip, and for this purpose I passed a bistoury through the lip, about two lines from the free edge, first on one side of the depression, and then on the other, and then carried the inci- sions downward to meet at a point on the lower edge of the chin. "The depressed portion of lip now lying between the two incisions was next dissected loose from the jaw, and then raised to a level with the remainder of the lip, and there re- tained by pins, after the manner of dressing a double hare-lip, the line of union forming a letter V. "This operation was as successful as the others, and the original deformity being now removed, the young lady., though still bearing evidences of the burn, has the free use of her head, eye-lids, jaws and lips, and may mingle in society without par- ticular note or remark." CHAPTER XX. DISEASES OF THE ANTRUM OR MAXILLARY SINUS. The cavity which bears these names is liable to be the seat of a variety of diseases. For the most part these are simple, and not at all malignant in their character ; occasionally, how- ever, tumors and ulcers of a carcinomatous kind fix their seat in this secluded cavity, where their presence is unobserved until their local devastations or constitutional impressions have reach- ed a most serious extent. The danger of diseases of the antrum, however, cannot be estimated entirely by their specific character. The geographi- cal situation of the cavity gives greater importance to its dis- eases than essentially belongs to them. Many a benign tumor, originating here, has proved fatal by mere growth and bulk ; the danger having been masked by the concealed position and the little sensibility of the parts, until interference was useless. Nothing can be more important, therefore, than early atten- tion to any of the, commonly obscure, symptoms which inti- mate the presence of diseased action of any kind in this patho- logically important sinus. The dentist commonly has the first opportunity to observe these signs and detect their cause, and he should always be ready to perceive and interpret them. The lining membrane of the antrum is liable to be affected by all the diseases common to the mucous tissues. It may be congested, inflamed and ulcerated ; it may undergo alterations affecting its secretions; it may be the seat of various tumors, or may be involved in sueh morbid formations commencing in the bony structures or the thin fibrous tissue which attaches it to the bones. In treating further of diseases of this cavity, I will ask the 284 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. attention of thareader to, 1st. Dropsy or retention of mucus ; 2d. Inflammation of the lining membrane ; 3d. Suppuration ; 4th. Caries, necrosis and other morbid conditions of the bony walls ; 5th. Polypi and other tumors ; 6th. The presence of insects in the cavity. Dropsy, or Retention of Mucus. The term dropsy is entirely misapplied to this affection, and should be discarded. The disease has no similarity to dropsi- cal swellings : those are occasioned by effusion of water, while the affection we are considering is a distension of the antral cavity by retained mucus. If from any cause the antral openings become closed, the secretion of the lining membrane, no longer finding exit by evaporation, must accumulate in the cavity of the sinus. Being retained, it will necessarily degenerate ; being degenerated, it will irritate the membrane, and the membrane being irritated, will pour^out more than its usual quantity of secretion. The quantity accumulated will at length completely fill the cavity, and when once the sinus is completely filled, every additional drop of fluid thrown into it will cause the whole mass to act with great power upon the walls which confine it. However thick the walls, and however strongly knit together, they cannot withstand the hydraulic pressure continually augmenting within them. They are gradually forced outwards, and a rounded solid tumor gives external evidence of the outward pressure of the contained fluid. Until the pressure becomes sufficient to distend the bones, the patient does not complain of pain ; but as the walls of the cavity gradually yield and press upon the soft parts, pain is felt, which becomes more and more severe as the tumor increases. The^integuments covering the distended antrum become swollen and red. A smooth hard tumor presents itself, either in the roof of the mouth, or under the orbit, or under the cheek, and unless the contained fluid be speedily evacuated, the contents of the antrum will force their way through the bones. DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 285 As the distension of the walls of the sinus indicates nothing more than the fact of its being filled with some distending body, it may often be difficult at first to decide whether the contents be mucus or some kind of solid growth. So long as the tumor presents a tolerably uniform hard surface, there can be no cer- tainty of the nature of the distending cause ; but the uniformity of the tumor, the sense of weight, the slight discomfort or pain attending it, and, finally, the discovery of fluctuation will deter- mine the diagnosis. The indication, of course, is to make an artificial opening and permit the escape of the contained matter, and then to make such applications to the lining membrane of the antrum, as will restore the natural secretion of the part- There is no difficulty in making the required opening. The antrum is accessible at many points, and might be perforated almost any where without danger. Yet it is a very important thing to choose that point where the wall is thinnest, and where the perforation may be made with least pain and least in- jury to the parts, and which affords the most facility for the es- cape of the matter, during such length of time as an artificial opening may be necessary. Jourdain, a French surgeon, who wrote very ably upon dis- eases of the sinus, recommended to the Academy of Surgery in Paris, that a sound should be passed into the antrum, through the natural opening. He represented that the operation was feasible, and being so, was, for many reasons, preferable to any other. Upon experiment, however, this mode of procedure has been found very difficult of execution in all cases, and altogether impossible in many, and it is no longer attempted. The fangs of the molar teeth sometimes penetrate the cavity of the antrum, and generally their extremities are separated from it by a very thin bony partition. The cavity of the antrum is de- pressed posteriorly, and the position of the molar teeth repre- sents the most depending part of it. It is, therefore, most ad- visable to make the opening through the alveolus of one of these teeth. Should one have been previously extracted, we should make the opening through its vacant alveolus; should all these 28 286 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. teeth be yet in the jaw, one must be extracted, and of course, we should sacrifice a carious, in preference to a sound tooth. Should all be sound, it would be best to extract the second mo- lar. Sometimes it will be necessary to extract two teeth, in order to obtain sufficient room for such an opening as will be desirable. Sometimes the extraction of the tooth will be followed at once by the discharge of the fluid ; an opening having been made into the antrum by tearing away the fang. More gen- erally, however, it will be necessary to puncture the floor of the cavity. The instrument preferred by Dr. C. A. Harris, for whose opinion, in such matters, I have great respect, is a straight tro- car. The point of this instrument having been passed into the alveolus, should be pressed against the bottom, in a direction towards the centre of the antrum. The intervening plate of bone, may then be easily pierced by a few rotary movements of the trocar. Care must be taken so to moderate the pressure applied, that the instrument may not, upon the giving way of the floor, be suddenly pushed across the cavity and made to wound the opposite surface. Upon the removal of the instrument, a gush of fluid will fol- low. Should the opening not be sufficiently large to permit of the free passage of the thick matter which may be contained in the cavity, it will be easy to enlarge it. Some surgeons advise that a bougie should be kept in the opening, others prefer a canula of lead or silver. Richter ob- serves, that if a canula be left in, it should be carefully stopped, lest particles of food and drink should find their way into the cavity. Deschamps and Harris advise that the canula be se- cured to the adjacent teeth, and left in the opening. If a bou- gie be used, it should be removed two or three times a day, in order to permit the matter to escape. If fistulas have previously been formed, they will generally close after the dependent opening has been made. Should they not heal readily, their closure may be facilitated by touching their callous edges with nitrate of silver. DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 287 Having removed the mechanical evil, by evacuating the ac- cumulated fluids, we must accomplish a cure by such constitu- tional treatment as the case may require, and by suitable local applications to the lining membrane of the antrum. At first, warm water may be injected, in order thoroughly to cleanse the surface of the membrane, and subsequently we may throw in astringent or mildly stimulating applications, such as port wine and water, solutions of sul. zinc, sul. capri, or even of nit. argenti. As the secretions are fetid, a weak solution of chloride of lime, or chloride of soda, may, be injected two or three times a day. Should the gums be inflamed, leeches must be applied from time to time, until the inflammation be sub- dued. As the morbid condition of the mucous lining of the cavity may result from the irritation of diseased teeth or fangs, all sus- pected irritants of this kind must be removed. In Mott's edition of Velpeau, I find the following remark — "If, as happens frequently, the sinus is distended by any liquid, its anterior wall swollen out in the form of a border under the cheek is, in general, so soft that a bistoury or scalpel penetrates it without any difficulty. The operation is then extremely sim- ple. Having freely incised the superior part of this border transversely between the cheek and malar bone, I excite its inferior portion with a second cut of the bistoury. The loss of substance thus made, remains fistulous, and prevents the sinus from filling up a second time. The three patients which I treated in this way were promptly cured." Should the teeth have been long previously lost, and the al- veolus obliterated, the operator must choose between dissecting off the gum and boring his way into the antrum at the point already indicated, or performing some one of the several other modes of operation which have been preferred. Lamorier di- rects, in such cases, that we should penetrate into the maxil- lary sinus immediately below the zygomatic process, between the cheek bone and third molar tooth. This is the point which corresponds to the summit of the cavity, where the walls are thinnest. An assistant, provided with a blunt hook draws the 288 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. labial angle outwards and upwards. The operator incises the fibro-mucous membrane, which covers the bone at the point des- ignated, by means of a scalpel or good bistoury; then perforates the osseous wall with a solid pointed instrument, enlarges the opening as much as he judges necessary, and finishes by in- troducing into it a tent of lint. Other surgeons prefer the method originally suggested by Molinetti, first to divide the cheek between the projection of the malar bone and the suborbital foramen, then to penetrate through this wound into the interior of the sinus. In a patient who had no longer any molar teeth, the idea oc- curred to Gooch of perforating the antrum highmoranium on its nasal wall, and of inserting therein a leaden canula. A buccal fistula of the maxillary sinus suggested to RufFel to penetrate that cavity with a trocar, and to compel it to come out above the gum, in order thereby to establish a counter opening. A seton was then introduced and kept in this pas- sage during the space of six weeks with such benefit that suc- cess crowned the enterprize of the surgeon. Cullison recommended that if the fluctuation should become perceptible at the vault of the palate, the artificial opening should be established there. Basch and Henkel have suc- ceeded by means of a meche introduced through a fistula in the floor of the orbit, and brought into the mouth through an open- ing in the alveoli. Bertrandi proceeded in the same manner, with the exception of not using the seton, in a patient who could not open his mouth, and who also had a fistula in the orbitar wall of the sinus. In the process of Weinhold, the surgeon first directs his in- strument to the upper and outer part of the canine fossa, directs it obliquely downwards and outwards, carefully avoids the branches of the suborbitar nerve, perforates the sinus and then leaves a roll of lint in the wound. If the sinus has no other issue, Weinhold recommends that we should perforate it through and through, either by pushing the first instrument through the palatine vault into the mouth, or by means of a curved needle above the alveoli, when we wish to place the counter opening DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 289 external to the guru. An eye which both instruments here en- ables us at the same time to pass through the sinus the con- ducting thread of a meche of lint destined to perform the duty of a seton, and which may be smeared with any proper oint- ment.* The disease we are considering is not by any means serious, as it depends upon slight and generally temporary alterations in the antral membrane. Recovery, however, is slow, and we must not expect to accomplish a cure under a period of several weeks. Inflammation. The lining membrane of the antrum may be inflamed from a variety of causes. Severe blows upon the face, injuring, per- haps breaking, the external walls of the cavity; cold acting for a long time upon the face ; the accumulation of mucus within the cavity, undergoing degeneration, and becoming irritating to the surface upon which it rests — all these may, occasionally, induce inflammation of the sinus. But, undoubtedly, the most common cause is found in the diseases of the teeth, gums and dental periostea, which are communicated to the lining of the antrum. The chief symptom of inflammation of the sinus is a dull, continuous pain in the upper jaw, gradually becoming more severe, spreading to the border of the alveolus, and seeming to fix itself in the roots of the molar and canine teeth. It some- times occupies the whole side of the face, extending to the or- bit and frontal sinus. The inflammation may begin in the teeth, and gradually extend to the antrum, in which case the severer and more paroxysmal pain of tooth-ache will accompany the duller, deeper, more continuous ache of the antrum. As the pain increases, fever is developed, which will be more or less considerable, according to the degree of the inflammation and the sensibility of the patient. * Mott's Velpeau's Surgery, vol. iii. 28* 290 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. Inflammation of the sinus can hardly be confounded with engorgement. In the latter case there is swelling of the bones, and in the former there is pain from the commencement of the attack. In fact, it cannot be mistaken except for inflammatory odontalgia, affecting the roots of the molar teeth; and from this, if these teeth be decayed, it cannot always be distin- guished. In inflammation of the antrum, we must use leeches to the gums, and, unless there be some good reason for omitting it, general bleeding from the arm, saline cathartics, and, in short, the whole antiphlogistic means. Opium may be used freely to lull the pain, and warm applications, by vapor or poultices, may also be tried. If, however, there be pain which seems to be similar to tooth- ache, and if some of the teeth, especially the molars, be dis- eased, and especially if one or more of them have been in the habit of aching, no permanent cure can be expected without removing them. For the most part, however, we ought not to attempt this operation while the inflammation is unsubdued, as the injury inflicted by the violence of extraction must increase the vascu- lar excitement of the part, and aggravate the distress of the pa- tient. When the inflammation has been subdued, and the morbid irritability of the parts has subsided, the mouth should be carefully examined, and all diseased teeth removed. Suppuration. The inflammation of the mucous membrane of the antrum generally terminates in resolution ; sometimes, however, it ends in the formation of pus, or suppuration. When such is unfortunately the case, the pain gradually be- comes less intolerable, and finally ceases in a great degree. The fever subsides, the patient may feel some rigors, and instead of acute pain there is felt a throbbing sensation in the part. If the outlet of the sinus be open, pus will escape into the nostril, and unless it finds a free vent, some pouting will, after a while, DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 291 be perceived in the alveolar border, or a bony protrusion will be noticed upon the cheek. Suppuration of the antrum may occur without preceding ac- tive inflammation. Some cachectic habits are exceedingly prone to a slow, feeble inflammation, which is not attended by acute symptoms, and is apt to end in the formation of ill con- ditioned pus, and frequently in ulceration of mucous membranes. This kind of suppuration is not uncommon in the antrum, and the inflammation preceding it is not unfrequently unperceived until the greater mischief of suppuration or ulceration has been accomplished. Even after suppuration, the true nature of the evil may be unsuspected ; the more so, that the preceding in- flammation has been unperceived. When there is dull, continuous pain along the border of the sinus, apparently not depending upon caries of the teeth, if there be swelling of the sinus, especially if the patient be of a strumous habit of body, we may suspect suppuration of the sinus. Should pus escape into the nostril, of course the diag- nosis will be complete. If there are any carious teeth, they should be removed. They may be the cause of the pain ; they may even be the cause of the suppuration. In any case, their presence is mischievous, and, moreover, we must have access to the cavity through the alveoli. The treatment must be similar to that recommended for mu- cous accumulation. Should the disease be the consequence of general ill health or depraved constitution, the proper consti- tutional means must be employed. The mouth must be cleared of decaying teeth, and the patient must avoid exposure to cold. Caries, Necrosis, and other Morbid Conditions of the Bony Walls. Caries is an affection of the bone, somewhat analogous to ulceration of the soft parts. In this disease there is loss of substance, causing, for the most part, irregular perforations of the osseous structure, giving, in many instances, a honey- 292 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. combed or worm-eaten appearance; at other times the destruc- tion may appear in a continuous superficial excavation. There is a discharge of a dark, fetid, sanious pus, and frequently a growth of fungous granulations shooting up from the excava- tions. The bones, though hard and dense, are vital structures. They are supplied with blood-vessels and nerves, and cellular tissue. They are capable of growth and reproduction, of ab- sorption, and separation of dead from the living parts, by a vital process. Of course they are subject to disease — and to diseases only differing in appearance from those affecting softer structures, by the necessary modifications resulting from the peculiar density of the osseous structures. Caries may occur in bones from the same causes which in- duce ulceration in the soft parts. Any thing which lessens the vitality of the parts, diminishes its nutrition, or causes exces- sive intersticial absorption, may cause caries. External injuries may be the exciting cause, though far more commonly productive of necrosis. Long continued inflamma- tion or irritation of neighboring parts; inflammation of the periosteum, and, above all, certain constitutional vitiations, are causes of caries. Scrofulous persons, and those whose fluids are tainted with the syphilitic poison, are most apt to engender this and other diseases of the bones. Generally, a fistulous ulcer, somewhere in the vicinity of the carious bone, will discharge the dark colored, fetid and often bloody pus which I have mentioned, and this will generally be a sufficient evidence that caries lies beneath. M. Strack, how- ever, is quoted by Jourdain, as having met with an ulcer in every way similar to those usually marking caries, which was, in reality, unconnected with any disease of the bone. When the finger can be brought in contact with the bone, which, however, can rarely be the case, the roughened .feeling of the surface will at once determine the diagnosis. When this kind of examination cannot be made, a silver probe may often be passed to the bottom of the fistula, and the rough, grated DISEASES OF THE ANTRUM OF MAXILLARY SINUS. 293 surface of the bone perceived. Very often, however, the canal through which the pus escapes is too tortuous to permit of satisfactory exploration. If caries be not checked, it will end in necrosis, or complete death of the diseased bone; caries, however, is not necessary to necrosis, for the latter may occur without being preceded by the former. Necrosis may be caused by any means which destroys the nutrition of the bone or any part of it. These causes are some- times external; more commonly, perhaps, they depend, at least for their predisposing cause, upon constitutional vitiations, or defects of nutrition consequent upon general pravity. When the walls of the antrum or alveoli are carious or ne- crosed, the soft parts adjacent inflame, ulcerate, and discharge a fetid, sanious or ichorous pus. Sometimes the gums lose their vitality, become gangrenous, and are slowly separated by sphacelation. Dr. Harris observes, that it frequently happens, that while caries is preying upon the antrum, its walls become softened to such an extent that they may be bent. This alteration of the bone, as well as the caries and necrosis, are, he says, in almost every instance, preceded by some other affection of the antrum. Caries and gangrene of the antrum are very distressing affec- tions, as, even when there is vitality enough in the bone to check the caries or throw off the sequestrum, the process is very slow; the fetid discharge of pus and the extreme sensitiveness of the inflamed and fungous soft parts, produce great misery to the sufferer, and excite the lively sympathy of all who witness his distress. The severest operation, which promises relief, will commonly be endured with patience by the unhappy victim of so protracted and intolerable a disorder. It is not always easy to detect the existence of caries in the antrum, as the symptoms manifested by the surrounding parts, or detected through them, are similar in different affections. Should sanious pus make its appearance, we may generally infer the existence of caries; but in a few instances, the pus has been of a normal character and appearance, and though 294 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. the presence of the pus, in appearance such as commonly attends caries, may satisfy us that such a state of the bone ex- ists, the absence of such pus is not equally satisfactory evidence that the bone is entire. The exfoliation of pieces of bone would of course dispel all doubts as to the nature of the disease. By probing where there is an ulcer, or by making an artifi- cial opening where none exists, we can gently introduce a blunt probe and explore the suspected bone. When the alveolar border or floor of the antrum is the seat of the caries or necrosis, there is little difficulty in ascertaining the seat and nature of the disease. The swollen and purplish appearance of the gums will attract attention to the alveolar border: and soon separating from the sockets, ulcerating and sloughing, they will lay bare the dis- eased bone, and expose the true character of the disease. "When situated in the floor of the antrum, the rough denuded bone may be easily felt with a probe or stilet, introduced through the fistula in the gums or alveolus of a tooth from which the matter is discharged." — (Harris.) Whatever may be the remote causes of caries and necrosis of the antral bones, the immediate cause is defective nutrition, resulting from disease or destruction of the periosteum; and among the most common causes of periosteal disease, are the irritation produced by diseased teeth, and that caused by the ac- tion of fluid detained in the cavity. The first step towards cure, must be to evacuate any mucus which may be distending the antral chamber, and to remove any diseased teeth which may be suspected of causing irrita- tion. The following case reported by Deschamps* will serve to show that I have not laid unnecessary stress upon the agency of diseased teeth, in the production of caries of the maxillary bones. Mr. Martin the elder, who enjoyed at Lyons, a well merited reputation, communicated to me the following case: *Traite des Maladies des fosses Nazales et de leurs sinus. DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 295 M. D. had a carious tooth in the upper jaw of the left side. A dentist having refused to extract it, a violent inflammation occurred in the alveolus, and subsequently was communicated, to the maxillary sinus. The result was a deposit of matter in the cavity of the antrum, and consequently a necrosis of the greater part of its anterior and inferior wall. When the patient called upon M. Martin, he was passing a bloody and very fetid matter through his left nostril. The pos- terior part of the alveolar border felt denuded, and was covered with fetid mucus. Externally a considerable tumor occupied all the left side of the face, from the orbit to the border of the lower jaw. The appearances fully satisfying Mr. Martin as to the nature of the affection, he decided to attempt the extraction of the pieces of necrosed bone, in order to open a way into the interior of the sinus, and explore the state of the lining mem- brane. By the aid of the elevator, he detached a fragment about ten lines in length, which appeared to belong partly to the alveolar border, partly to the palatine and partly to the malar apophysis. In the meantime, carrying his finger into the opening he had made, he perceived yet two or three rough points, which led him to believe that he had not yet got away all the fragments. He postponed further efforts to the next day. Then he took away another fragment which appeared to belong to the ante- rior wall of the sinus, and which was larger than the piece pre- viously removed. After this he could find no more asperities, and he assured the patient that the operation, so far as the ex- traction of bone was concerned, was completed. No fungus could be perceived, and after the first day, the discharge of pus through the nostrils and mouth had nearly ceased. In less than five days, the tumor of the cheek had subsided : the patient suffered no pain, and his breath ceased to be fetid. The only remaining inconvenience was an imperfection of speech, which resulted from the communication between the sinus and the mouth, and which would be remedied when the opening of the alveolus should be closed either by the junc- tion of the gums or reproduction of osseous matter. 296 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. Dr. Francis, of New York, describes a form of this disease which occurs in infants in hospitals, and under circumstances when the nutrition is impeded, as by scrofula, unwholesome air, insufficient aliment, &c. The disease frequently begins at the edge of the gums in contact with the incisor teeth. The soft parts become tumid with hardness and pain. Sometimes the greater part of the side of the face assumes an erythematous as- pect without any premonitory signs ; and this is subsequent- ly marked by spots of a dark purple or brown color. Sometimes the part becomes speedily sphacelated, sloughing commences and emits fetid exhalations. The tongue is loaded with a foul sordes, and the breath becomes exceedingly offensive, when coma will supervene and death suddenly ensue. In other instances the teeth will become loose in the commencement of the disease, and not unfrequently drop out on the slightest ex- ertion or motion of the jaw. The necrosis in some cases, will involve full one side of the jaw, and the ulceration extend equally over the soft parts and affect the alae nasi, the nose itself and the cheek nearly to the orbit of the eye. Very soon the sphacelated flesh falls in, and the internal structure of the mouth will be exposed, while the lips will become tumid, painful and dis- colored. These mordid changes, to a greater or less extent, are found to involve, very speedily, the teeth, alveoli, mucous surfaces and cheeks. The disease is very dangerous, and often rapidly fatal. In these cases, the disease is evidently the effect of con- stitutional causes, and no local treatment can arrest the devas- tation. It was once fashionable for surgeons to make use of the most violent means for the cure of caries. The diseased bone was cut or burnt away, and the subjacent part carefully cau- terized with a red hot iron, in order to prevent the spread of the disorder. Such terrible means were rarely justifiable. When the disease is entirely local, and the constitution sound, all that the surgeon can do is to remove the cause of the caries, if yet existing — to lay bare the diseased part, in order to give egress to the fluids, and admit the atmospheric air, which is a stimu- lant to the parts — or any other moderate stimulant which may DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 297 seem likely to hurry the process by which the great surgeon, nature, is limiting and repairing the injury. The diseased parts should be cleansed with astringent and detergent washes; loose pieces of bone should be removed, and the patient ren- dered as comfortable as possible, and properly sustained by such nutriment as may be best adapted to his state of strength. Med- dlesome surgery is bad. When there is constitutional disorder, causing caries, or pre- venting the curative process, there will be no prospect of relief, unless the constitutional disease be removed. If the venereal poison has tainted the system, it must be counteracted by the specific means which so generally neutralize it. Should scrofula be the form of constitutional pravity, we must use, with far less hope, those general measures of regimen, diet and medication, which promise most in such cases. When necrosis has taken place, the bone must be removed. By doing this, we do not interfere with, but assist nature, ac- complishing at once, by mechanical means, what by the natural effort might not have been effected during weeks or months. Should a very large opening be made in the floor of the an- trum, it may not be closed by the unaided efforts of nature. In such case, it has been recommended to cauterize the interior circumference of the opening, in order to remove the edges, and induce greater activity in the parts. If the opening has been too great to permit of closure by the process of reproduction, we must make the best substitute we can for the lost parts, as it is imperatively necessary to close the cavity. "An obturator of gold should be accurately fitted to the parts, and secured by means of a broad clasp to a molar or bicuspid tooth; and if there be none suitable on the side of the mouth to which it is to be applied, the gold should be extended to one on the oppo- site side. If it be necessary to replace the teeth lost with arti- ficial ones, these may be so mounted that the plate upon which they are set shall cover the opening into the maxillary sinus, and thus obviate the necessity of any other obturator." — Harris. •29 298 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. Softening of the Bony Walls. Mollities ossium, or softening and increased flexibility of the bones, is due to a diminution of the normal quantity of the phosphate of lime, to which earthy ingredient the hardness of the bones is due. This may occur either from absorption of the earthy matter, or failure of the arteries to deposit it in sufficient quantity. It is a rare disease, but it sometimes occurs in the antrum. Unless accompanied by a similar condition in other osseous structures, it may be regarded as the consequence of some pressure from within the cavity, either by a tumor or con- tained fluid. So far as the softening itself is concerned, it cannot be considered a subject for medical or surgical treatment. Exostosis. This affection is a hypertrophy or morbid growth of the bone, in which the phosphate of lime is deposited in unusual quantity, and a hard tumor occasioned. It is not painful of itself, but by distension of the periosteum and superincumbent soft parts, it may gradually become a source of great distress. Generally, however, as the tumor augments slowly, the soft parts adjust themselves to the increased bulk of the bone, and the patient escapes serious suffering. Much, however, will depend upon the magnitude and position of the swelling, and upon the attendant condition of the periosteum. Should this be inflamed and sensitive, it may occasion acute pain. I have already described this kind of morbid growth, in treating of tumors. The bones of the face have very often been the seat of exos- tosis, and many formidable operations have been performed for the removal of such tumors. A number of such cases and ope- rations have been described, both by the older and modern sur- geons.* These tumors sometimes attain to great size. M. Beaupreau *|See Mott's Velpeau, vol. iii, p. 134. DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 299 presented to the French Academy, in the year 1767, an ana- tomical preparation, consisting of a tumor which occupied the whole right maxillary sinus, and several of the neighboring bones. Its largest circumference is about twelve inches. The upper part of the maxillary bone projects on the side of the orbit, and straightens the cavity ; the os unguis is included in the mass of the tumor, and is nearly effaced. The nasal bones of the left side are displaced, and the right nostril entirely closed up; and the exostosis projects so much on the left side as to be nearly under the malar bone. "Exteriorly," says Bor- denave, "the tumor had a smooth and polished appearance, and its upper part was very hard. Interiorly, the substance of the bone was spongy, and not unlike pumice-stone." Sir Astley Cooper describes a case of exostosis of each an- trum, which pushed out both eyes, and eventually destroyed the patient by pressure upon the brain. Jourdain notices an interesting case of this kind, reported by M. David, chief surgeon of the Hotel-Dieu of Rouen, and adds the following, which came under his own observation : Joseph Forcade, surgeon, had a son, who in early life gave promise of great vigor of mind and body. When six years old, he had the small-pox, which ran a most favorable course. When twelve years old, his father lanced a tumor at the inner canthus of the right eye, which suppurated for a long time after. Immediately after this, a prominence appeared about the mid- dle of the nasal process of the right superior maxilla; and in spite of every application, steadily increased until it had attain- ed considerable size. When the boy was fifteen, both maxillae were equally enlarged ; the bones of the nose seemed buried between the tumors, and its cartilages were so compressed as to impede breathing. The deformity was great, and at the age of twenty became, by the growth of the tumors, monstrous. The lower jaw became also exostosed, and acquired a very great size. Though the deformity was shocking, it did not prevent the lad from travelling about and gratifying his naturally curious disposition. He was clever, lively, fond of good living, and 300 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. particularly of stimulating drinks. At the age of forty-four he was seized with a malignant fever — his first sickness since infancy — from which he was slowly recovering, when he was seized with pneumonia, of which he died. Upon post-mortem examination, says Jourdain, I could find on the face no trace of any muscles except those of masti- cation ; but the skin seemed tightly drawn over the periosteum covering the numerous tumors. The head and face were every where exostosed, and as hard as marble. When the brain and soft parts were removed, the bones weighed in all more than eight pounds. The lower jaw alone weighed one pound, three ounces. The usual weight of this bone in an adult is one pound, nine ounces, showing an increased weight, in consequence of these exostoses, of six pounds, seven ounces. The patient had never complained of pain, either in his head or face. The symptoms of maxillary exostoses are very obscure. We have already seen that the disease may exist to an enormous extent without causing pain, the soft parts gradually thinning and distending before the pressure. When pain does exist, that symptom alone is not sufficient to convince us of the pres- ence of exostosis. We have no certain sign but the peculiarly hard bony swelling. When the disease is accompanied by periostitis, which it is particularly liable to be when occasioned by syphilitic constitu- tional vitiation, the pain may be sufficiently acute. It is in cases such as these, that constitutional treatment has been found to arrest the deposition of bony matter, and the remedies most successfully used have been precisely such as are most efficient in constitutional lues. When no such taint exists, little can be done except to remove the tumor before its extent renders an operation difficult or impracticable. In many instances this has resulted in permanent relief. Fistula of the Superior Maxillary Bone. Bones seem, notwithstanding their density, to be capable of inflammation, and even of abscess. I have already mentioned DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 301 caries as a kind of osteose ulceration, and there are many cases on record which seem to show that pus may be formed within a bone, distend its layers and ultimately perforate its structures and evacuate itself through a fistulous opening. Probably in such cases, the suppuration is in the cellular tissue of the or gan, rather than in the proper osseous tissues. Jourdain records ten cases of this character, of which I have selected the following : Case I. — A lady suffered with inflammation of the root of an upper first bicuspis on the right side, followed by alveolar abscess. After the inflammation had subsided, the tooth was removed ; but a fistulous opening still remained, emitting an ichorous discharge. After three months endurance of this, the patient took advice, had the fistula cut out and dressed with balsam. It healed, and for five months seemed perfectly cured. But the bone again swelled on the site of the old disease, and now extended as far as the second molar, was very hard, and was attended with deep seated pains : the. gums were inflamed and the tumor increased daily. Consultation was held, and opinions differed. Some thought it exostosis, others that the sinus was involved. The late M. Morand called me (Jourdain) into the case, and we concluded, upon careful examination, that by piercing a swollen spot in the gum just above the old fistula, we should come upon an open- ing into the interior of the bone. The introduction of an in- strument to the depth of a line and a half caused a free discharge of sanguino-purulent matter, and the probe passed very freely into the cavity in the bone, the walls of which, above and below, seemed very firm. The socket of the extracted tooth had com- pletely healed up. M. Morand was in favor of an incision through the bone for the purpose of excising the distended portion of bone, but with that unprejudiced liberality which always marks the man of true wisdom, he yielded to my arguments in favor of the cav- ity. I introduced the hot iron into the fistulous opening three times in eight days, following it up with suitable injections, which frequently brought away small fragments of bone from 29* 302 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. the interior of the cavity. The alveolus was soon reduced to its natural size, and in forty-three days the patient was perfect ly cured. Case II. — Madame Massonet was referred to me by M. Mo- reau, of the Hotel Dieu, for a fistula above and between the first and second superior incisors. At the posterior part of the palatine arch there was a considerable tumor, without pain, softening, or change of color. From the summit of this tumor along the inner side of the alveolar ridge was a prominent line which seemed to mark the course of a fistulous canal from the external orifice to the tumor behind. No further cause could be assigned than the fact that some years previously, the patient had received a severe fall, from which time the second molar became painful and gradually loosened. I removed this tooth, but without any benefit to the tumor. The other teeth were sound. Injections and other means had been tried at the time of the appearance of the ex- ternal fistula, but unsuccessfully. I regarded this case as one of true abscess of the bone. I ventured, M. Morand approving, to enlarge the external opening and make an incision through the entire palatine tumor, which discharged only blood. Suit- able injections and gargles were used, but to no purpose. I then decided to lay open with a knife the whole course of the supposed canal above mentioned, and touch it with mercurial water. On the third day, exfoliation of the parts thus touched exposed this canal. The subsequent treatment was very sim- ple. The fistula was readily closed ; and in six weeks the pa- tient was sent home, perfectly restored. Case III. — Madam Boillard had a fistula on the anterior surface of the superior maxillary bone, the result of an alveolar abscess of one of the incisors. Those teeth were so much worn away as scarcely to project above the gum, but were not at all carious. An operator, who was consulted, extracted the second right incisor, which was immediately under the site of the abscess, and subsequently the first incisor of the same side, but without benefit. He then gave up the case, and the lady consulted me. DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 303 I discovered by the introduction of the sound that the fistu- lous canal extended from the right second incisor in a tortuous direction, to the left canine, and as the two incisors on this side were very loose, I extracted them and found their sockets much softened. By destroying this softened bone, I established a free and direct communication for the escape of the purulent secretion of the fistulous canal. By medicated pledges of lint, I healed the parts. There was some exfoliation of the alveolar substance, and a cure speedily resulted. We see from this case, that caries is not the only cause of this disease. Irritation and inflammation of the dental pulp may occasion suppuration within the tooth cavity, which find- ing no vent in the direction of the crown, must escape at the extremity of the root, and may cause abscess, infiltration of the alveolar structure, and other grave injuries. In such cases a canal might be drilled through the crown, thus giving a direct escape for the matter, but if the suppuration have already ex- tended to the alveolar socket, the extraction of the tooth is most advisable. (Extraction is always most advisable.) Case IV. M. Petit sent to me a boy, who for a year past had been troubled with a fistula just above the left nostril. It had come without any previous dental inflammation or tooth- ache, and had, therefore, been supposed by those who saw the case before me, to be consequent upon caries of the alveolus. A long and painful treatment based upon this diagnosis, served only to increase the ulcer. With my probe I could touch the root of the second incisor, which, however, had never given any pain or uneasiness. On pressing my probe up with some force, I gave vent to a considerable discharge of pus, yet there was no tumefaction of the gum or loosening of the tooth. With some difficulty I prevailed upon the patient to allow the extraction of the tooth. This done, the pretended cancer healed in eight days. In this case there was evidently inflammation of the alveolar or exo-dental periosteum. Case V. A person came to Paris for the relief of an affection which resulted from alveolar abscess over the fangs of a decay- 304 DISEASES OP THE ANTRUM OR MAXILLARY SINUS. ed first molar of the right side. After the first attack, although the abscess discharged itself freely, a sensation remained in the cheek, as though there was a small stone there. The second attack though attended by a free escape of pus, left the cheek hard and swollen, and the eye-lid much distended with a pecu- liar clammy feeling in the region of the zygomatic and malar bones. I first saw the disease at this stage. On examining the mouth, I found a fistula between the gum and cheek, which penetrated the latter in a tortuous direction, and discharged an ichorous fluid. I removed the fangs of the first molar, but only blood followed the extraction. On the fourth day, fluctuation was perceptible under the eye- lid, and on the sixth day, I made an incision then in the direc- tion of the fibres of the orbicularis muscle. As the swelling subsided, I used a compress bandage, taking care to keep open the incision till all deep seated suppuration had ceased. The subsequent cure was attended with no difficulty. The student will find a number of other cases reported by Jourdain, whose work on the diseases and surgical operations of the mouth is a treasury of information upon these subjects. Though an old work, it is little known to the profession in this country, as it was not translated until the present year. An excellent translation, enriched with a number of very just ob- servations, has recently been published by Messrs. Lindsay & Blakiston of Philadelphia. This translation is the work of a graduate of the Baltimore College of Dental Surgery ; a young gentleman of much promise, whose extreme modesty has not permitted him to announce his name. The work should be in the hands of every surgeon, and surgeon dentist in the land. Ozena* This is a term applied to all these cases of fetid breath occa- sioned by inveterate ulcers of the primary air passages. These ulcers are sometimes seated in the antrum, sometimes in the * 0£i7, a stench. DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 305 nasal fossa and are frequently connected with and owe their fetor to caries of the bones. They are, therefore, more com- mon in syphilitic and scrofulous subjects. The breath of persons afflicted with ozena is often so offen- sive as to render them almost intolerable to others, and the consciousness of the disgust which their presence occasions, is naturally a source of continual mortification and distress. Where the ulcer can be perceived and reached, it should be touched with the nitrate of silver, and the application repeated until cure is effected. When no direct application can be made through the natural openings, as must be the case when the sore is seated in the antrum, an opening must be made as before directed, and a solution of nitrate of silver in- jected, if the caustic cannot be immediately applied to the part. If the patient be tainted with syphilitic disease, no local remedy can be effectual. He must be placed at once under proper con- stitutional treatment, and this must be persevered in until the vice be eradicated. In case of scrofula, the same remark ap- plies. Local remedies, however, are not by any means to be neglected. They may very much hasten the cure, and perhaps may render effectual, constitutional means which otherwise might be impotent. Every expedient should be tried before leaving the patient to suffer the distress and serious inconveniences attendant upon such a disgusting disease. Polypi and other Tumors. Polypi* are tumors of various consistencies and rapid growth, which appear in several cavities of the body which are lined by mucous membranes, but are most common in the nose, uterus and maxillary sinus. They also occur, occasionally, in the rec- tum and vagina. They occur much more frequently in the nose than elsewhere, and next to the nose, in the uterus. * IIoXv;, many — «ouj, a foot. 306 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. The tumor growing into all the irregular cavities of the nasal fossa, &c. has sometimes an irregular form, which from a fancied resemblance to the animal of the same name, has originated its designation. Several varieties of polypoid tumors are described by writers. Mr. Pott thought one class of them always malignant, and an- other benign. The one like carcinoma being painful, causing constitutional irritation through morbid processes developed within itself, and tending to convert adjacent tissues into its own morbid structure, the other not painful, not causing any suffering, local or constitutional, except indirectly by producing pressure upon other parts or rilling up cavities which are necessary to be kept open. In short, he considered that one class of polypi, the benign, are inconvenient or even fatal, merely by mechani- cal action ; while the other, or malignant class, though equally troublesome by their pressure and obstruction which they cause, are per se pathologically dangerous to the health and life. Deschamps describes four varieties, which he calls vascular fungus, mucous lymphatic, scirrhous and sarcomatous. Dr. Warren classifies polypi as membranous, fibrous and vas- cular. The latter, he says, is rare. Jourdain recognised three kinds — one loose, pale, indolent and benign, also called vesic- ular polypus ; another, hard, unyielding, livid and painful, marked with veins, and often hideous ; and a third, fleshy, elongated and easily stretched. Samuel Cooper observes, "Some polypi are red, soft and sensible, but free from pain, and exactly like a piece of healthy flesh. When this kind of polypus is of a softer consistence, semi-transparent, and of a pale, yellowish color in consequence of being less vascular, it is called the gelatinous polypus, and usually arises from the mucous membrane of the side of the an- trum, or the middle of the cavity of the nostril between the up- per and lower turbinated bone. No doubt carcinomatous tu- mors in the antrum have occasionally been confounded with polypi, but there is no good reason for believing as some have asserted that true polypi never originate in that cavity. Many eminent surgeons have testified to having met with true antral polypi. DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 307 When a polypus of the benign kind occurs in the antrum, it may escape detection until it has completely filled the cavity and begun to push its way into the nose and distend the walls of the sinus. A tumor of the malignant kind might be suspected from the pain seated in it, and when enlarged sufficiently to press upon the bones, the twofold suffering produced by pressing and being pressed must cause greatly aggravated distress. The mechani- cal consequences of the continued pressure soon show them- selves. The cheek swells, or rather is pushed out, the palate and alveolar ridge are depressed ; the molar teeth are loosened, the gums become inflamed and spongy, the floor of the orbit is elevated ; fistulous openings are often found through which sanious pus percolates, or the matter finds its way through the opening into the nose, and at length the tumor, pushing through the floor of the antrum, appears in the mouth, or forcing its way through one or both of the distended nasal openings is seen in one or both of the nostrils. Of course, the parts subjected to this pressure and disrup- tion, become diseased, and inflammation, suppuration, ulcera- tion, caries and necrosis, may all be added to the list of secon- dary diseases incident to polypus. The causes of polypus are not satisfactorily ascertained. Probably they require some con- stitutional predisposition to render the parts where they appear capable of producing them, and when the susceptibility exists, any irritation may be the exciting cause of the morbid growth. It is certain that diseased teeth and fangs must be regarded as the most common of the existing causes of polypus in the antrum. The following cases from Jourdain are in point: "In 1772, I had occasion to visit a shoemaker, living in the Faubourg St. Marcel, who had for some years had a kind of exostosis of the right superior maxillary. The tumor was as large as a medium sized apple, displaced the nose, deranged the palate, and threw the eye upward against the superciliary ridge, permitting the lids to open but slightly. The sinus had three fistulous openings: one below the malar process, a second 308 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. near the bicuspids, and a third near the inner canthus of the eye. In none was there any discoloration of the skin, and alternately, from the two first, there was discharged an acrid reddish humor. Most of the teeth of the affected side were lost; those which remained were sound, but much displaced by the tumor. The right nostril was obstructed by a polypus of a scirrhous hardness. In sounding the sinus through the fistulous openings, the instrument came in contact with fleshy masses in that cavity, some hard, some soft, giving out, when wounded, a bloody discharge, resembling wine lees. The na- sal wall of the sinus was destroyed, but the maxillary bone was not softened. "The disease seems to have had its origin in repeated attacks of alveolar abscess, the consequence of bad teeth, which usually terminated in fistula. Gradually the bone began to swell, and the nostril to become obstructed, till his appearance was such as I have described. Had I been suffered to operate, I would have removed all the teeth, good and bad, involved in the tumor, and then making a crucial incision through the cheek, would have exposed the bone, which, from its ex- treme thinness in this case, I might hope readily to remove. I would then have removed the exposed tumors from the antrum, by knife, cautery, or both combined, as occasion might suggest; looking carefully to the condition of the bone, and seeking, after the operation, to establish a healthy suppuration in the part. "Case II. — Polypus in the Right Sinus. — In 1773, a lady, whose right cheek had been swollen and singularly hard for nearly two years, applied to me. "The tumor was the result of successive inflammatory attacks of the first bicuspis and three molars of that side, only the fangs of which remained, and these were covered by a polypous tumor that had distended and softened the outer plate of the maxillary bone. "I first made an incision down to the alveolar sockets, and after the arrest of the hemorrhage, removed the roots, twelve in number, each having at their extremity a morbid growth, show- ing that here was the chief cause of the disease. Their remo- DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 309 val caused considerable hemorrhage. I examined the wound on the next day, and found that the bulk of the tumor lay be- tween the plate of the maxillary bone, diminishing upwards, and terminating at the orbit. "Between the cheek and gums were two fistulous openings, which discharged a dark, fetid humor. The diseased state of the bones decided me to remove the tumor by two vertical in- cisions through them. This space permitted me to introduce my finger into the sinus. Its membrane was swollen, and there was yet a portion of the tumor attached to the orbital plate. This, from its propinquity to the eye, I feared to cauterize with the hot iron, and therefore used spirit of vitriol, with a small quantity of corrosive sublimate dissolved in it, [nitrate of silver would be much better,] being careful to employ dry dressings, that the escharotic might not, by spreading, cause injury to the surrounding parts. "After eighteen days use of the same, a healthy appearance of the membrane was induced, suppuration established, and at the close of the fourth month, after some slight exfoliation of bone, the patient was restored." With regard to the treatment of antral polypi, it resolves it- self simply into making an opening into the sinus, and removing the tumor. Unfortunately, many of these morbid growths recur after remo- val, and grow with more rapidity than at first, and therefore it is necessary to destroy the mucous membrane upon which they are seated, so as perfectly to eradicate the disease. For this purpose, the old surgeons used the actual cautery freely. Proba- bly the free application of lunar caustic would accomplish all that could be expected from the heated iron. It is often im- possible to apply either so completely as to remove every par- ticle of the diseased product ; and if the tumor be a result of constitutional pravity, we, for the most part, gain little by the operation. Dr. C. A. Harris thinks that in cases of malignant tumors seated in the antrum, the application of the white hot iron is indispensable to safety. 30 310 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. In remarking upon the bold practice of the French surgeons in the treatment of these affections, Mr. Thomas Bell commends their mode of procedure as worthy of praise and imitation, and expresses himself very severely against the timidity of English surgeons, who have shrunk from the use of the actual cautery, and have left the patient to die with a lingering and painful disease, without any attempt at relief. Certainly, as life is rendered intolerable, and death inevita- ble, by these tumors, we are justified in using any means which may promise relief. I have already, (chapter nineteen,) de- scribed a malignant fungous tumor which occasionally makes its appearance in the antrum. When the disease. is of the ma- lignant character, a cure cannot be expected. The mode of amputating the superior maxillary, as described by Mr. Liston, has also been given in the nineteenth chapter. bisects in the Cavity. The human body has many parasites inhabiting its various tissues. More than a score of these have been described. Some infest the intestinal canal, others are found in the heart and large arteries; some dwell in the muscular, others in the cellular tissue ; some prefer the liver, others the kidneys, and some the sinuses of the head. The mode by which these creatures are produced, has long been a subject of curious inquiry, but it is not necessary for me to discuss the subject. It is enough to know that they exist within the body, and often prove troublesome inmates. That the larvae of insects do find their way into the maxillary sinus, is proved by abundant evidence. In the Memoirs of the Academy of Surgery, vol. v, p. 233, as quoted by Deschamps, it is recorded, that in the course of a disease of the maxillary sinus, there issued, from day to day, a considerable number of whitish worms, two or three lines long, some of which were living. The same author relates two in- stances in which long round worms were found in the maxil- lary sinus. DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 311 The most singular case of the kind is reported by Mr. Hey- sham, a medical practitioner of Carlisle, and may be found in Cooper's Surgical Dictionary. In this case, the patient was a strongwoman of sixty, who was for many years subject to acute pain in the antrum, extending over one side of the head. These pains never entirely ceased, but were more severe in winter than in summer, and were always subject to frequent periodical exacerbations. The patient had tried anodynes without advantage, and had submitted to a mercurial course, by which her sufferings were aggravated. All her teeth on the affected side had been drawn. At length it was determined to open the antrum, though there was nothing to indicate abscess or any other disease in this cavity. In four days no benefit had resulted from the operation. Bark injections and the elixir of aloes were thrown into the sinus. On the fifth day a dead insect was extracted by means of for- ceps. It was more than an inch long, and thicker than a com- mon quill. The patient now experienced relief for several hours ; but the pains afterwards returned with the former se- verity. Oil was then injected, and two other insects similar to the former were extracted. No others appeared, and the wound closed. She was much relieved for several months, when the pains returned worse than ever, and were particularly com- plained of in the frontal sinus. We are not informed of further treatment. Should worms be found in the cavity, they must be destroyed by the injection of oil or other liquids likely to effect the purpose. CHAPTER XXI. DISEASES OF THE PALATE The palate is often incomplete through congenital defect. It is frequently the seat of disease, which destroys its soft parts, and even its bones. As the palate forms the vault or roof of the mouth, separating it from the nasal cavities, and furnishing a most important part of the organ of voice and mastication, its diseases and defi- ciencies are of great consequence, exceedingly impairing the comfort and usefulness of the subject of them. Congenital defects of the palate may differ very much in ex- tent. Generally the deficiency is found along the median line, sometimes involving only the soft, sometimes also the bony structures. At times the fissure extends from the lips entirely along the median line of the roof of the mouth, presenting the appearance of the two lateral halves of the body not being united at this point. Congenital defects, however, are not always so regular. Errors of formation may occasion an increase of the con- cavity of the arch, forcing the alveolar ridges too far apart, and producing deformity in the dental range. Sometimes, from an opposite condition of things, the alveolar borders maybe brought more than usually close together. The teeth may be imper- fectly developed, and their texture less dense than usual. Mr. Stearns makes three classes of congenital fissure of the palate. The first class embraces all the cases in which the fis- sure extends through the velum, palate and maxillary bones, to the alveolar border, and sometimes through the whole extent of the median symphysis. This is usually complicated with hare-lip. In the second class, the bones of the palate are apparently 30* 314 DISEASES OF THE PALATE. entire, though the cavity of the arch may be somewhat greater than usual, and the fissure extend a short distance into their posterior margins. In this case, the lesion is almost wholly confined to the velum palati. The third class embraces those cases in which the fissure is confined to the soft parts, extending, perhaps, only a short way up into the uvula. This form of fissure is, probably, less fre- quently met with than either of the preceding.* When the palate is defective, the voice is impaired, and the impairment is in proportion to the extent of the lesion. Some- times it is almost entirely destroyed by the inability of the pa- tient to utter distinct sounds. Nothing can be more distressing than this calamitous injury to the organs of speech, which com- bines the distress arising from the consciousness of ludicrous appearance with the inconvenience of difficult and imperfect ar- ticulation. Interference with the voice is not the only evil attending de- fects of the palate. Mastication and deglutition are also impeded. Food, notwithstanding the patient's careful or in- stinctive efforts, will find its way into the nose, causing great unpleasantness, and depriving the unfortunate subject of the deformity of much of the pleasure of eating, which, after all that has been said and written in its disparagement, is unques- tionably the most universally prized of all sensual gratifications. When the deficiency is congenital, the young infant finds difficulty in nursing, but generally, with that preservative in- stinct which is given to the little helpless creatures, in such perfection as to supply abundantly all lack of experience in such matters, the child generally contrives to manage its de- fective organs so well as to obviate much of the inconvenience naturally attending the deformity. Instead of taking the nipple between the upper surface of the tongue and superior gum, &c, the infant places the tongue on the nipple, and presses it against the lower gum, closing the palatine fissure with the tongue, as with an obturator.f * Harris' Dictionary of Dental Science, f Delabarre. DISEASES OF THE PALATE. 315 The mechanism of nursing is perfected as the child advances in life ; dexterity of course increasing with the constant use of the parts, until such a proficiency is acquired that solids are masticated, and speech is as far as possible performed. The mechanism of mastication as performed in such cases is then described by Delabarre. When the food is chewed, the ali- ment is conveyed between the tongue and movable floor which serves for a point d'appui to it, and then it is brought back be- tween the teeth. Thus it is that the complicated operation of mastication and deglutition is performed without the alimentary morsel getting into the nose, or if this does sometimes happen, it is the result of accident. When perforations of the palatine arch occur in mature life through the agency of disease, the patient is in a much more unfortunate case than the subject of congenital deformity. The latter gradually habituated to the performance of mastication and deglutition with his imperfect organs, accomplishes these functions, if not well, yet with comparative comfort, while the former having been habituated to use the tongue differently, is not capable of adopting the mode of procedure applicable to his new condition, and consequently is continually passing his food and drink into the nose. If the teeth be not properly coapted, another source of difficulty and vexation is added, as the introduction of the food is thus rendered very trouble- some. If the velum and uvula be defective or wanting, deglutition is exceedingly difficult as the alimentary matters, instead of passing comfortably along the pharynx, are, to a greater or less degree, forced into the posterior nares. This is the case whether the lesion be congenital or accidental. Sometimes deglutition can only be effected by throwing back the head as far as possi- ble and casting the food into the pharynx. The inconvenience of imperfect speech is as serious as that of incomplete or difficult mastication and deglutition. Mr. Stearns says, that perforation or fissure of the palate may render the articulation of some of the letters impossible, and at the same time vitiate the character of all the others. The indis- 316 DISEASES OF THE PALATE. tinctness of utterance is usually proportioned to the extent of the lesion. Thus, when the fissure extends as far as the alveo- lar processes, the patient loses several of the letters, which an- other, with only a portion of the soft palate involved, is able to produce with considerable distinctness. In cases of fissure, particularly those of the more extensive kind, the movements of the tongue are comparatively limited, as the patient is instinc- tively aware that the very effort he should make in order to give letters their appropriate articulation, often serves to ren- der the impediment more painful. So far, indeed, is this inac- tivity of the organs sometimes persisted in, that speech becomes little else than the emission of a succession of vowel sounds, which, in lieu of receiving proper consonant adjuncts, are only made intelligible by the accompanying inflection, key, gesticula- tion and expression of countenance, all of which are, more or less, the vehicles of thought.* With the limited action of the tongue, nearly all the muscles concerned in the formation of ar- ticulate sounds, in a greater or less degree, participate, while the muscles about the nose, as the compressor nasi and depressor nasi are violently contracted for the purpose of closing the nos- trils and preventing the escape of the sound. This gives a par- ticularly disagreeable aspect to the features. The most common cause of lesions of the palate is syphilis. This terrible disorder, when once it becomes constitutional, pro- duces a number of strange local affections, differing very much from one another, all of them distressing, and some of them dangerous, and not unfrequently fatal. Beginning as a local affection, usually a primary sore, syphilis may gradually poison the whole circulating fluids and cause defects of nutrition and alterations of tissue in various parts of the body. The manner of effect produced by secondary syphilis, differs very much in different persons, as it is influenced by a variety of determining or modeling circumstances. Eruptions upon * Observations on Congenital Tissue of the Palate, with some remarks on Articulation and Impediments of Speech, by Charles W. Stearns, Esq., Surgeon, London. DISEASES OF THE PALATE. 317 the surface, local inflammations, ulcers, augmentation and loss of parts, may all be occasioned by the penetrating and potent virus. The soft parts about the throat are particularly apt to be the seat of constitutional syphilitic ulcers, and the bones of the palate are very frequently perforated or wasted by venereal caries. It is very necessary, however, to be aware that palatine ul- ceration, caries and necrosis may occur from other than a vene- real cause. It would be terrible indeed to add the cruel suspi- cion of such a malady to the sufferings of a patient whose dis- ease, having no affinity to lues, should claim sympathy instead of begetting contempt and disgust. We must, therefore, be very careful to make no mistakes in matters of such delicacy. Moreover, the treatment of these affections must depend upon the accuracy of the diagnosis, and that which would be judi- cious in the case of syphilitic affection might be very improper under other circumstances. When the true history of the case can be obtained, the facts will give much assistance in forming an opinion, but this can- not always be procured ; we are, therefore, commonly obliged to form our opinion from the appearances before us. The only constitutional vice, other than the venereal, which may cause a similar palatine devastation, is scrofula, and when scrofula is the cause of the affection, the prevalent vice will display itself elsewhere, in derangements of the lymphatic sys- tem, and the other affections which usually attend upon this general pravity. Syphilis is more rapid than scrofula ; and the local affec- tions produced by it are more painful. According to Mr. Hun- ter, venereal disease generally makes its appearance, in these parts, at once, in the form of an ulcer without much previous tu- mefaction. He describes the ulcer as a fair loss of substance, part being dug out as it were from the body of the tonsil (if seated upon it.) It has a determinate edge, and is commonly very foul, having a thick white matter like a slough, adhering to it, and not admitting of being washed away. All authors, how- 318 DISEASES OF THE PALATE. ever, admit the extreme difficulty of distinguishing venereal affections in these parts, with absolute certainty, by merely local observation, and no appearance of sores about the palate, warrant us in declaring the disease syphilitic, without corres- ponding symptoms justify the suspicion. While this is the case, however, any suspicious sore will authorize us to try such remedies as are known to be efficacious in syphilis, it being much more dangerous to neglect a syphilitic sore than temporarily to maltreat a scrofulous one. No purity on the part of a married female can always be satisfactory of her free- dom from syphilitic taint, as, disgraceful as it is to human nature to make the confession, we are frequently compelled to recog- nize the ravages of the disease in these victims to the matrimo- nial tie, who are perfectly innocent of any impropriety. I need not say, that when the dentist discovers such a conditon to ex- ist, though humanity will demand that in some way or other the cure be provided, benevolence, no less imperious, requires, that the unfortunate subject of the odious inocculation shall be kept in blissful ignorance of the nature of the malady. Of course, where venereal or scrofulous disease is at work upon the parts, proper constitutional remedies must precede all mere mechanical attempts to repair existing damage. The devastation of the palatine tissues, soft or bony, may sometimes result from the local irritation produced by dead teeth, &c. This, of course, can only occur in those enfeebled constitutions in which nature is not able to resist even a trivial morbid impression, but seems barely capable of maintaining a nutrition equal to the ordinary wear and tear of tissues. That such cases do occur, is stated by Jourdain, Harris and many others. Harris says,* "The local irritants occasioning the palatine diseases are dead and loose teeth, roots of teeth, salivary calcu- lus, mechanical injuries, acrid humors, &c. The case of a lady of irreproachable character is related by Jourdain, in whom a scratch on the palate with a fish bone, caused a tumor, which * Dictionary of Dental Science, art. Palate. DISEASES OP THE PALATE. 319 suppurated and degenerated into an ulcer with hard elevated edges and a fungus in the middle." Dr. Cone mentions a simi- lar case. The following are reported by Jourdain : Case I. — Mr. Noel had a tumor of the palate, which, on pressure, discharged pus through one fistulous opening on the outer side of the right alveolus, between the canine and incisor, removed some time since. The patient would not consent to and another in the socket of the second molar, which had been proper measures in the first instance. The canine incisors and first molar became loose and were extracted : the alveolus around the site of the second molar sloughed away. The tu- mor still continued to enlarge, and some embarrassment was felt in the nostril : the patient then put himself under my care. The tumor, when lanced, discharged a very fetid pus, and I found, on introducing my probe, that a portion of the palate and max- illary bones were necrosed and almost completely detached. I removed them with ease : the one from the palate was the size of the nail of the index finger, that from the maxilla, larger. The removal of these sequestra, exposed the pituitary membrane of the floor of the nostril, as was proved by the sneezing ex- cited by touching it on the lingual side. I dressed the wound for some days with dry lint, and then used gargles, &c. In twelve days the cicatrix was complete. I have treated many similar cases, arising from simple ab- scess, the sequel of dental disease. I have always, when the opening was of sufficient size either awaited the natural separa- tion of the sequestrum, or when assured that it was no longer adherent to the second bone, gently withdrawn it. Simple causes may often be productive of extensive injury, as the fol- lowing case will show : Case II. — A bailiff, named Broch had a tumor of the palate is large ae a pigeon's egg, with swelling of the nose and upper lip, consequent of a decayed condition of the teeth. Pus escaped from the nose and there was a fistulous canal from the second incisor to the first molar of the left side. As the case seemed an urgent one, I removed the decayed 320 DISEASES OF THE PALATE. teeth and stumps, thus destroying the fistula. I then excised the the palatine tumors, found the bone carious and the nasal mem- brane covering it perforated, which accounted for the discharge of pus from the nostril. I first employed dressings of dry lint, emollient and detergent gargles, and after the subsidence of lo- cal inflammation, touched the bone with mercurial water twice in eight days. In this time the sequestrum separated, leaving an opening into the nostril about the size of a quill, which was closed by a prolongation of the mucous membrane. I made use of dressings of dry lint, gently applied, and occasional styptics to suppress exuberant granulations. The entire cure occupied six weeks. For a great number of similar cases, the reader may consult Jourdain's work. When local irritants cause or seem to be connected with the disease, they should be promptly and completely removed. The after treatment will be conducted upon general surgical principles. When a fissure has been permanently formed and its limits ultimately defined, whether it has been congenital or accidental, the indication is to remove the deformity by producing a closure of the fissure, or, if this cannot be done, to supply the defi- ciency of the parts by such mechanical appliances as may be deemed most suitable. When the soft palate or some portion of it has been lost, the lesion has been substituted by means of an operation, which has been termed staphyloplasty* The operation can be successful only when the perforation is small. It consists in detaching a portion of mucous membrane from the surrounding parts, and so adjusting them with refer- ence to the perforation, as to procure a permanent covering of the cavity, when adhesive inflammation has been effected. The operation is difficult, and requires great dexterity in exe- cution as well as ingenuity in contrivance. Dr. Pancoast, in his Operative Surgery, describes an operation of this kind, *2ta$v%rj, the uvula, and mkaSSco, I form. DISEASES OF THE PALATE. 321 successfully performed by himself, to close a hole near the centre of the hard palate, which formed a communication be- tween the nose and mouth. The operation for closing a cleft palate is called staphylor- aphy.* It consists in paring away the edges of the fissure and closing them so perfectly as to produce union by adhesion. The operation has been successfully performed by a great number of surgeons, European and American, and several methods of performing it have been adopted and suggested ; each having its advocates. Dr. S. P. Hullihen, surgeon dentist of Wheeling, Va., of whose surgical skill I have already made mention, had performed this operation successfully eleven times, up to the year 1849. This ingenious surgeon has invented a bistoury for paring the edges of the fissure, which possesses decided advantages over the ordinary double edge knife. It is composed of two parts, which open like scissors, but when closed, form a double edged knife or bistoury. The manner of using it is as follows : after first seizing the cleft edge of the velum, at the base of the uvula, with a pair of curved forceps, and putting it on the stretch, the bistoury with its back towards and against the palate bone, should be pushed through the velum near its edge ; then, by opening it, the edges will be pared off in the most even and perfect manner possible. Further procedure should be suspended until the hemorrhage, although seldom very great, shall have partially subsided. A needle, armed with a well waxed ligature, and held in a pair of suitable forceps, should be passed from before backwards, through the most dependent part of the left margin, about three lines from the edge. As soon as it is seen on the opposite side, it should be grasped by the assistant, with a pair of long handled forceps, and as soon as the hold of the port-aiguille is relaxed, drawn through, replaced in the latter, and passed through from behind forwards, the right margin of the velum opposite to the * tt atyvht], and Pa^, a suture. 31 322 DISEASES OF THE PALATE. left. After the patient has rested a few minutes, a second, third, or fourth ligature should be introduced.* Dr. J. C. Warren and his son, Dr. John Mason Warren, have each performed this operation repeatedly, and with great success. In most of these cases the fissure has extended through both soft and hard palate, and in one case through the jaw and lip. Dr. J. M. Warren's method has been to dissect off the mu- cous membrane from the hard palate, on either side, and stretch this across the fissure and then unite the edges by sutures. Although it is generally asserted by surgical writers, that when the fissure of the hard palate exceeds an inch, no union can be expected, Dr. Warren has proved by his success in such cases, that the opinion is erroneous. f Dieffenbach recommends that a longitudinal incision be made at a short distance from the edges of the fissure, in order to permit the closure to be accomplished in the way before men- tioned. A great variety of instruments has been invented by different surgeons, and recommended to be used in this operation. I have already mentioned the cutting scissors of Dr. Hullihen. A variety of needles and needle-holders has been proposed. Dr. J. C. Warren uses a needle with a movable point. Dr. N. R. Smith prefers a simple lance-shaped instrument, mounted on a handle, and having a slit near its point, which opens at its posterior end. The needle is broader in front of the eye than behind it, which renders the passage of the back part easier. Armed with a ligature, the curved portion of the needle is car- ried beyond the fissure, and its point introduced behind the middle of the uvula, and as soon as it has come out far enough to expose the ligature in the slit, the ligature is taken hold of with a tenaculum, disengaged from the slit or eye in the needle, and the needle is withdrawn. A second ligature is introduced, half an inch higher up, and, if necessary, a third, at an equal * Die. Dental Science. f Reese's Cooper's Surgical Dictionary. DISEASES OP THE PALATE. 323 distance from the second. With the ends of the ligature passed through the uvula, this part is drawn forwards, until the fissure in the soft palate shall assume a nearly horizontal position. Its edges are then cut off with scissors or bistoury. The ligatures are then tied, and the ends cut off. Dr. Hullihen has invented an instrument for passing the needle, which he calls an acutenaculum, and which he thinks better adapted to the purpose than any other. It is composed of a staff and a slide. The staff is a small steel bar, six inches in length, a fourth of an inch in breadth, and an eighth of an inch thick, with an arm at the upper end, rising at a curve from the staff, and half an inch long. On the external or superior side of this arm a duplicate arm is retained by a steel spring attachment, which brings the two arms in close contact, form- ing the jaws of the instrument. Between these two arms, and on the duplicature, is a small groove, formed to receive the ligature; and when the ligature is pressed between the jaws of the instrument, they open, and it slides to the point designated for its reception, and immediately below which, the jaws are perforated with a hole for the introduction of the needle. Two inches from the inferior end of the staff, a pair of rings are affixed, to receive the thumb and index finger, the rings standing parallel with the staff, and sideways to the direction of the arms of the instrument. A slide formed of steel, equal in length, thickness and breadth to the staff, is made to fit the upper surface of the staff, and to move with ease up and down upon guides placed on the same. From the superior end of the slide is a short straight spear-shaped needle, constructed with an eye just back of its point, with a small notch opening to it from the upper surface. When the ligature has been fitted in its place in the jaws of the instrument, and the slide adjusted to the staff, the slide is forced upwards, the needle and jaws approach each other, and the needle passes through the hole in the latter, just under the ligature, which is caught in the notch of the needle, and as the slide is drawn backwards the eye of the needle is threaded, and the ligature drawn through the velum. This instrument is cer- 324 DISEASES OF THE PALATE. tainly an ingenious one, and the preference given it by the in- ventor, who has operated so often and so well, is sufficient com- mendation. For a more particular description of this instrument, made intelligible by an accompanying plate, the reader is referred to an excellent article on cleft palate, by Dr. Hullihen, published in vol. v, page 166, of the American Journal of Dental Sci- ence. Concise and admirable directions will also be found in that paper, for conducting every step of the operation. When the loss of parts is so great as to forbid an attempt to close the fissure by an operation, nothing remains to be done but to cover it by a gold plate or obturator, such as the cir- cumstances of the case will admit. The skilful dentist will often be able to remedy these serious lesions to a very great extent, by well devised and artistically executed substitutes. For a description of these mechanical means, and the mode of adjusting them, I refer the reader to the works on mechanical dentistry. _^