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r 1 1 » If** * 



I. 






DENTAL MEDICINE, 



AS ":0X5«CTED XTITH THK 



STUDY OF DENTAL SURGERY. 



PRACTICAL TREATISE 



DENTAL MEDICINE, 



COKFENDIU)! 01 MDICAL SCIEltCE. 



STUDY OF DENTAL SURGERY : 



AN INQUIRY INTO THE USE OF CHLOROFORM, 
AND OTHER ANAESTHETIC AGENTS. 



SECOND EDITION, 

Hepiseb, QTorTened, anb (Sntargeb. 



THOS. E. BOND, A.M., M.D., 




PHILADELPHIA: 

LINDSAY AND BLAKISTON. 
1852. 






• • • 

• • • 












• • 






• • ' 



• • • 



Kntered, accozxltDg to Act of Congro5^ in tb« 7«ar 185*. 

BT LIND8AT AND BLAKISTON, 

In the Clcrk> OflBce of the District Court for the Baftem Diffirict of I't-nnyylraniH. 



c. h :i K KM \ X. I' r. ; \ T E R, 
I'» St .UmM Sln-fi 



TO 



M^ /at^M, 



THIS WOBK 18 RB8PECTFULLT DKDICATKD, 



BY UTS SON. 



PREFACE 



TO THE SECOND EDITION. 



Thb author of the present treatise gave it to the public 
with little expectation that it would meet a favourable recep- 
tion. Indeed, but for the urgency of a friend, in whose judg- 
ment he had reason to confide more securely than in his own, 
he never could have overcome his reluctance to risk the expe- 
riment of the publication. 

In the result, however, he has been agreeably disappointed. 
The unpretending volume was very generally noticed by medi- 
cal reviewers, in every instance, so far as he is informed, with 
decided commendation, and a practical evidence of its accepta- 
bility was given in the ready sale of the edition. 

The author is well aware that he is very much indebted to 
the personal regard of professional friends for some of the 
favourable notices of his book, and that, in other instances, he 
has shared the common urbanity and indulgent consideration 
with which the conductors of our best Medical Journals are 
accustomed to encourage all respectable efforts to contribute 
to the literature of the profession. Nevertheless, he thinks 
himself authorized to believe, that, after all proper allowance 
is made for the expression of personal kindness and profes- 
sional amity, he may, without vanity, ascribe some portion of 



XVi PRBFAOE TO THE SECOND EDITION. 

the commendation lavished upon the work, to its adaptedness 
to supply what is felt to be a want; and he, therefore, has 
determined to offer to the public a second edition. 

In preparing this for the press, it was not thought advisable 
to enlarge the book to an extent that would require a consi- 
derable increase in the price; nevertheless, some important 
matter has been added where the treatise seemed most imper- 
fect. 

A chapter upon Anaesthetics has been appended to the work 
as originally published. The great importance of the subject, 
and the interest felt in it, required that it should be discussed 
in a treatise designed for the purposes for which this was 
written. 

The arrangement has been altered where perspicuity and 
connexion required it. A great number of verbal errors have 
been corrected; and the typographical execution very much 
improved. A copious index has also been added. 

The author sincerely hopes that the book may prove useful 
to all who may do him the honour to read it. 

Baltimobk, September ISth, 1S52. 



PREFACE 



TO THE FIRST EDITION. 



The Baltimore College of Dental Surgery was organized 
with the design of teaching Dentistry as a regular branch of 
Medicine, in which relation, only, it can be regarded as a 
scientific pursuit, and the practice of it esteemed as a pro- 
fession. 

With this view it was arranged that the Faculty should con- 
sist equally of Dentists and practising Physicians, and to the 
author of this treatise was intrusted the chair of Special Pa- 
thology and Therapeutics. Commencing the performance of 
his duties with no larger amount of knowledge of the subject 
than is commonly possessed by medical men, he has been led 
to discover much more importance in it than at first he could 
have supposed to exist. Endeavouring to avoid the very na- 
tural error of exaggerating the value of isolated facts or 
doubtful statements, upon matters at once novel and from the 
circumstances peculiarly interesting, he has found that many 
things which at first he was disposed to regard as unlikely, 
are, nevertheless, well-attested and established facts; and, 
after mature investigation, he has become fully convinced that 
the relations of the teeth and their appendages with other 
and even with vital parts, are sufficiently important to be 
carefully studied both by the Dentist and Physician. 



XVIU PREFACE TO THE FIRST EDITION. 

After ten years' experience as a teacher of these subjects, 
he has found it absolutely necessary that a compendium of 
medicine should be furnished, in which might be brought to- 
gether, in a small compass, such selected information as the 
wants of the Dental Surgeon demand ; — and as none has been 
prepared by another, he has reluctantly undertaken the task. 

The difficulty of performing it will readily be conceived, 
when it is observed how much was proper and how much irre- 
levant ; how cautious it was necessary to be, that no needless 
matter should be introduced, and how careful that nothing 
pertinent should be omitted. 

Without the pretension of having done it well, the author is 
yet gratified that it has been done at all. 

Though particularly intended for the Dentist, the author 
flatters himself that he has presented the subject in such a 
form as will render it deserving the attention of the general 
practitioner. 

It is not the custom of our profession to consider anything 
unworthy of attention that has a bearing, however remote, 
upon the benevolent pursuit to which we have devoted our 
lives, but to the most fastidious it may be said, that subjects 
which have been thought worthy the attention of Hunter and 
Rush, may be investigated by any without fear of degrada- 
tion. 

The Author. 

Baltimore, Dec. 31, 1850. 



CONTENTS. 



PAGK 

Introduction, ........ 25 



CHAPTER I. 

pREUMiNA&Y Considerations, ..... 31 

CHAPTER II. 

Etioloot, ....... .34 

The Atmosphere, ...... 36 

Heat and Cold, ....... 37 

Malaria, ....... 41 

Chemical Causes, . .44 

CHAPTER III. 

Symptoms of Disease, ...... 48 

Progress of Disease, . .49 

CHAPTER IV. 

Diagnosis, ........ 52 

CHAPTER V. 

Treatment or Disease, ....... 50 

CHAPTER VI. 

Nature of Disease, ...... 61 

Inflammation, .68 

Conseqaences of Inflammation, .... 71 



CONTENTS. 



CHAPTER VII. 

PAGE 

Inflammation of thk several parts composixg the Mouth, and of 

the parts adjacent, ...... 81 

Phlegmon, ....... 81 

Erysipelas, ........ 82 

Tonsillitis, ....... 82 

Stomatitis, ........ 88 

Inflammation of the Gams, ..... 88 

Antrum, . . .85 

Inflammatory Fever, ...... 86 

CHAPTER VIII. 

Treatment of Inflammation, . . .87 

Treatment of Inflammation and Abscess of tbe parts composing 

the Mouth, ...... 88 

Mercurial SaliTation, . . . .91 

Cancrum oris, ....... 08 

Chronic Inflammation of the Gums, . .08 



CHAPTER IX. 

(^ARiES AND Mortification, 
Caries, 

Mortification or Gangrene, 
Necrosis of the Teeth, 

CHAPTER X. 

Ulcers, 

Local and Constitutional, 
Simple Ihirulent I' leer, 
ViUatcd Ulcer, 
Callous Vicor, 
Fungous Ulcer, 
Sinuous Ulcer, 
Carioun Ulcer, 
CHUoonms* Uloor, 
Ulcers Popoudcut upon iVnstitutioual Cause, 
Veuen»»l or SvphiUtio UK'ovs 
Scorbutic I Icors. 
8cnk(\ilou3i I' leer. 



05 

95 

OG 

100 



103 
105 
105 
lOt} 
107 
108 
109 
110 
111 
115 
115 
119 
121 



i'UAPTKH \l 



f ; >ioi a*« 



12t( 



CONTENTS. 



UUKB. 

Malignant — Osteo-Sarcoma, ..... 


PAoe 
128 


Fungus HsBmatodes, Bleeding Fungus, Spongoid Inflammation^ 




Soft Cancer, Medullary Sarcoma, .... 


128 


Polypus, ....... 


129 


Benign Tumours, ....... 


130 


Sarcomatous or Fleshy Tumours, .... 


131 


Encysted Tumours, ...... 


131 


Bony Tumours, ...... 


182 


Exostosis of the Teeth, ...... 


135 


Osteo-Sarcoma, ...... 


137 


Spina Ventosa, ....... 


188 


Aneurismal Tumours, ...... 


138 



CHAPTER XII. 

Diseases of the Teeth and Face depexdekt upon Morbid Condi- 
tions, EITHER QENERAL OR OF OTHER PARTS, . . 189 

Neuralgia, ....... 189 

Neuralgia Faciei, or Facial Neuralgia, . .141 

Intermittent Neuralgia, . . 144 



CHAPTER XIII. 



Morbid Secretions of the Mouth, 
Dyspepsia, 
Syphilis, 
Exanthemata, . 
Mercurial SaUyation, 
Scrofula, 
Pregnancy, . 



149 
158 
160 
160 
161 
162 
163 



CHAPTER XIV. 

Morbid Effects of Conditions of the Teeth and Gums upon the 

General System, . . .165 



CHAPTER XV. 
Morbid Effects of First Dentition, 



. 168 



CHAPTER XVI. 



Sympathetic Diseases of Dentition, 
Cholera Infantum, . 
CouTulsions, 
Cutaneous Eruptions, 



179 
180 
183 
184 



XXii CONTENTS. 

PAfll 

Intertrigo, ....... 184 

Crusta Lactea, or Milk Crust, ..... 185 

Strophulus, Tooth Rash, Red Gum, .... 185 

Second Dentition, ....... 187 

Third Dentition, ...... 187 

CHAPTER XVII. 

Effects of Diseased Teeth akd Gums upon Adjacent Pabts axd 

THE General System, ... ... 188 

CHAPTER XVIII. 

Wounds of the Mouth and Face, .... 229 

Bums, ........ 242 

Fractures, ....... 245 

Fractures of the Jaws, ...... 247 

Dislocations, or Luxations, ..... 249 

Dislocations of the Lower Jaw, ..... 250 

CHAPTER XIX. 

Pabticulab Affections of the Mouth and adjacent pabts, . 258 

Diseases of the Gums, ...... 258 

Epulis, ....... 258 

Parulis, ........ 257 

Fistula of the Gum of the Lower Maxillary, haying an Exterior 

Opening at the Hollow of the Chin, .... 259 

Spongy or Fungoid Inflammation of the Gums, . . 260 

Hemorrhage from the Gums, ..... 262 

CHAPTER XX. 

Diseases of the Lips, ...... 264 

Hare-Lip, ........ 264 

Adhesion, ....... 268 

Contraction, ....... 268 

Cancer of the Lip, ...... 272 

CHAPTER XXI. 

Diseases of the Glands and Gland-Ducts, .... 277 

Salivary Tumours, ...... 277 

Tumours of the Submaxillary Gland, .... 280 

Notes of the Operation. ..... 284 

Tumours of the Parotid Gland.'<. ..... 290 

Salivary Fistula, .... 292 



CONTENTS. XZIII 

CHAPTER XXII. 

PAOy 

tumocas requibiko amputation of a part or the whole of the 

Upper Jaw, ....... 204 

Amputation of the Lower Jaw, 296 

CHAPTER XXIII. 

DUSA8R8 OF THE AUTRVM, OR MaXILLARY SiNUS, 805 

Dropsy, or Retention of Mucus, . 30 G 
Inflammation, . .811 

Suppuration, . 312 

Caries, Necrosis, and other Morbid Conditions of the Bony Walls, 313 
Softening of the Bony Walls, .320 

Exostosis, ....... 320 

Fistula of tlie Superior Maxillary Bone, .... 322 

Oiena, ........ 32G 

Polypi and other Tumours, ..... 827 

Insects in the Cayity, 332 

CHAPTER XXIV. 

DlSKASRS OF THE PaLATE, 334 

CHAPTER XXV. 

Tbi Use of Chloroform and othkr An.chthetic Agents, 340 

Effects of Chloroform, ...... 353 

Modus Operandi of Anipsthetics, .... 354 

Conditions Forbidding tlie Use of Ancesthetics, . 355 

Ansesthesia in I>ental Operations, ... 355 




INTRODUCTION 



h taoBga, i( 



The bodj 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 
tbe work of the whole ; and a beautiful unity of porpoae, and a 
necessary dependence of parts, are observable throughout the 
organization. 

So remarkable ib this unity, and so certain this dependei 
that a naturalist, by examining a fragment of any one of the 
bones of an animal, may determine the character of tbe indivi- 
dual it represents. Having ascertained the size, figure, &c., of 
say bone, he may infer, with infallible certainty, that every 
other part of the body to which it belonged was formed in 
perfect proportion to this part, and with strict reference to the 
purposes for which this particular portion was designed. Should 
a naturalist ascertain that a single bono presented to him was 
constructed for purposes of prey, he would immediately infer 
that a beast so provided must have had strong muscles and 
bones of the neck and jaws, to enable it to bold and tear the 
ftnimala upon which it was intended to subsist ; hind legs of 
such a formation as to enable it to spring upon its prey ; claws 
to seize and hold it, and a digestive apparatus suited to the re- 
ception and assimilation of the food thus procured. 

Those who are familiar with the writings of Cuvier, will not 
Deed to be reminded of his beautiful reasoning upon this sub* 
ject. 

The body of man must then be regarded as a unit, and 
though, for the convenience of description, we speak of its mul- 



UNE LIBRARY. STANFORD UHWOS 



36 IHTHODnCTlON. 

titude of parts, it is a single organization, fed by one aliment, 
nourislied by one blood, vitalized through one nervous system, 
directed to a common purpose, subject to one sovereign will, 
and pervaded by a general law of continuance, decay, and dia- 
solution. 

As one part of tbe body ie 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 ia, from its nature 
liable, and from its condition e.^poaod to injuries. It ia con- 
tinually assailed by enemies from without and within. It has, 
therefore, certain signals of suffering, and is endowed with cer- 
tain aptitudes, through which any part more particularly attack- 
ed may receive succour from the rest. Moreover, the parts being 
connected together by extension of common tissues, by blood- 
vessels and by nerves, the morbid conditions of one may readily 
be propagated to another. All this concert of parts, whether 
healthy or morbid, le called sympathy ;* though, in the case of 
healthy action, improperly so — and constitutes ono of the most 
interesting and beautiful peculiarities of organized structures. 

In many instances the dependence of one part upon another 
is 8D direct, and tho mode of communication so obvious, that 
there is no difficulty in detecting tho process of sympathetic 
action or sufi'ering that may bo 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, 

* &r, with, wttii, inffsilog — ftUoW'iiiffering. 



ISTRODUCnON, 27 

however eomparatiTcly unimportant, will commonly induce a 
general derangement of health, and may involve the whole body 
in serious and even fatal dieorder. 

Although in many cases no change in the structure of mor- 
bidly sympathizing parts might be discovered upon autopsic* 
observatioQ, yet there ia good reason to believe that sympathy 
IB it) fact a transfer or propagation of actual molecular change ; 
ftsd 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 
eHt&blished 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 facta above stated are universally admitted by the medi- 
cal profession, and for the most part are recognised as impor- 
tant practical truths ; so much so, that the study of particular 
parts as isolated from the rest, with a view to treat certain local 
affections as independent phenomena, has long since fallen into 
£suse, and every physician and surgeon is expected to become 
eonvcrsant with all of medicine, as necessary to the proper care 
*f any one of the organs of the body. An oculist, unless a 
thorough physician, would be utterly unqualified to treat dis- 
Mses of the eye : the obstetrician must extend his knowledge 
br beyond the uterus, if he would claim any participation in 
l^e fellowship of science. 

Until very recently, however, the treatment of diseases of 
Uie 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. 
k Surgeons and physicians were generally profoundly ignorant of 

I ttw importance of these organs to general health, and were con- 

t 



'• own er^HMtukl light of the patti of a diaa«et«d bodj. 



c 



IKTRODUCTIOK. 



I 



tented to leave them to the care of any who were willing to 
take charge of them. Even now diseases of the teeth are rarely 
mentioned in the medical schools, and an eminent professor of 
eurgerj has publicly confessed himself incompetent to teach 
students how to extract them. 

In the course of time, however, men of inquiring minds and 
studious hahits, 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 profea- 
Biou, have turned their attention to dentistry, and of necessity 
have applied their previous information to the augmentation of 
dental pathology and therapeutics; and, finally, the manage- 
ment of the teeth has come to be an acknowledged specialty of 
medical science, and is rapidly advancing in public and profes- 
sioDal 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, hold 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- 
tified by men of the first talents, and greatest scientific and 
literary acquirements. 

To our country belongs a large share of the honour of placing 
these two departments of medicine upon their proper level 
with other professional pursuits. 

The depressed condition of surgery and midwifery waa the 
consequence of the vulgarity and ignorance of those who prac- 
tised in these departments of medicine, and the bad reputation 
thttfl acquired was a formidable obstacle in the way of those 



who attempted to elevate them to the dignity of Bcientific pup- 
eoits : but patient cootinuance in laborious and honourable effort 
H eventnally succeeded in accooipliBhing the desired result. 
The practice of Dental Surgery was long degraded, from 
nnsea 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 boneat pride, that our 
intry is again foremost in this laudable work. 

e purpose ofthe present work is to treat of Dental Surgery 

a distinct and proper specialty of medicine, and to present 

D the reader a digest of information, prepared with particular 

■fercnce to the morbid connexions certainly existing between 

; teeth and the rest of the body. 

These connexions are far more important than is generally 

■iPOpposed by physicians or dentists. The reader of the following 

iges will probably be surprised to find so large a variety of 

IdiBordere treated of as directly or indirectly concerned in the 

reduction of pathological conditions observed in the mouth ; 

i his snrprise will perhaps be greater to find so many and 

B serious diseases of other organs traced to their primary seat 

t morbid conditions of the teeth. Yet the object of tbe author 

B been to condense this treatise as much as consistency would 

mit, and to admit nothing foreign to the eubject properly 

r consideration. 



TREATISE ON DENTAL MEDICINE. 



CHAPTER I. 

PEBLmniABT CONSIDERATIONS. 

Thb human bod; is liable to changes irhtch more or less 
disturb the regular and healthful performance of the many 
fonctioDs* necessary to the completeness of its life, or in other 
words, to di»ea»e. These changes are commonly attended 
with alterations of the phenomena Tchich experience autho- 
rizes ns to regard as natural or normal, or in other words, by 
tymptorm,^ Trhlch indicate the character and Beat of the 
change which produces them. 

When parts thus diseased are inspected, we generally per- 
ceive alterations in their usual appearance and structure. Not 
nnfrequently, however, the changes are too obscure to be de- 
tected by our present means of investigation. 

Many attempts have been made to deSne the essential nature 
of disease, but all have necessarily failed. It is impossible to 
frame with philosophical accuracy a definition of disturbed or 
altered conditions, since we do not perfectly understand the 
■ature of the organs, and the mode of their acts. We cannot 
nnderstand the ultimate cause of morbid phenomena, while 

• Bj/unefion is tneaDt the p»rticalar part irhioh eaoh organ perfonna in 
Iha mecfaiuiism of life. The Urer is an organ, iisfatirlion is to secrete bile. 

t Sgfmptonu »re thixe observable differences from the henlthy performance 
OtflntttioK vhieli lead na to swpeot tad often to detect disasa*. 



d 



I 



PRELDtlSABT CONSIDERATIONB. 

1 of the oauatial natore of life itself, as manifested in 
tte knilkr {wrfitrmanee of function. 

b tt importMit to the student to know that medical lan- 
n^a JMB QoC pntwod to the precision of abstract philosophi- 
flil aoMM*. H«dic«l dcfinitioDs are not to be regarded as ac- 
QitnMly at»lbag th* nature of things, but simply as descrip- 
IMM nUoh li^ MCT* for practical purposes. This fact has 
btM fii^fo«t«ii bv many eminent medical vriters, and their 
«AcU to b» ftbtUtttvI; accorato hare often led to serioos mia* 
nlHl. aaJ alwk^ to confu&ion of ideas and contradiction of 
Ikekk Tfw uwJjr i>f Miwnoes b<^lougs to metaphysics, not to 
ItfMtioftl »«M«««, ukI iMviiig ful<ed to reach any important 
ittik b; wwtywb^ aiad, it will hardly prove succeesful in its 
iiviiiiUrT u|HMi Uw body. 

W» wit tl iktw to W e)««rtj understood, that medical terms 
^««» W t«o«tT«d ill » eooTvntional sense, and that, while they 
I to eonvej what knowledge we have of 
s th*y will not bear the test of strict philosophi- 
iM^«MHWitliM> Tur example, the word life, as used by medi- 
<4gll^Kife«<i iloM »ot tt«an the essential vital principle, but the 
MM^iatw >>f ^ nuiotions of the body : not the ultimate cauae 
vpk >«'(«, Uko machinery in motion, but its effect in the pro- 
^MiiM ^ ^fi«uw kX», Disease means all the morbid phe- 
^|g|g^ t^HMkvJ in a case, together with the structural 
«^|M||^<|||l|lk %hiiA these phenomena depend, and any other 
^^^^Utto '«yi«y which may be concerned in their pro- 
llm^ 'Bfctt* * pAtient may complain of nausea ; this sick- 
^DfUfW ^vuJMtuout upon defective digestion ; the defective 
a WMlfc uiW«Ttt(>tIv>u of the fnnction of the liver ; the 
k^ tJht b»p*ti«* function upon change of structure 
%; v*«t lJ^ change of structure upon more minnte 
Strictly speaking, we might regard 

_ . 1 •»( iMih »» aynjptoms merely of some obscure 

^^^MiC*4^MK >Aw^ wki«h constitutes the disease, but in 

»0»<. dtsoourse ; IhM which relates to 




PBBLIMINABT COKSIDBRATIONS. 88 

that case the word would be of no practical use. These in- 
stances may suffice to illustrate our meaning, and the student 
may be saved from much embarrassment by keeping the fact 
thus presented always in his mind. Many false theories and 
much bad practice have resulted from attempts to philosophize 
in medicine. It is an experimental science, embodying the 
results of long experience and protracted investigation. As 
such it is true, and worthy of all confidence. It b impossible 
to tell why any medicine produces its effect — ^we do not under- 
stand the phUoBophy of it ; but we know what effect it does 
produce, and that knowledge is sufficient, and very much more 
important. 

I will not trouble my readers with a recapitulation of the 
many definitions of disease proposed by eminent writers ; let it 
suffice to say, that all of them are improper, and many of 
them strangely absurd. We can describe dbease readily enough, 
but we cannot detect and exhibit its primary elements. Pro- 
bably we would not be practically wiser if we could do so. 

Lifey then, may be considered as the effects produced by or- 
ganization. Healthy the regular and orderly development of 
these effects. DiseasCy 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 aqts, and physiological medicine or hygiene with the 
preservation of health. Pathology is the science of diseased 
conditions. TherapeiUicSyX 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. JEtiohgyy^ 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, Noayeaax Elements, f «i/ric, nature, A.e>6ff, disooorse. 
X d^TMMv, I onre. 3 Ar«T%uvai, I oat np. 

I Xi^ the handjifytr, work. \ £t0c, oause. 



PBELIHINAItT COVSIUBI 



ignorsDt of the essentiftl nature •• 
the healthy performunoe of funni 
It is important to the st-i '. ' 
gnage does not preteml i' :! 
cal science. Medii-ul i!r;ii 
curately stating (he untn. 
tions which may scnc: 1' . 
been forgotten hy I'l-- ■ 
efforts to b« 1.1 
takea, and ii,' 
facts. Thf 
practi;,;' 
tnith 
atU;; 



_ r ztutrHal. By ext^rTiai 

_i^ w« independent of our 

^« ^eir impression npoa 

yitir. ThuB, poison, in- 

, i€3al caoae, though acting 



^ ^^ 10 la^ aa are prodaced from 

• ^ Mliri of one part of the body 

,^MMB aad dependence of parts ; 

I wh ■iii'n itself, which often em- 

_M«finT the physical machine. 

istf saeb as affect simultaneously a 

^ •««■■■. By local, those which are 

^ t&«r sphere of action. These 

^ ««J in descriptive science, are not 

^ ^M» c'vy cause must bo supposed to 

^^ » ^ ejceraption of olbcrB ; but they 

^ l» «Htwy the moaning intended. It 

i ^t jwtrn^ causes necoBsarity produce 

f ,ca «M*(k A local cause, acting only 

^^0^ wtj produce universal disorder, 

T^\^ Wtf fc*g** * strictly local disease. A 

k^rtUaS ^^ whole surface, may pro- 

^ l^b a toothache ; while a prick of 

g MMral disorder and even death. 

iKi)f vMCS are baeod upon the character 

** ^^ l-~ i i il ifciT r™*"" Some itimulatc or increase 

oi "^ ^^? .^ ..L I ignt^ f others debilitate or lossen such 



BTIOLOGT* 85 

action. Some act mechanically, dividing, tearing, braising, &c.; 
others chemically, burning, corroding, or decomposing. 

Predisposing causes are those which exert an influence suffi- 
cient to make parts more liable to disorder, without actually 
disordering them. This term, again, is not absolutely accurate, 
for we cannot conceive of these causes acting in any other way 
than in the production of disease, which doubtless they do, but 
in so feeble a degree as to give out no symptom of its existence. 
JSxeiting or efficient causes are those which immediately pre- 
cede disorder, and are reasonably inferred to have induced it. 
It must not be supposed, however, that these divisions are abso- 
lutely descriptive of certain agents which permanently belong 
to either of them. A cause which predisposes in one instance 
may excite in another, and vice versa. For example, a man 
may be exposed to intense cold, and while extremely chilled 
he may drink a large quantity of ardent spirits, and fever may 
ensue. In this instance the cold would be regarded as predis- 
posing and the alcohol exciting. On the other hand, a man 
may become intoxicated, and while thus enfeebled he may be 
exposed to cold, and fever or inflammation might result. In 
this case, the alcohol and its effects would be the predisposing, 
the cold the exciting, cause. 

Some causes are utterly unknown, but are inferred to exist 
as agents differing essentially from known causes, 'from the 
peculiarity and uniformity of their effects. These are called 
specific. The causes of scarlet fever and of whooping cough 
are examples. 

Almost everything without and within us may be in some 
way or other productive of disorder to the human body. The 
air we breathe may carry into the inmost recesses of our system 
invisible poisons, to injure the delicate tissues of the lungs or 
impair the vivifying quality of the blood ; it may withdraw our 
heat too rapidly, or it may fail to relieve us of our excess of 
caloric ; it may itself undergo chemical changes which deterio- 
rate its qualities and render it more or less unfit for respira- 
tion. The food we eat may pain or sicken or convulse us. It 
may suddenly prostrate, or gradually destroy us. Water, even 




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 
Bun'a heat exhaust the strength or inflame the brain ; while that 
all-pervading and powerful agent which we call electricity, en- 
tering our bodies at will, and playing upon our nerves at plea- 
sure, may work in us fearful but inscrutable changes. 

We are constantly exposed to the rude contact of bodies 
harder than our own, by which our tissues may be divided, 
broken, torn, or penetrated: while other substances possess a 
mysterious power, to combine chemically with the elements 
which compose our bodies, and form of them new products, thus 
altering and disorganizing the parts subjected to their action. 

Nor are the enemies of health and life within us less active 
or efficient. The exquisitely organized body is continually un- 
dergoing change, and in all its parts is at work an irresistible 
law which impels the whole to decay and dissolution. Linked 
together by exquisite sympathies, traversed by numberless 
nerves and blood-vessels, performing most delicate and import- 
ant functions, and pervaded by a powerful moral intelligence, 
whose passions and appetites excite and depress the physical 
system to its utmost limits of endurance, the parts of the body 
are continually liable to become diseased, and to radiate disor- 
der throughout the whole. 

It will be impossible for me to introduce into the present 
work a full examination of each of the many causes of disease 
which might bo 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 eorgeon is expected to treat. 




The air acts upon us in a variety of ways. By its pressure 
upon us it keeps ub in form. Without that pressure the fluids 

• the abaosphere it ooraptwed of two graat elamBnla, called Qifgen &iid 
nilrogea, with a «iDall portion of oarboiuc scid. 



ETIOLOGY. 37 

coursing within us would overcome the resistance offered by the 
coats of their vessels, and universal turgescence, interruption 
of function, and death would ensue. 

It furnishes us with the oxygen necessary to preserve the 
vitality of the blood. Were the natural proportion of this ele- 
ment increased or diminished, we must suffer hurt. It is also 
the vehicle by which watery vapour acts upon our outward and 
inner surface, and the medium by which caloric or the matter 
of heat is brought into contact with us. It is therefore the 
means by which we feel those hygrometrical changes which 
have so much to do with our health, and the vicissitudes of 
temperature which, as morbific causes, are hardly less important. 

Increase in the density of the air has been known to produce 
serious epidemic affections. Persons who ascend high moun- 
tains generally suffer much from embarrassed respiration ; and 
hemorrhages and pulmonary affections have been traced to 
changes in the mechanical action of the atmosphere. 

Unless the supply of air be unequal to the want, the quantity 
of oxygen in the atmosphere has never been found deficient ; 
but where persons have resided or been confined in crowded 
and ill-ventilated rooms, the most serious consequences have 
often resulted. When the deficiency of air is not so great as 
to produce rapid and violent results, the health often languishes, 
the complexion fades, the strength fails, and diseases of various 
kinds make life wretched, and shorten its duration. In the 
gorges of mountains are often found decrepid, deformed, and 
even idiotic people, who bear sad testimony to the evil effects 
of depraved air, though the precise mode of vitiation is yet un- 
discovered. 

Heat and cold are universally recognised as having much to 

do with the causation of disease. Caloric or the matter of heat 

pervades all bodies, and constantly tends to an equilibrium. 

The animal heat which is elaborated by some obscure process, 

but little understood, obeys the common law of caloric, and 

constantly passes off to bodies less warm, or receives increase 

from those more heated. Our sensations of heat and cold are 

therefore nothing more than indications of the loss and supply 

4 



38 ETIOLOGY. 

of caloric to our surface. When it passes off in greater quan- 
tity than we can supply it with comfort to ourselves, we com- 
plain of cold ; when surrounding bodies draw less from us than 
we are in the habit of supplying, or communicate to us of their 
own excess beyond our wants, we feel heated. These yariations 
in our state of calorification are not limited in their effect to the 
production of certain sensations. They are capable of causing 
great disorder in the performance of function, and creating 
morbid conditions of the most serious kind. Heat is an ex- 
citing, cold must therefore be a depressing agent. Heat induces 
increased action of the heart and arteries ; cold diminishes that 
action. But in considering the consequences of agents acting 
upon the human body, we must always remember that it is a 
living machine, and is not merely passive under modelling in- 
fluences. A thorn penetrating the substance of an inanimate 
machine, would produce no other consequence than the mere 
perforation ; but should it pierce the human body, it would in- 
duce a succession of phenomena, depending upon the vitality of 
the parts injured. Heat acting upon a bar of iron will expand 
it ; cold will contract it. Acting upon the human body, heat 
will not only expand its tissues, it will excite the parts to in- 
creased action. Gold will not only contract the tissues, but 
lessen action. Further, heat, if long continued, will exhaust 
the vigour of the nervous and vascular system, and thus debili- 
tate the whole frame ; for it causes the organs to work more 
rapidly than usual — consequently to consume more of the means 
of action, while it adds nothing to those means. It does not 
increase the amount of blood, nor enrich its quality, but it causes 
it to be more rapidly circulated and consumed; it provides no 
additional nervous energy, but causes greater expenditure of it. 
In the course of such unusual consumption and expenditure, 
the parts appear more than commonly vigorous, but the result 
Ibust be that the supply of means shall soon fall below the 
usual consumption, and languor, depression, or exhaustion result. 
Heat,'*' in other words is an excitant or stimulant, and all agents 

* It will be perceived that we use this word in the popular sense, as oon- 
ireying the idea of a certain sensation. When we speak of heat as an exter- 



BTIOLOGT. 89 

of this class will enfeeble as their secondary and ultimate 
effect. 

Gold, being the opposite of heat, is of course depressing, as 
being the withdrawal of an excitant. But there is in the living 
body a recuperative power which exerts itself energetically to 
overcome morbid influences. This power we call reaction, and 
its chief phenomenon is increase of vascular action, up to and 
beyond the natural standard. When cold is suddenly applied 
to the body, the first effect is to lessen vascular action and 
nervous sensibility; but unless the application be very long 
continued, the circulation will soon resume its vigour, a glow of 
warmth will succeed to the chill, and perhaps the heart and 
arteries may work with a force and frequency incompatible 
with health. 

In order to explain certain pathological conditions, of very 
common occurrence in every part of the body, it is also impor- 
tant to observe that when parts are suddenly chilled by the 
rapid abstraction of their natural heat, their nervous excita- 
bility, or the power of being impressed by agents, is increased.* 
Every one has remarked the extreme sensibility of the fingers 
on a cold day, and dentists are well aware that delicate pa- 
tients cannot endure protracted and painful operations in the 
winter as patiently as in the summer. 

To a man nearly frozen, it would be death to bring him to a 
blazing fire. Frost-bites are nothing more than burns inflicted 
at very low temperatures, upon parts unusually susceptible 
through the abstraction of heat. 

If this be true of cold, the converse is true of heat. Pro- 
tracted heat, as indeed the long action of all stimulants, wears 

n&l 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 yitality when present in its normal or natural 
quantity. 

* This is true in the case of the sudden diminution of any of the essential 
means of life. If food be withdrawn for a considerable time, the accumu- 
lated excitability of the system will make it dangerous to giye the starring 
man an ordinary meal. If blood be abstracted, the whole system becomes 
more easy to be acted upon by food, medicines, &c. 



40 STIOLOQT. 

out the excitability, and renders the body difiScult to be im- 
pressed. Debility or weakness may be connected with both of 
the nervous conditions ; hence weakness alone is not a charac- 
teristic of any disease, it is merely a circumstance of it. A 
man half-starved would be very weak, and might be too much 
excited by a single glass of fermented liquor: another, ex- 
hausted by long-continued intemperate drinking, might be 
equally debilitated, but could not be excited by immense quan- 
tities of distilled spirit. 

These remarks upon the effects of cold and heat will enable 
us to understand the mode of production of many particular 
affections, through the agency of atmospheric changes. 

Excessive moisture in the air is also a common cause of dis- 
ease, but only because the watery vapour withdraws our heat 
much more rapidly than dry air, at the same temperature, 
would do. 

Air is also the vehicle through which aerial poisons of various 
kinds are brought to act upon us. 

We have mentioned specific causes, as the unknown agents 
which produce peculiar and uniform disorders. Some of these 
causes can only produce their effects through the air when it is 
highly charged with the poison ; others can act at great dis- 
tances from their source, and apparently when much diluted 
by atmospheric mixture ; and others have never been traced to 
any local origin, and while apparently poisoning the air over 
immense spaces, produce no change in it which is appreciable 
to our nicest tests. 

Of the first class are the contagions^ which may be propa- 
gated either by direct contact or by atmospheric infection 
within short distances ; of the second are the causes of endemic 
diseases; and of the third are the inscrutable agents which 
produce those widespread disorders which we call epidemics,* 

"i^ Endemio, fr^juoc ; epidemic, iti^/uoc Bj endemios we mean diseases 
largely preyalent in a certain yicinity, and often traceable to a local cause, 
and always dependent upon such. An epidemic has no connexion with lo- 
cality, and evidently does not spring from a local cause. The yellow fever 
is an example of an endemic ; cholera of an epidemic. 



ETIOLOGY. 41 

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. 

MALABIA. 

It has been observed, &om time immemorial, that the bor- 
ders of sluggish streams and stagnant pools, and the vicinity 
of marshy grounds, are unwholesome, and that persons who 
dwell in such places, or even remain there during a short time 
at 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 are ob- 
served, 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 In- 
dies 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 productions 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 most pestiferous fens has not developed any alteration in the 
proportion of the elements of the atmosphere, nor any foreign 
matter whatever. Yet we have sufficient evidence to justify 
us in believing that the poison does act through the atmo- 
sphere, and the failure to detect the subtile agent only proves 
the inadequacy of our means of analysis to separate it from its 
atmospheric connexion or combinations. 

4* 



/ 




Malaria is evolved during the day by the action of the buo 
upon wet ground containing dead vegetable matter. This is 
apparent from long-cou tinned observation of the circum stances 
attending its development. It is only when decayed vegetable 
matter is subjected at the same time to heat and moisture 
that malarious diseases are engendered. Many neighbourhoods 
in this vicinity are healthy in June, when vegetation is in 
luxuriant growth, which become pestiferous in the latter part 
of summer, and the early part of autumn. The reason evidently 
being that it is dead, not living vegetation, that produces the 
poison. 

Several attempts have been made to establish the indepen- 
dence of malaria upon vegetable material, but no writers hare 
presented satisfactory evidence to sustain the supposition, and 
the whole tenor of human experience is adverse to it. 

That malaria is extricated by the sun, is evident from the 
well-known fact of its lessened production during cloudy wea- 
ther. That it ascends rapidly during the day seems to be 
shown by the circumstance that deadly localities may be visited 
with impunity when the sun is high, the visiter being obliged 
to make hia retreat before the evening dews begin to he preci- 
pitated. 

It ascends with the watery vapour which is simultaneously dis- 
engaged, and commonly requires to be precipitated and con- 
centrated by the cold of evening before it exerts its malign in- 
fluence. Hence the popular dogma that summer dewa are 
unwholesome ; an opinion based upon the experience of the 
fact juat stated. The danger, however, is not from the dew, 
but from the concentrated malaria simultaneously present. 

There are cogent reasons for supposing that the cause of the 
endemics in question is not one and the same for all of the 
distinct disorders belonging to the category of malarious 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. 

The commonly received opinion ia, that the several forma of 
disease ascribed to malaria, are the consequences of the action 



ETIOLOGT. 48 

of one poison more or less diluted bj atmospheric mobture. 
Yellow fever, for instance, representing the effect of a highly 
concentrated malaria ; remittent bilious fever, of a more diluted 
poison, and intermittent fevers and neuralgias being the product 
of the agent in a yet more free atmospheric commixture. 

This theory receives some confirmation from the fact that 
yellow fevers occur only near the source of malaria, while agues 
may be induced several miles from it. 

But a moment's consideration will convince us that this ex- 
planation is opposed by invincible objections. The diseases 
produced by malaria have little resemblance. The mode of 
treatment required by them is, in some cases, as widely different 
as the treatment of any other distinct disorders ; and moreover, 
if bilious remittents, quotidians, tertians, &c., are representa- 
tives of a gradually declining intensity of poison, their violence 
should certainly be, barring the accidents attending individual 
cases, invariably in the same ratio with the poisonous concen- 
tration. 

This, however, is not by any means the fact. The conges- 
tive bilious fever of our Atlantic coast is in every respect as 
formidable a disease, in fact more so, than the yellow fever of 
New Orleans ; and a malignant intermittent will destroy its 
victim in as little time as any other disease engendered by 
malaria can do. 

I fear that what, I venture to think, the common mistake 
upon this subject, has caused much unfortunate practice. The 
treatment of remittent and intermittent fevers having been 
conformed to much too closely on account of the supposed iden- 
tity of cause suggesting an analogy of nature, which certainly 
does not exist. 

It would be incompatible with the design of the present work 
to discuss fully 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 connected with it, which might be learned in a few 



44 ETIOLOGT. 

boars, annnally causes the death of many, who annecessarily 
expose themselves to the asEanlts of fatal pestilence. 

The only known prop hjl actios* 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 hy fires. 



It is not necessary to particularize the mechanical and che- 
mical causes which may injure the human body generally, nor 
would it bo consistent with my purpose to examine in detail the 
effects of aliments, occupation, &c., in the occasional produc- 
tion of disease. These considerations belong to general hygiene, 
and if introduced here, would augment this work to an incon- 
venient she. I will, therefore, only allude to those matters as 
occasion may require in the progress of our discussions. 

In organs endowed with a high degree of vitality, the laws 
of chemicul 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, time, and form 
new compounds with it, breaking up, of course, the integrity of 
the organ. The enamel is a crystallioo mineral substance and 
possesses no vital organization, coQBequcntly it is quite as liable 
to bo octcd 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 bo 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. Un- 

* njif*»jif«,— prophjluU, from wftuKtm—l gawd kgkiiitt. 



of 



fortuoatolj tfac word ia used to express an affection of the 
bones entirely different from the peculiar disorgaaization called 
cariea 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 
snterestiog experiments made bj him for the purpose of testing 
'"te actirity of certain chemical agents upon the teeth. The 
le of these experiments was as follows : 

A water-bath was prepared, kept constantly at 98° by a 
it lamp, and regulated by a thermometer. In these were 

tced vials containing the substances to be tested. In each 
»f these was placed a human tooth — care being taken to select 
those of as similar organization as possible, and whose enamel 
perfect. 

A hundred articles, such as arc most commonly nscd as food, 
indiments, or medicine, were thus tested, and uncommon care 
ras taken to watch the progress of the chemical action upon 
.tbe teeth, subjected to such application. 

The results of these experiments are summed up by Dr. 
.Tf estcott in the following declarations : 

Ist. Both vegetable and mineral acids act readily upon the 

ne and eoamel of the teeth. 

2d. Alkalies do not act upon the enamel of the teeth. The 
flaustic potash will readily destroy the bone by uniting with its 
animal matter. 

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 

itil after fermentation takes place, but all of them capable of 
■cetic 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 
the experiment, no visible phenomena were presented 




* Tide Amer JourDal of DeaM Science, Bept. 1S48. 



.ed J 



48 ETIOLOOT. 

except a slight deposit upon tlic surface of a greenish slimy 
matter Bomewhat resembling the green tartar often found upon 
teeth in the mouth. 

Acetic and citric acid so corroded the enamel in forty-eight 
hoUTB 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, hut is formed in the mouth vfhenever Bubstances 
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. 

Malio acid, or the acid of apples, in its concentrated state, 
also acts promptly upon the teeth. 

Murintic, sulphuric, and nitric acids, thongh largely diluted, 
soon decompose the teeth. These are in common use as tonics.* 
Sulphuric and nitric ethers have a similarly deleterious effect ; 
these are used frequently as diffasihlo stimulants. The acids 
of some of the salts also corrode the teeth. Supertartrate 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 hy corroding their surfaces.) Raisins so corroded 
the enamel in twenty-four hours that its surface presented the 
appearance and consistency of chalk. 

Sugar had no effect until it had undergone acetous fermen- 
tation. 

Mechanical causes breaking the enamel, although the fis- 
sure through it may bo very small, will ultimately cause the 
destruction of the tooth by permitting access to it by the 
flmds of the mouth, particles of vegetable food which being 
detamed undergo aceUc fermentation, and even the atmo- 
spheric air which is very irritating to all parts of the body not 
intended to be exposed to its action. The habit of cracking 
nuts, &c., with the teeth, and the very absurd use which femaies 

ir impart Umt to the 




ETIOLOGY. 47 

make of their, front teeth to do the office of scissors upon 
threads, cause a great destruction of these organs. 

The lamentable extent to which the young people of this 
country are subject to disease and loss of their teeth calls for 
close observation and anxious inquiry into the cause. Hitherto 
I confess that I have heard of no satisfactory explanation. 
The evil is of great magnitude and seems to be extending. A 
mouth full of artificial teeth is no longer an indication of age ; 
we look for porcelain almost as naturally in the mouth as in 
the cupboard, and the bills of the dentist are as regular and per- 
haps as large as the grocer's. Were deformity, vexation, and ex- 
pense the only evils attendant upon this devastation of the mouth, 
it might be endured more philosophically, but in truth, digestion 
can hardly be said to be perfectly performed after a large part 
of the teeth are destroyed. No artificial substitutes are more 
than appurtenances in usefulness to the natural organs. The 
fact that the chewing must be done by them, leads to the self- 
denial of much nutritious food and to the substitution of less 
suitable aliment, while even that is often sent to the stomach 
without proper preparation. 



CHAPTER III. 

SYMPTOMS OF DISEASE, 

All ehugM in normal phenomena observed to attend dis- 
MMB an Mllsd symptoms. Sometimes ve know nothing more 
oCike diMwe th&n that it citusca certain appearances, and in 
fact we arc commonly compelled to regard the symptoms as 
the evUa 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 correct- 
ly and pursuing their indications to the desirable result. 

Sometimes a case will present hut 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 jittention and 
clamour 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 ; gympathetic, such as are manifested 
in other organs than that primarily affected, and which are 
dependent upon the distant disease, being due to their relations 
*ilh it through the brain, spinal marrow, and sympathetic 
wxsv». General symptoms are such as affect a large part of 
th« \»Ay wmultauoously. 

OflueraUy speaking the local symptoms are the most import- 
(MW M lh»y indicate the seat of the disease, upon the extent and 
art«»»Mty ttf which the suffering of the sympathizing organs de- 
>***^ U 19 always exceedingly important to detect these lo- 
'** ^\*^**•" »nd deduce from them correct knowledge of the 
•UK"*) c^nulition they represent. But this is often a 




STMPT0M8 OF DISEASE. 49 

matter of great difficulty, as the greater intensity and obtru- 
siveness 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 w^tch them carefully, especially if the 
brain be the seat of them. 

General symptoms are those manifested by the heart and 
arteries, and the nervous system, which, acting throughout the 
whole economy, when disordered give out everywhere signs of 
distress. 

PBOORB88 OF DI8BA8B. 

A disease is said to be continuou8 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 a 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 belongs to this class. 

Diseases are said to be acute when they run their course 
rapidly : chronic* when they occupy a comparatively long time 
in their progress. 

The student must not suppose that the term cumte^ 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 



* X^ofof — time. 
6 



50 SYMPTOMS OF DISEASE. 

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. 

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 paroxysms 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 inter- 
mission 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 
tertian,t if there be two days of intermission, a quartan,^ &c. 

Sometimes there will be two paroxysms a day, a double quo- 
tidian ; sometimes there will be a paroxysm every day, but the 
time of access corresponding on alternate days ; this is called 
a double tertian. Sometimes there will be a double paroxysm 
upon alternate days, with a single paroxysm upon the interme- 
diate day ; this has been called a triple tertian. Many other 
modifications of periodicity occur in the disease, but the inter- 
mission is distinct in all. The quotidian and tertian are by 
far the most common forms of ague. Gases have happened 
in which the paroxysm has returned after an intermission of 
two weeks, and continued to occur regularly for months to- 
gether. 

It not unfrequently happens that the paroxysms occur regu- 

* Qaotidian — quotidies, dailj. f Tertian — tertius, third. 

X Quartan — quartus, fourth. 



SYMPTOMS OF DISEASE. 51 

larly, but do not present 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 parox- 
ysms do, and is known as intermittent neuralgia.* 

It is very important that the dentist should be well acquainted 
with this form of disease, as it frequently occurs in the teeth 
and parts about the jaws, &c., and may be easily confounded 
with toothache from local causes ; a mistake which has caused 
the infliction of much unnecessary pain, and the loss of valu« 
able teeth. 

Remittent diseases are characterized by a remarkable diur« 
nal abatement of their symptoms, not amounting to intermis- 
sion, but apparently analogous to it. Some of the most fatal 
diseases which afflict the human family are of that class. For 
example, 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 
dass. They arise from specific causes, and are sometimes 
called specific diseases, though this term includes other dis* 
orders of entirely di£ferent character. 

* Neuralgia, from ftufoc, neuros, a nerye, and atxycf algos, pain. 




CHAPTER IV. 



DlAONOBlB* IB the art of following symptomB 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 impossible. 
When one or more local eyinptoms are prominent beyond 
others, we may Bometimes ascertain at once the seat of the dis- 
ease, but even in such cases we must not decide until we shall 
have ascertained whether these local symptoma are primary or 
sympathetic ; an inquiry which often requires much general 
knowledge of disease, and a capacity for close consecutive rea- 
soning. 

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 outcry of organs, the attentive observer will ge- 
nerally detect one voice of distress more earnest than the rest, 
and directing his inquiry to the part thus designated, he fre- 
quently will come at once upon the cause of the general trouble. 
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 sympathctJo symptoms cor- 
roborate our suspicions, that is, whether they can aU be ac- 
counted for upon the supposition that we have found the local 

* ^t ■iiHiia. 1 know tkroagh, or tborongblj. 



68 



caose, and whether unj are absent which are nniformly or com- 
monlj coacurrent 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 a 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 distinguish in g dental diseases and those of the 
parts adjacent to the teeth and mouth ia fully set forth in works 
of dental surgery. I will, therefore, omit any particular di- 
rections upon this subject; but I would earnestly urge upon 
every dentist to eitend hia knowledge until it shall embrace 
the entire snbject of diseases and their cure. 

Independently of the necessity of diagnosing the local aifec- 
tionfi, 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 ner- 
Tous centres and vascular system are participating in a disor- 
der. A number of symptoms, very variable and difficult to he 
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 
puhe, • i. e. hy the heating of the arteries due to the propulsion 
of blood through them. 

The artery which is generally examined for this purpose is 



54 CIAONOSIS. 

the radial, wluch is of Bufficient Bize, and passing near the sur- 
face at the wrist is most conveniently situated for esamination. 
The fre«[uency, quicknessj force or resistance, volume, and any 
peculiar seoBations given by the pulsation, are all subjects for 
observation, and contribute to the discovery of the nature, Beat, 
and degree of disease. 

Since the days of Galen, judicious and succcBsful physicians 
have paid much attention to the pulse as a guide to correct 
diagnosis and practice, and although it is too common in this 
day to hear the inferences drann from it decried as uncertain, 
yet the fact is, that to those who know how to interpret its 
communications, the pulse 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 wo 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. Whyli 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 senaibilty of 
the gentler bcx, 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 exalting drinks, and 
in pregnancy. It is also often very much accelerated after 
copious evacuations, and under circumstances uf great prostra- 

* Some writers, ib Billard nni Vdleii. ksaert that Ibe pulse ot f oung iu- 
fanti )■ not nenrlj to fycqueac m it geDerall; Buppoaed. See Chomel, Ge- 
&«ral PaUiologf, p. 171. 



tioD. It is dinuDisbed by the horizontal poetare, by rest, by 
incKlerate bleediog, and by the influence of certain drugs, such 
I digitalis and the tartrate of antimony. 

Indeed, the frequency of the pulse is subject In bo great a 
degree to the control of idiosyncrasy* and accident, that no posi- 
[ tire inferences can be drawn from this solitary symptom, un- 
less the habitual pulse of the patient be known. Chomel says, 
** I hare seen a lady whose pulse during the paroxysms of in- 
termittent fever did not beat above sixty per minute, to the 
great astonishment of her physician. This astonishment 
Tould have ceased had he counted the number of pulsations 
daring the intermission, these being not above forty per mi- 
Bnte." 

Quickness and frequency are not synonymous terms. Fre- 
quency has reference to the number of pulsations in a given 
time, as a mlnnte ; quickness to the time required for the com- 
pletion of a single pulsation. Slowness is opposed to fre- 
quency, not to qaickness. 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 quiek, physicians frequently use eluggUh or 
labouring. 

The natural pulse is sofi 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, whou 
the regular succession is broken by omissions of pulsations. 

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 
tation which would be imparted by the passage of a fluid 




throngli a shattered quill. Ossification of the coats of the ar- 
teries deatroya their elasticity, and of course renders the pulse 
very hard. The hard pulse ia usually attended by a peculiar 
condition of the blood, which when drawn and coagulated, 
presents a yellowish lymphy surface, which is called the bufl^ 
coat, with but few exoeptiona, a very important sign of inflam- 
matory action.* The following precepts for feeling the pulae, 
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 
conclusions 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. 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 
artery 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, be should he upon his back, ho 
that he may neither incline to the right nor left, and thus im- 
pede the circulation of blood in the arteries. The arm should 
be placed nearly in & state of extension, and sustained in its 
whole length, bo 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 at any other point. All bandages 
should be removed so that there be the least possible compres- 
aion. By means of these various precautions, we may be cer- 
twn that there is no foreign obstacle to the flow of blood 
through this veesel. 

The artery of the left side should be felt by the right hand, 
and vice versa : the four fingers placed parallel on the same 
• The buffj co»i \t also >peD upnn the lilood drum from pregnut f«in»le», 
»tid persona under mcrourid impregnnliuii. 



DIAGNOSIS. 67 

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 
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 af- 
fording solid support to the fingers by which the pulse is ex- 
amined. The latter should at first receive a slight lateral 
movement in order to ascertain the situation of the vessel. 
When the fingers 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 difierent 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 minute these precepts may appear, they 
cannot be neglected without inconvenience. — Ghomel, 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 consider 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- 
rately represents 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 



68 DuaNosis. 

happens frequently, that diseases of the nervous centres, and 
of the nerves themselves, occasion pain at the extremities of 
these organs of sensation, instead of at the point actually at- 
tacked. Violent pain in the nerves of the face may depend 
upon disease located in the brain or intermediate parts ; and 
similar conditions are noticed in other nerves. 

Nor does the degree of pain represent necessarily the degree 
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, arbi* 
trarily, yet with wonderful wisdom and mercy. Pain is in- 
tended to warn us of danger and compel us to preserve the in- 
tegrity 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 ; while those most carefully pro- 
tected, are 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,^ wl|l0 an unimportant injury to the eye or skin will cre- 
ate greiiCt 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 inci- 
dent to protracted su£ferings, by morbid conditions of the 
nervous centres, 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 mortis 
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. 



TBEATHBin OF DISEASE, 



The first step towards the cure of disease is to remoTe the 
cause nhich 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 imprac tic ability of doing this effectually, forms the most 
•erioDS obstacle to the successful treatment of many disorders- 
Children teething during very hot weather are subject to the 
action of combined causes, that often induce diseases which are 
very serious and very difficult to be controlled, while the causes 
eontinne to act. Bead teeth remaining in the mouth may pro- 
vote 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 
pnmary 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-balt may manifest themselves in 
serious and fatal disease long after the instruments of the in- 
jury have been withdrawn. The same truth holds good in all 
kinds of injuries by whatever class of agents they may be 
produced. 

The absolute rest of a diseased part, when the nature of its 
Unction permits, and the least possible exertion of others, is 
Tery conducive to cure. 

There are, however, certain exceptions to this rule. Certain 
morbid conditions of the articulations are improved by exer- 




j^mum. sTANfora mv^^ 



TKGAXMEITT OF DISEASE. 

ciae ; a particular mode of ocular affection requires the light, 
&c., — but the exceptions are few and the rule general. 

The regimen of the patient, that is his diet, clothing, exer- 
cise, employment, &c., require judicious management. 

Finally, the most important part of treatment consiste in the 
skilful application of therapeutical agents, and surgical means; 
but of this part of the subject I will treat particularly when 
considering special diseases. 




61 



CHAPTER VL 



NATURE OF DISEASE. 



Many of the morbid alterations which seem to constitute 
disease, or cause symptoms, have been observed upon the 
living and the dead subject : many others have as yet escaped 
detection. We are unable, therefore, to compose a full list of 
these different conditions of parts, but those which are of com- 
mon occurrence, 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 
feveTy 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 commonly 
such as mark diminished action. 

3. Red indurations ; vegetations ; fungi, polypi. 

4. Vesicles, pustules, suppuration, erosion, ulceration, per- 
foration, gangrene. 

* Inflammation— >^im ma, a flame, ilt/^, fire — from the burning sensation 
&nd heated appearance of patients in fever. 

6 



62 VITTEB or DJSMABM. 

5. Thickening, gntnoladong, thickness of tissues natnrallj 
transparent, adhesions, effusion of serum, false membranes. 

6. Conyersion of one tissne into another. 

7. Graj induration, gelatinous degeneration, tubercles, en- 
cephaloid matter, cancerous matter. 

8. Contraction, dilatation and complete obliteration of natu- 
ral canals. 

9. Accidental canals, fistulas, accidental tissues, cysts. 

10. Deyelopment of gas in cavities. 

11. Living bodies in organs. 

12. Effusions of blood, collections of blood. 

13. Chalky^ stony, hairy, homy, and melanotic* produc- 
tion. 

14. Changes of form and relation, wounds, ulcers, disten- 
sion, lacerations, ruptures, fractures, and dislocations. 

15. Foreign bodies. 

16. Vices of formation.t 

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 vrhich 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, conditions, 
which are only incidental to other previous and more important 
phenomena. Nevertheless, it is as accurate, or nearly so, as 
the present state of medical science will permit. 

It is my purpose to select from this list such pathological 
conditions as are particularly connected with the pursuits of 
the dentist, omitting none, which, even in a remote degree, 
concern him, and passing by those in which he has no profes- 
sional interest. 

* Mf^«r — black. f Roche & Sanson. Path. Med. Chir. 



NATURE OF DISEAgS. 



The most common, and for several reaaons the most import- 
ant of all morbid conditions, is one which is characterized by 
redness, swelling, pain, and increased heat. This is called in- 
flammation, and may occur io any parts naturally possessing 
Bcneibility. 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 
Itlood from ruptured vessels and its deposit in surrounding tis- 
sues. This is called chemosU or ecchemoiit.* 

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- 
cnlation. 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 
■ystem 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 he uniformly correct. All patho- 
logical conditions attended by heat, redness, swelling, and pain, 
we considered inflammatory, whether the parts immediately 
concerned be in a sthenic! or asthenic state. 

Theoriaers upon inflammation have been much perplexed to 

reconcile the distension of the capillaries with the apparently 

excited state of the parts : for distension or yielding of the 

Mrallfl of the vessels being connected in their minds with the 

*Bb, outoC X«;u«<, hnuonr. flStfoi, ttrengtlt. 



64 NATURB OF DISEASE. 

idea of force 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 rational to use exciting applications in order to arouse 
the capillaries to exertion, so that they may empty themselves 
of superfluous 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 
passive, 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 stimu- 
lus 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 capillaries when their activity is diminished. The erectile 
tissues furnish us with an example of the operation of a simi- 
lar 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, 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. 

That the distension of parts is connected under the peculiar 
circumstances accompanying inflammation with the pain pro- 
duced, is obvious, however, in the disproportionate amount of 



Boflpring experieoced between loose tiasaes, and those nhich 

boat DalQre or situatioD, admit of little freedom of expansion. 

DmibtlesB the morbid condition of the nerves of the part, is 

the primary cause of the pain. 

The pain of inflamed parts is bo much modified by peculiatb-j 
ity of Blrncture as often to enable the observer to diatioguiA 1 
[he WBt of ihe disease by the character of its sensation. Aj | 
a general rule, the external parts arc the most sensitive. Th* j 
itio when inflamed is affected by a horning or scalding senaft^ j 
tion, often intermingled with itching, even more distressing | 
thiin ibe borning itself. The inflamed mucous membrane pari. 
t»l;«oftbia sensation, though generally in less degree, onleu 
in taperficial situations. 

TLe serous membranes when inflamed, 'cause a sharp, darting, 
lucitit'e pain. The pain of the cellular membrane under simi- 
J kr circumstances, differs very much according to its position 
I ind relations. When in connexion with the skin, it partakes 
§tf the pungency which characterizes the inflammation of that 
■JMBitive organ ; when the cellular structure of the internal 
jera is inflamed, the pain is usually dull, or obtuse, in con- 
iqnence of the manner in which these viscera are supplied 
\i nerves. 

When nerves are the seat of inflammation, very acnte, dart- 
ing pangs are felt, and the surrounding structures aro gene- 
rally very sore, tender, and more or less inflamed. When the 
ranacles are inflamed, the sensation is aching, mingled with a 
feeling of fatigue. The pain is greatly aggravated by motion. 
Inflammation of ligaments and bones, causes sensatioDs not 
very diflferent. 

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, occasioo 
a peculiarly distressing, darting, and burning pain: slight 
inflamma^on of the pulp of a tooth produces intolerable 
agony, &c, 

Pain does not always proceed from inflammation : it may 



k 




NATUBB OF DISEASE. 

Mtend very opposite conditioiia. Ice lield upon the Bkm will 
cause great suffering. 

The secretions of organs ure very materially modified by Jn- 
flamtnatioQ. If it be eliglit, the natural secretion niay be 
slightly increased, more often vith increased secretion there 
vill 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 diminiahed, 
or altogether suspended. An abundant discharge of thickened 
secretion often precedes, and seems to be the means of relief to 
the inflamed parts. 

It has become common to designate inflammation of the dif- 
ferent parts by attaching the common termination "i(j's" to 
the Greek name of the part afl"ected. Thus, atomatitia indi- 
cates inflammation of the n-o^uc, stoma, or moutb — gastritis, of 
the ynif, gaater, 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 yet to be continued, though as exceptions to 
the rule. Thus, pneumonia signifies inflammation of the lung ; 
rheumatism, of the muscles. The term myitis is sometimes 
used instead of rheumatism. 

Inflammation occurs in two very distinct forms, called 
Phlegmon and Erysipelas. 

Phlegmon is the common form of healthy inflammation in or* 
gans composed largely of cellular tissue. It generally results 
&om some local cause, as a, blow, pinch, or other mechani- 
cal injury, or from the in-itation of acrid matters, or foreign 
substancea. Sometimes, however, it depends upon constitu- 
tional causes. 

When phlegmon is seated in the subcutaneous cellular tis- 
sue, it presents a hard, circumscribed red tumour, which is ge- 
nerally very painful. At first, the senaation is burning and 
darting, subsequently, as the tumour softens, thi'obbing, or pul- 
sating. After a longer or shorter time, according to the in- 
tensity of the inflammation and nature of the afiected parts. 



HATUBB OP DISKASB. 



fluid is felt to 6actnate in tho tumour ; in other words, an abscess 
filled with pus, baa been formed, the skia ulcerates, the matter 
is discharged, and the cavitj is obliterated. 

What is called a, boil is the best example of genuine phleg- 
niDD. It is a possible thing for a phlegmon to terminate by 
molution, bot this very rarely happens, unless the incipient 
inHanimation bo actively combatted by the resources of art. 
Id by far the greatest number of cases the best treatment 
faiU to prevent suppuration, after the phlegmonous tumour boa 
been fairly formed. 

Circumstances of position may vary the phenomena of phleg- 
mon. If it be seated in important viscera, the constitutional 
eymptoms will predominate very remarkably over the local dia- 
Ireas : if it be formed nndcr aponeuroses or muscles, the ten- 
sion occasioned by the resistance of these unyielding tissues 
greolly 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 inflammatioa 
fts far &s 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 »{mis, or sinuous ulcer, may be the consequenco. 
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 peculiar 
pain of these inflammatory tumours. 

When phlegmon is deeply seated Its presence is often attend- 
ed with an oedematous appearance of the surface, — an observa- 
tion worth noting. The period of suppuration, even in super- 
ficial abscesses, is often marked by rigors, or chilly sensations. 
In deep-seated abscesses these rigors are stlU more remarkable. 




f 



■ATcms or DISUSE. 

the pain abates, and assumos a heavj, 

i pecnliar to the akin, and mucous membrane, 
lally met with in the former organ. It dif- 
|m> fioa plitcginon particularly in this, that it is not circum- 
iMiftrl hj Ijmphj barriers, but is diffused until gradually lost 
« knUthy parts. The effusion which occurs in erysipelas is 
MKMS. When the skin only is afiectcd, the scrum is effused 
^ider the cuticle, and occasions vesications. Sometimes the 
MDnlar tissue beneath the skin becomes inflamed together with 
tl, and putting on its own phlegmonona condition, though im- 
perfectly developed, forms a compound disease, which has been 
enlled phlegmonous eryaipeUs, The effused serum, and un- 
healthy pus, diffused through the loose cells of the cellular tia- 
sue, carry destruction to this substance, far and wide, among 
tkfl muscles and beneath the skin, while the latter organ ulce- 
rating, and sloughing rapidly, gives way before the advancing 
inflammation. 

This aggravated affection takes place in persons of debili- 
tated constitutions, and as the result of wounds, and epccifie 
poisons. 

In erysipelas, the circulation of the skin is not impeded, and 
therefore the pressure of the 6nger on the skin temporarily re- 
moves the red colour. The pain is burning, or stinging. 

Simple erysipelas does not tend to form pus, but ends by 
reeolutionor effusion. The constitutional symptoms attending 
it. are generally much more serious than those resulting from 
pblegnion. 



larLAMMATOKT FSTER. 

nvM.t or pyrexia,! b a morbidly increased activity of the 
Iwan and arlenes, the proximate cause of which is little under- 

from tlie tendcooy to iaToWo sttrrounding 
X l\«,. Sre. 




KATURB OF DISEASE. 69 

, but whicli IB attended with general disturbance of func- 

Merely increased action of the heart and arteries is not fever, 

r such escitement may be purely physiological and attended 

rith no functional distress. Violent exercise and mental emo- 

niona will fretiuently cause the vascular system to work with 

istly greater energy than usual, while the individual who is 

Ifae subject of the accelerated circulation will not be at all mor- 

idly affected. 

But in fever, the increased vascular action is the effect of 

Bturbing morbid causes. Often, perhaps always, the blood 

»elf has undergone change, and the vital fluid thus altered, 

keing supplied to all the organs, begets universal disorder of 

met ion. 

Fever js either idiopathic,* or symptomatic. 
By idiopathic fever, we mean that form of it which appears 
9 Ufl to present the primary, or original disorder, being the 
observable effect of the morbific cause. Such fevers aro 
lot, so far as we know, preceded by a local disease, whose ox- , 
■tence and intensity are represented by the vascular action. 
Ke cannot, in the present state of our knowledge, go behind 
s fever to find out its immediate cause, structural change, or 
motional error. 

Symptomatic, or secondary fevers, or as they are often called, 
a the nature of the couditions they most frequently repre- 
snt, inSamniatory fevers, are merely consequent upon local 
isease, having no independent existence, but rising and falling 
irith the flow and ebb of the disorder they represent. 
These two conditions, though called by the common name, 
lAver, are entirely distinct and different in their cause, nature, 
rogress, and treatment, and are only allied together, by the 
tct, that each of them is attended with morbidly increased 

nilar action. 

Neither is symptomatic fever a unit ; for when it represents 
' inflammation, it differs essentially from the vascular condition 
irhich is consequent upon another state, which is called irrita- 
■JJ»(, proper, or pMQiUr, ntSct, disesa«. 



i 



^ 
^ 
^ 

N 




• merely augmented sensi- 
oocuioned through it. 
fiMdrr «f iaftunmfttor^ ferer consiata ia 
of the pulse, and the buffy coat of 



r A* p«lse may be quick and frequent, 

^ to which the exceptions are very few, we 

» M indicative of Inflammation. 

Ik 3ln«l iA ilrawn in a full stream from the veins of a 

k iMMunii( under inflammatory fever, it vtiW, upon coagu- 

■ Ik fibrinous surface of a yellowish hue, the 

»i iwltioli will, to a great extent, mark the inten- 

ration it represents. Very often, too, it will 

r farm, being depressed in the centre, and 

• ; ft& appearance which is called "cupped," 

inoe is nearer to a saucer. 

s that this appearance is more manifest 
I progressed several days than in its inci- 
giMPt: ^B*^ * vftvu more observable upon a second, than a 
%|^4M)tai^ ft tun which has led to the very erroneous opi- 
«j|i^ Jm* tlM ftlWtraoUoQ of blood favoured this kind of altera- 
1(1^ IVtH tMM mode of observing this buffy coat is to catch 
iig( blood in a deep narrow vessel, such as awine or 

of fibrous tisauoa produces more of the bofiy 
aA consequent upon the same disease in other 




1%* (MMrked, however, that the buffy coat is found 

M»o<l drawn from pregnant women. It is occa- 

Mntjr mot with when the circulation is morbidly 

MUses than inflammation. Mercuriallzatioa 

likjh uppmrance to the blood.* 

■ ■■■■■.J> W ili»l>>t>*wt. Iftbonrlng under alight enUrgemcnt of th* 

^■■^'^■**^**»**V»I*«"">t»<i» buffy ooat. Id « iomewbat exten* 

- — - 1^ ilahiMO /Mrs, he hu never found the blood of h 




NATUBB OV DI6BASB. 71 



TEB OOirSBQUBirOBS OV XXVLAXKATIOir. 

Inflammation never continues long without the Bupervention 
of certain results, often of greatly more importance than the 
phenomena we have described. When it passes away without 
consequences, we call the process reaoltUion. 

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 
patient, &c., &c. 

The consequences of inflammation are chemosis, oedema, 
suppuration, yesication, 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 adhesiye inflam* 
mation is more often a reparative and conservative than noxious 
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 
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 inflam- 
mation, in debilitated subjects, and is unfavourable to reco- 
yery; 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 



NATURE OP DISEASE. 

also attends certain specific conditions, as scarlet fever, and 
may be proiluced by medicinal agents, as arsenic. When oede- 
ma is general, it is called " anasarca."* It is readily detected 
by the bloated, translucent aspect of the skin, and by its loaa 
of elMticity observed by pitting under presBure. 

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 
Tera. This may occur as the result of topical applications of 
an irritating kind, or, in conaer[uence of local or constitutional 
disorders. This condition is frequently produced aa part of 
medicinal treatment, and gives the name of vcsicatorics to a 
class of means employed for this purpose. 

Suppuration, or the formation of a peculiar fluid substance 
called pus, is one of the most common and important of the 
consequences of inflammation. 

Pus, when pure, is thick, cream-like, yellowish, of a- f«int 
and peculiar odour, and somewhat sweetish of taste. It is not 
at all irritating. To this kind of pus, the terms "laudable" and 
" healthy" have been applied. That which is thin, dark, and irri- 
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 abate- 
ment of local inflammation, it may, nevertheless, give clear evi- 
dence of a state of disease incompatible with the integrity of 
organs, or with life itself. Suppuration of the eye, of the lirer, 
or of tho lungs, would be a very eerioua m&tter, 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, or growth of new flesh. 

Although it is true that suppuration often intervenes be- 



rx.^— UiTougbout tbo flesh. 




NATURE OF DISEASE. 



73 



I 'twecQ iofiammation and cure, and tbat the painful sjmptoms 
I -fif inflammation abate or disappear after tlie copious secretion 
1 -of pus, jet we must regard the formation of this matter, how- 
J «Ter pure, aa a great evil, though certainly preferable to others 
I vhich occasionally affect inflamed parts, and it is one of the 
eatest cares of tho surgeon and physician to prevent it. 

s may form in several situations. First : it may be found 
« upon the inflamed surfaces of parts, as the skin, the eye, 
d macouB membranes, without any other apparent change of 
^nizatioQ than an increase of the natural vascularity. Se- 
mdly : on the naturally unexposed surfaces of the body after 
f have acquired a now organization, by increase of red ves- 
, and usually, if not always, by the addition of coagulablo 
mpb ; for it may be questioned, whether in any instance the 
9 of the cellular, synovial, serous, and medullary mem- 
mes, tbe pia mater, or periosteum, can furnish genuine pus, 
Lhout the deposition and organization of some coagulablo 
mph. The third situation in which pus is generated is the sur- 
e of the peculiar structures called granulations, the vascu- 
rity of which exceeds that of all the natural surfaces of the 
>dy. Tbe pus formed on tbe granular surface of an ulcer is 
e best example of this kind.* i 

I partA of the body have a much greater disposition to 
pus when inflamed, than others. The cellular tissue, 
I, and mucous membrane are very prone to suppurate, while 
t fibrous tissues manifest no disposition to it. 
' Pus is modified by the nature of the part where it is formed, 
' tha constitution of the individual, by various accidents, 
occurring in tbe process of its formation, and by certain ob- 
scure laws, which control the phenomena of those afifections 
which are called speciflc. It will also present diflerent ap- 
pearances, as it may be mixed with other fluids, as blood, 
mUvu, bronchial mucus, &c. 

If pus mixed with blood, serum, &c., be long confined undor 




r 



74 SATURB OF DISEASE. 

dreasings, or in cavitiea, it beeomea very offenBlve, and often 
irritating. If it be produced from the irritation of diseased 
bone, it is also very fetid. When thin, oiized with blood, and 
evidently "unheallby," it is called "aanieB." 

When pus is irritating, it is so, not to the surfaces which 
secrete it, but to the adjoining healthy structures over which 
it flows. 

Pu3 is heavier than water, and this quality frequently ena- 
bles us to distinguish it from mucus. It is coagulable by mu- 
riate of ammonia, which Mr. Hunter considered a peculiarity 
sufficiently marked to distinguish it from mucus, and all other 
natural secretions, but the accuracy of the test is disputed. 

From the fact that hard inflammatory tumours in the course 
of inflammation become soft and yielding, and filled with pus, 
it was naturally supposed that the original solid parts were 
converted into this fluid. It is now welt 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 comiition is called abacees,* 

The phenomena of abscess are very curious, and through 
them, nature snccceds in relieving the body of foreign matters, 
and repairing extensive injuries. 

When a part capable of suppuration is subjected to inflam- 
mation of the required intensity, some of the small vessels 
give way, and blood is effused into the surrounding parts. 
Simultaneously with this rupture, or nearly so, the arteries 
begin to throw out a peculiar plastic matter, which is called 
coagulable lymph. This is capable of becoming organized, and 
being thrown round the diseased parts, and between them and 
those which are healthy, it forms a barrier to the infiltration of 
extravasated fluids. By some strange process, to us altogether 
inscrutable, the walls of lymph become vascular, and capable 
of performing the vital functions of secretion and absorption, 
and by them the pus is furnishe*!. As this secretion proceeds, 
the previous contents of the abscess, including the effused 

• AKKtOB, I depart, deaoUng the low oT sutMUac*. 



NATUBE OF DISEASE. 



75 



I 



blood, are gradually absorbed, and freah pua deposited in their 
ttrid, 60 that, if the tutnour be opened at an early stage, the 
pus will be more or less mixed with blood, but if the opening 
be delayed, the cavity will be found to contain only pure pus. 
The process of suppuration is announced by some relief of 
local symptoms, and a change in the character of the pain. It 
loses its burniHg sensation and becomes throbbing, at the same 
tine, the tumour becomes softer, and at last fluctuatos readily 
wder pressure of the fingers. Very often, and especially 
vben the disease is extensive, or when it is seated in the vis- 
•era, the formation of abscess is announced by shivering or 
.«hill. 

While the arteries of the walls are depositing the pus, other 
ipcoceeeea equaily obscure are moving the abscess towards the 
:|itrface, and preparing for its evacuation. The bottom of the 
kvity is constantly contracting and filling up, while the oppo- 
Bte side is thinning and expanding. The absorbents at one 
fide of the abscess are busily engaged in removing matter, 
irhile the arteries at the other, are as actively supplying new 
itertal ; at the same time, a temporary organ, made for the 
occasion, faithfully performs its peculiar functions, supplying 
pQs, and remoring mixed fluids from the cavity. 

The parts lying upon the summit of the abscess are rapidly 
thinned, the tumour is pushed towards the surface, the skin ul- 
cerates, an opening is made, and tbo pus evacuated. ThoDgh 
an abscese may discharge itself anywhere, there is evidently a 
(trong disposition in such tumours to find their way to the out- 
le of the body. In order to eS'cct this, they will often tra- 
rae dense opposing structures when a nearer opening through 
ire yielding tissues might readily be effected. Sometimes 
vliea an abscess occurs in an important viscus, artificial adhe- 
moD will be formed between its surface and an adjoining struc- 
ture, and a continuous canal being pierced through, then the 
pas 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 




A 



76 NATURE OF DISEASE. 

regard them in any other light ihan as manifestationa of divine 
and Bnperintending Providence. 

Foreign bodies are removed precisely in tlie same way as 
pnfl. When the nbaeeas has reached the surface, a thin point 
appears, which is soon perforated by a very small opening 
through which the pua 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-hoil, the pus failing to be evacuated, is ultimately ab- 
sorbed. 

When the attempt is made to form an abscess by weak or 
scrofulous conatitntions, and in situations where the cellular 
substance is lax, the progress of the disease is very different. 
The 6rst extravasation is serum, which passes easily into the 
loose cells of the cellular membrane with little or no injury to 
their structure. The parietes of the tumour are not composed 
in the beginning of organized and vascular lymph; no genuine 
puB, therefore, is found in such cavities in the first instance ; 
the fluid they contain is serous, mi.i:ed with coagulahle 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 
arc effected by Tital processes, and open secreting sores pro- 

■ ll»caTin*]r on iBflammatiaiL. 



NATDRE OF DISEASB. 

doced. Inflammation !b hj no means nccesaarj to this result, 
Bod some of tbe best writers upon pathology have declined to 
recognise it as one of the consequences of inflammatory action. 
Nevertheless, as ulceration does frequently occur in the pro- 
gress of inflammation, and is an evil to be guarded against by 
the dental practitioner especially, it seems proper to consider 
it in this connexion. 

The process itself is very curious, and at first sight, the 
facta explanatory of it are hardly credible. It is not easy to 
comprehend how a body can destroy itself and take itself 
away, and the difBculty is not solved by the fact, that only 
small portions are thua 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 facta, as Mr. Cooper ob- 
serves, are equally well confirmed. 

Every part of the body is continually undergoing waste and 
reparation. It seems that the molecules of tissues are con- 
stantly becoming effete, and having undergone some mysterious 
change, are taken up by tbe absorbents and carried off to the 
several waste gates of the system, from which they are ulti- 
mately discharged. The bowels, the kidneys, tbe skin, the 
langa, all the emunctories* are continually at work, and all 
ultimately discharging the debris of the system. 

At the same time that this disintegration is going on through 
tbe action of the absorbents, another set of vessels, the nutri- 
tive arteries, are everywhere depositing new matter. Bone 
receives bone, muscle is supplied with muscle, and viacus 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, yel not so positively as to load 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 



i^rrr, to cleknae — any organ wboie offiae it iB to illHchBrg* e 



b; I 



[ 



78 KATUUfl OF DISEASE. 

the wants of the man than tbe activity of the absorbents. If 
hia 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 tlie absorbents of a part beyond what 
is usual, and should not sintultaneously stimulate the nutritive 
vessels ; or, should any circumstances render parts unusually 
susceptible of absorption, that the result would necessarily be 
an obvious loss of parts, and the interruption of their conti- 
nuity. It is also obvious that the converse of these conditions 
would be attended with similar results ; for if nutrition be im- 
peded, either through defect of supply, or any cause rendering 
the part less capable than usual of converting blood into its 
own tissue, loss of volume, and breach of continuity might 

Ulceration may result from any of these causes. Pressure 
is a common cause of ulceration, and acts probably by inter- 
rupting the circulation, and nutrition of a part. Pressure may 
produce absorption and waste without causing ulceration, and 
the dentist when fixing artificial pieces in the mouth must be 
careful so to adjust his plates and springs as to avoid both of 
these evils. 

Inflammation probably produces ulceration in a manner 
somewhat similar; viz., by causing such impediment to circu- 
lation, aa prevents nutrition from being properly performed. 
It is also probable, that the blood itself undergoes changes 
under the influence of inflammation, which render it less ca- 
pable of supplying the loss of parts. 

Diseased parts, and those which from any cause have become 
useless, and these only, are liable to be wasted by absorption- 
Unhealthy products, such as fungus,* are often removed with 
wonderful rapidity, and even bone will be removed when, being 

* foDguB, a muBhrooai ; proud (t«ah. 



KATHRE OF DISEASE. 



79 



riio longer needed, it has become foreign matter. The roota of 
I the decidaoua teeth are thus entirely removed, and the dead 
I bngs of permanent ones are subjected to continual waste from 
I the same cause. That they too are not entirely removed, is due 
1 to the comparative ehortneaa of time which the present term 
f of human life allows for the process, rather than to any resis- 
tance they are able to ofier to the action of these all-subduing 
' lymphatics. 

Extraneoua substances are generally removed by ulceration. 

Thus, a ligature will be separated from an artery, or a foreign 

\ fobstance from a wound : no more of the surrounding substance 

I l»eing absorbed than is necessary to loosen and dislodge the 

■ntmder. 

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, 

uid is then called phagedenic* In such cases, it is evident 

that the ulceration is only the consequence of the destruction, 

' not the cause, for, until the parts have become too much enfee- 

I Uetl to subserve their natural purpose, they will not be subject 

to this rapid absorption. 

Adhesion is often consequent upon inflammation, though 

' liko ulceration, it is not always dependent upon inflammatory 

\ action. It is a process by which nature unites parts, either 

' DBtnrally separate, or artificially divided. The bond of union 

is coagulable lymph. 

This process is of immense importance, in checking hemor- 
I rhage, closing fissures, and in providing means of safe transit 
1 for pus from the viscera to the surface. 

Both of these processes are sanatory. Mr. Hunter calls 

I olcoration the natural surgeon, and declares that even in the 

[ qireading of an ulcer, there may be considerable advantage ; 

and another writer very properly observes, that the same 

remark would apply to the effusion of lymph. The one acts 

£ke the surgeon that unites parts ; the other like the one who 

• «.}•, I eat. 



i 



80 NATURS OF DISEASE. 

removes them, because they are not fit to remain ; and it would 
not appear more justifiable to call adhesion and ulceration in- 
flammatorj processes, than to consider the operations of Bur- 
geons themselves as particular modes of inflammation. 

Inflammation may result in a permanent cbange of atruc- 
ture. Parts may become denser and harder, or, indurated; 
sometimes certain structures, under the influence of alow in- 
flammation, are softened ; sometimes a permeable cellular struc- 
ture, as the lungs, becomes changed into a dense impermeable 
tissue, like liver, or hepatized:* and sometimes accidental 
inflammation begets, in persons and parts inclined thereto, 
morbid growths of a specific character. 

The most disastrous result of inflammation is the absolute 
death of a part, reducing it to tbe condition of a foreign body, 
and subjecting it to the play of chemical affinities. 

When this takes place in soft parts, it is called gangrene or 
mortification ; in bones, necrosis. The dead soft part, when 
separated by ulceration from its connexion with living parts, 
is called sphacelua,\ or slough ; a fragment of dead bone is 
called aequestrum.X 

Caries is a condition of bone somewhat analogous to ulcera- 
tion of soft parts. Caries of the teeth is the result of chemi- 
cal agents acting from without, and decomposing their struc- 
ture ; they are, however, subject to necrosis, as other bony tia- 
sncB, and the fact of their being liable to a peculiar erosion, 
does not probably exempt them from the kind of caries ob- 
served in similar structures. If, however, such idiopathic 
caries does occur in the teeth, it must bo very rare, and is 
always confounded with tbe erosive caries peculiar to these 



• Btpar, the lirer. t ^9'^', I destroj. J Srqurtlro. I gepar«le. 




CHAPTER VII. 



IKrLASMATIOK OF THK SBVEKAL PARTS COMPOSIKa THE MOUTF, 
ASD OF THK PARTS ADJACENT. 



Tbb mouth is very complicated and esquiaitolj organized. 
It subserves a variety of very important purposes. Spoech, 
mastication, insalivation, taste, inhalation, and expiration, are 
all performed in this small, but admirably constructed cavity. 
Such Diimerous and complicated functions require the presence 
of various and delicate organs closely packed together, and a 
large endowment of nerves and blood-vessels. Glands are 
bidden in every part of the walls of tbe cavity ; their ducts 
perforate its floor, and open on its sides ; nerves and blood- 
raasds, of extraordinary size, creep along every bony channel, 
lad spread in expanded network over the whole surface ; while 
tbe mocoDS membrane, with its innumerable crypts and follicles, 
covers the whole, and connects every sentient part with the 
sympathies of tbe external and internal surface. 

Into tbe 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 
piss. 

Besides all this, tbe mouth is the scat of the extraordinary 
process by which two sets of teeth are matured and evolved, 
ud ooe 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 tbe cellular tissue enters largely into the composition of 




J 



IKFLAM«ATION OF THE MOCTH. 

the fltnietiires of the mouth, the form of inflamination most 
common in that cavity, is nhat is called phlegmon. 

Sometimes this form of disease occurs in the month, as the 
consequence of wounds, and even as an idiopathic aBcction. 
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. 
Eryaipelous inflammation in these parts is rare, but sometimes 
occurs in the mucous membrane lining the gums, cheek, and 
palate. The submasillary glands often take on inflammation 
from the effects of cold, and from the irritation produced fay 
the presence of diseased roots in the alveoli of the lower jaw. 
The pain and difficulty of mastication, with the swelling of the 
gland, readily indicate the seat and character of the disorder. 
Unless the inflammation be speedily subdued, and especially 
if it he 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. AVhen the open- 
ing takes place internally, the flow of pus into the mouth is 
very disagreeable, and the access to, and lodgment of, alimen- 
tary matters in the suppurating gland often keep up ibe in- 
flammation until an external issue is secured. 

Removal of the diseased teeth generally causes a speedy 
cure. Of other remedial means I will discourse hereafter. 

Inflammation in these, as in all glandular structures, is apt 
to leave permanent indurations. 

Inflammation of the tonsils is of very common occurrence. 
Its most common exciting cause is cold. The inflammation ia 
generally very acute, rendering deglutition, and even speech, 
very difficult, sometimes impossible. It is generally attended 
by severe constitutional symptoms. 

Tonsillitis or cynanoho* tonsillaris usually terminates by re- 
* Cj'nuicho, rroTo ■«■>, a dog, >nil >>;t*. I choki, is b nnmo uf a oIosb 
of dlMUH of itliioh sbiliuoled rMpiraliaa U mora ar leas a B)Diplom. 



» 



INFLAMMATION OF TDB MOCTH. 83 

Bolatioii. bnt very often by suppuration. Permaneiit enlarge- 
ment and induration often enaue upon repeated attacks of the 
disease, and tbc swollen tonsils sometimes offer serious obstruc- 
tion to respiration. When this is the case, they may be re- 
moYed with little difficulty, and without subsequent inconvo- 
nieoce. These little organs are also subject to a chronic 
inflammatioD and slow suppuration, which gradually waste them 
■way. The palate and uvula are often the seats of inflamma- 
tion. The latter is liable to erysipelas and a?dema. 

The parotid gland is rarely inflamed, except when it is the 
seat of a peculiar specific disorder, which is called cynanuhe 
parotides, or muvipa. 

InflammatioD of the lining membrane of the mouth is called 
atamatitU. 

Simple inflammation of this membrane is characterized by 
increased redness, swelling, and heat, but it rarely occurs ex- 
cept in connexion with inflammation of the tonsils, larynx, or 
pharynx, or as the consequence of the irritation of dentition, 
or of acrid, or stimulating matters taken into the mouth for 
the purpose of allaying toothache. In such cases it terminates 
by resolution. 

It ia much more common to find tliis inflammation presenting 
the appearance called *'aphthfe."* 

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 aro red and irritable, the cuticle being 
peeled off, and the cutis vera exposed. 

This disorder is generally supposed to indicate a correspond- 
ing disease of the surfaces of the digesting organs. It attends 
Bome forms of constitutional disorder, and constitutes a pecu- 
liar infantile disease, called thrush, of which I will bare occa- 
sion to say more in connexion with dentition. 

The gums are very liable to inflammation, which is charac- 
terised by redness, swelling, soreness, and often by very severe 
■ching pain. 

• Atth, I baro. 



i 




The moat commoD cause of inflammation in these parts, is 
the irritation produced bj dead teeth. We have already ob- 
served that dead parts are subject to the same laws which af- 
fect foreign bodies lodged in the flesh, and that nature removes 
them, or attempts their removal, by instituting inflammation 
and ulceration around them. In other words, it is provided in 
the fundamental laws of the animal economy, that dead parts 
shall irritate the surrounding parts, and produce in them those 
conditions which naturally lead to the expulsion of the o&'enders. 
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, tborefore, that they remain long after their partial or 
complete dia organ! Eat ion, to plague the soft parts with which 
they are connected. The gums under these circumstances are 
kept in a state of chronic inflammation, and are rendered ex- 
ceedingly sensitive to the action of irritants. Cold, or any 
local application of an exciting kind, will, under these circum- 
etanccs. occasion aggravation of the chronic affection, and cause 
acute inflammation, of a severe character, which is remarkably 
liable to end in abscess. 

The chronic ioflammation ia often attended with ulceration 
around the decayed tooth ; the soft parts being separated 
therefrom, in the vain attempt of nature to remove them. In 
conse<iuence of the long-continued and unavailing ulceration, 
an imperfect attempt ia made by the vessels of the gums to 
supply tli« loss of parts hj granulations. These are unhealthy, 
■pongy, loose, and incapable of cicatriiing; in other words, 
they ar« ftiHgPUt. Those fungous growths bleed freely upon 
being touched with a brush, or hard body, and being constantly 
dMtroycd and r«now«l, add much to the fetor of the fluids of 
tha mouth, which under Ihpse eircumstance«, is of^on intolera- 
bl*. Inflannation of the pulp, and th« lining membrane of 
iU earity is oommonly, perhaps always, the coa8e<|uence of 
MtriM of ^ boBJ' Mnictare of Ibe toolb, and expoeure of its 
MMttiTt iMMval puts to Uw aeUon of external agents. It 
gtvM riM to vMwt paia, vluoh only anbudes to be renewed 
•«liift by OOBlMl witll wy kaid body, or trriuting substance. 
Tbia UltaMBiattim mar continnv for a coasid«rable length of 



INFLAMMATION OP THE MODTH. 85 

time, passing through successive suppurations, and, ultimately, 
eoioplet«lj destroying the vessels and nerves of the pulp, and 
vitb them, the vitality of the tooth. 

Sometimea the matter formed within the tooth perforates the 
alveolus and the gum, and forma a fistulous* orifice into the 
month, through which putrid fluids are continually weeping. 
This 13 what ia called alveolar absceaa, 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 ease, which 
occurred in my practice, and which is related in Prof. Harris's 
Dental Surgery, as the most singular instance of alveolar ab- 
Bcesa which ever fell under his observation, affords a striking 
instance of this fact. 

The subject was a lady about thirty years old. She con- 
ralted 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 
preriong. 

Upon a close examination of her mouth and throat, I could 
discover no tumour or any indication of a deposit of matter 
except two protuberances, each nearly as large as a hazelnut, 
sitnated behind the two superior central incisors. Being 
strongly inclined to believe that the matter came from these 
abscesses, I requested the advice of Prof. Ilarris, who fully 
coincided in my suspicions. Upon our joint advice, the pa- 
tient submitted to lose these valuable teeth, and was rewarded 
by the cure of the troublesome complaint which had caused her 
to 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 

* Fittnla — a pipe, a canal whose sides tmd edgw Br« Lord and iooapable 



A 



86 INFLAMMATION OF THE MOCIH. 

upper jaw frequently send their roots into it, and thus affect it 
readily, when, happening to become diseased, they are quali- 
fied to provoke disorder in neighbouring parts. Even when 
they do not penetrate the floor of the antrum, they are often 
separated from it by a partition go very thin as to afford no 
adequate protection to the antral membrane against the pro- 
pagation of inflammation. 

When tho membrane of the antrum is inflamed, it pours out 
a vitiated secretion, which accumulates for some time before it 
produces sufficient uneasiness to excite tho attention of the 
patient. The pain of inflammation depends upon the degree 
of pressure to which the parts are subjected, and the peculiar 
structure of the antrum prevents much suffering from this 
cause until the cavity is completely filled. 

Generally, however, some dull pain is felt in this region in 
tho course of the inflammatory action, but the patient com- 
monly refers it to the teeth. After a while, however, tho dis- 
tension of the walls of the cavity produces more serious suflTering : 
matter escapes through the nose or mouth, and n Lard bony 
tumour indicates the projection of the antral walls, 

Tho fluid thus accumulated is usually not pus, but vitiated 
mucus. The disease has been very improperly called dropsy* 
of tlie antrum, for the contents arc by no means serous. 

The discharged matter, having been long retained, is gene- 
rally very offensive. 

Ulceration may also take place in the membrane of the an- 
trum, and puH 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 oases of disgustingly fetid breath, which are called 
ouvna-t 

Sometimes, when the disease is permitted to proceed with- 
out proper remedial moans being used, the walls continue to 
swell, the bones soften, the tumour opens, and a fetid discharge 
fldWH through the aperture over the check. 

• iV*^-niicr. AcoumiUtlioniJ of Mlrir»!Ml*J »erum are ao oolted. 
t O^M, la inicU. 




In all cases of inflamination it is desirable to bring about 
the disappearance of the disease without any disorganization of 
strnctnrc. In other words, to accomplish cure by resohition. 
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 cnre of infiamma- 
tion is to remove, if we can, the cause which produces it. This 
will often render further treatment very simple and easy, or 
altogether unnecessary. Where the gums, or lining membrane 
of the antrum are inflamed through the irritation caused by 
diseased or dead teeth, no treatment short of their removal 
will do any good ; and this will generally he 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, theee remedial measures 
are comprised under the general name antiphlogistic* and are 
all intended to lessen the vascular action, of the general or 
local circulation. 

Antiphlogistic treatment is negative or positive. The nega- 
tive consists in withholding every local application likely to 
excite the vessels, or irritate the morbidly sensitive nerves of 
the part; and preventing the taking of such drinks or aliment 
as would tend to sustain the morbidly active circulation. In 
short, the withdrawing as far as possible of all local and gene- 
ral excitants. 



^1 •Jnti, 



*Ai>ti, Bgunat; jililofulon, the old u 






i 



88 TREATMENT OP INFLAMMATION. 

The positive treatment consietB in the use of means whicli 
lessen vascular action and diminish nervons sensibility. The 
general remedies are bloodletting, purgatives, diaphoretics, 
and lovr diet; among the local are bloodletting, from the 
affected part, or its immediate vicinity ; cooling, emollient, 
sedative, and astringent applications, and counter-irritants. 

When pus has been formed in a cavity, it is often necessary 
to evacuate it by an artificial opening ; sometimes, even after 
the tumour has opened spontaneously, a counter- opening is 
necesaary. 



It is rare that inflammation of these structures requires ge- 
neral treatment. Sometimes, however, it is sufficiently seriona 
to occasion inflammatory fever, and call for decided constitu- 
tional remedies. 'When such is the case, the patient should be 
bled from the arm until a decided impression be made upon the 
circulation, and the operation must be repeated, until the de- 
sired efl'ect be accomplished. If the bowels of the patient be 
constipated, saline cathartics should be employed. Nauseating 
remedies, such as tartar emetic, will also be found useful in 
lessening the general inflammatory action and withdrawing the 
nervous sensibility from the aSected 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- 
(pent upon the presence of diseased teeth, or parts of teeth, 
they must be removed. This being done, the inflammatory 
action will commonly subside and speedily disappear. 

The teeth are liable to a peculiar calcareous deposit, called 
tartar,* or salivary calculus, which adheres with great tenacity 

' Tartar, or BsliTary unloulus, is camposcd, according to Beneliua, of 
Phns. limo and magnes, 71) 00 

Bslirary niunus and salirinr. l;i-r.r> 

Animal matlor, 7-50 

100-00 



TREATMENT OF INPLAMMATIOS. 89 

to them, and insiDuatmg itself under the edges of the gums, 
detaclies them from the teeth, nnd acting as a perpetual irri- 
tant, inflames, and often ulcerates them. 

This Babstance is deposited from the saliva under certain 
conditions of that fluid, and is most liberally deposited upon 
the teeth nearest to the salivary ducts and upon those of the 
lower jaw. When it contains a larger proportion of earthy 
salts, it is hard, and brittle ; when the animal matter is in ex- 
cess, it is soft and moist. Under whichever of these forms it 
appears, its removal is indispensable to the successful treat- 
tsent of the disease of the gums which it causes. Sometimes 
this can be efl'ected by the brush alone ; often the hard mineral 
substance requires to be broken up and elevated by an instru- 
ment of steel. IVhen once removed, its subsequent accumu- 
lation must be prevented by persevering use of water and the 
bnifh. 

It often happens that the gums will be inflamed through the 
»gency 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. 

Id 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 
•nd 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 woand inflicted upon an inflamed 
part must increase the inflammation to a certain extent, and 
unless the quantity of blood taken away be more than sufficient 
to counterbalance the additional evil inflicted, the patient will 
lose by the operation. Scarification produces copious bleeding 
for the instant, but the clean superficial wound is soon closed 
by coagolum and lymph, and the oozing of blood continues 
but a short time. 



90 T8EATMEKT OF IXFLAMMATIOX. 

When the guma present the condition called fungus, scarifi- 
cation will cause much freer bleeding, owiug to the increased 
vascularity of the part. Under such circumstances it is an 
important means of cure. 

Leeching is a far more efTectual process. It is true that 
wounds are made by the leeches deeper and more irritating 
than those inflicted by the lancet, hut the flow of blood con- 
tinues very much longer and the quantity discharged is far 
greater. 

Two or three leeches placed upon a gum will often cause a 
bleeding which will continue for several hours, and will cure 
severe inflammation in almost as brief a space of time. 

In order to be efi'ectual, leeching should be employed in the 
early stage of inflammation. If delayed until matter has be- 
gun to form, no benefit can be expected, except, perhaps, in 
the lessening of the quantity of pus. 

Other local applications are of little or no use in the treat- 
ment of acute inflammation of the gums. Their position pre- 
vents the continuance of any fluid upon their substance. Cold 
water, however, may be used by repeatedly filling the month 
with it. This remedy is serviceable only in slight inflamma- 
tions. All stimulating applications used to irritate the sur- 
rounding parts and thus alter and divide sensation so as to re- 
lieve pain, ultimately aggravate the disease. It is erroneously 
supposed that tho increased flow of secretions which is occa- 
sioned by the irritation, must relieve the vessels and abate the 
inflammation, for the very irritation attracts to these parts a 
larger supply of blood than usual, and augments secretion only 
by increasing arterial activity.* 

Where tho inflammation is excessive, leeching and blistering 
behind the cars or under tho jaw may be resorted to. 

As great and long-continued sufi'ering frequently attends 
this lUsease, full opiates at night may be given with great ad- 
vaatago ; securing at once temporary relief and grateful re- 

■ t'fti iWi'jfw, iti tixiMt — where iher« ii irritRtian, \a Uimt pliae will tx 
Ul» Bdv, Ii k wsU-knovn tufdicat aJkei^ Tb« law appHN to the nferraut tia 
««Q M tilt tawulkr ijattn. 



L 



TREATMENT OP INFLAMMATION. 



91 



te, and aiding materially tho efforts of nature to remove the 
tfiammatioii. 

loflammatioii from mecbanical violence must be treated upon 
B same principles. 

The gams are liable to inflammation of a specific character. 
When raercurial preparations have been used to a certain ex> 
tent differing mach in different individuals, a constitutional im- 
pression is obtained, which announces itself by a peculiar 
tenderness and inflammation of the gums and an increased 
secretion of mucus and glandular fluids into the mouth. This 
s called salivation or ptjalism.* 
The first symptoms of this mercurialization are observed in 
1 increased tenderness and some swelling of the gums, which 
■axhibit a pale rose-colour, except at the edges surrounding the 
teeth, where .they are of a deep red. The soreness and swell- | 
ing now rapidly increase, the discharge of mucus and salira 
^ .becomes excessive ; and is accompanied by a very peculiar and 
(agreeable odour ; a metallic or coppei-y taste is constantly 
present in the mouth, and the tongue and salivary glands are 
iflamed and swollen. 
Such is moderate salivation, but it sometimes happens that 

a excessive dosing with mercury, or from peculiar suscepti- ' 

lily of the patient, all the symptoms above enumerated are 

reatly aggravated. The gums are very much swollen and 

lovered with ulcers; irritative fever appears; the enormons 

r of the tongue pushes beyond the lips and hangs out of 

e mouth, preventing the closure of the jaws ; the flow of fluids 

■ prodigious, the patient wastes excessively; gangrene of the 

BiuGoas membrane of the mouth and gums, and extensive 

Kdoughing of the soft parts and bones sometimes occur ; the 

leth are loosened and sometimes drop from their sockets and 

lally the patient expires from exhaustion. 

A very frequent consequence of extensive mercurial saliva- 

I'tion and the attendant ulceration and sloughing, is contraction 

f the macoos membrane in the neighbourhood of the anterior 



* Ptf klUm— •atitfttioD 






92 TBBATMBKT OF INFLAMMATIOV. 

arches of the palate, whereby the patient is prevented from 
opening the mouth, except to a very slight extent. In one 
case this condition resulted from salivation produced by a few 
grains of blue pill. The patient was unable to open the mouth 
wider than half an inch. Surgical aid could give only tempo- 
rary relief. In another instance of a child four years old, the 
patient when seen several years afterwards, was obliged to suck 
food through the spaces left between the jaws by the loss of the 
alveolar process.* 

It sometimes happens as a consequence of salivation, that 
adhesions form between the mucous membrane of the lips and 
cheek and that of the gums ; very much deforming the face 
and lessening the usefulness of the mouth. 

A great variety of remedies have been suggested and em- 
ployed for the relief of excessive salivation, but there is no 
specific means of relief. No local applications of an irritating 
character can be borne, and no astringent but of the mildest 
quality can be used. Besides demulcent lotions and some very 
mild astringents, such as table tea, we have no topical applica- 
tions to recommend. 

The only rational treatment is to abate the inflammation by 
the use of antiphlogistics, to such extent as the strength of 
the patient will permit. Leeches under the jaws procure the 
greatest relief, and blisters to the throat and opiates are useful 
accessories.f 

A form of disease very nearly resembling salivation, occurs 
occasionally in children, and sometimes it is said even in adults. 
It is ulceration of the inside of the cheek, causing gangrene 
and a copious secretion of fetid saliva. It is called Cancrum 
oris. 

This disease is not properly inflammatory, being rather a 
consequence of debility ; but lest I should not have an oppor- 
tunity to describe it hereafter, I will do so now. 

* Pereira's Elements of Materia Medioa and Therap. 

f It is important to remark that saUvation, however severe, does not ne- 
cessarily prove the previoas administration of mercury. For some curious 
observations on this subject, see Pereira's Elements of Mat. Med. and 
Therap. 709. 



^^^if th 



Canonun oris is a foul, fetid ulcer, beginning upon the inside 
of the cheek and rapidly slougbing through it until it opens 
upon the outside. The gums and alveoli are often seriously 
involved ; the teeth become carious and loose, and drop out ; 
abscesses form in different parts of the mouth, and make open- 
ings for themselves in different directions. The progress of 
ihe disease is attended by a copious discharge of fetid saliva 
and mucus. Exfoliations of the bone are not unfrequent and 
extensive sloughing sometimes occurs. 

The disease generally occurs in ill-fed children, crowded in 
a hospital or living in lov, swampy situations. The remedies 
must be tonic and invigorating. The principal, are fresh air 
and nutritious diet. The best Ioca,l applications are diluted 

iaeral acids ; burnt alum, sul. zinc, tinct. of myrrh, &c. 
m The disease is exceedingly rare in our country. 
F Syphilis, or the venereal disease, often produces uloerations 
r the throat, which are described in the many books upon 
that subject, and require no particular notice here. 

It is proper, however, for dental surgeons to know that a 
peculiar and destructive ulceration of the gums, which will defy 
all but specific remedies, sometimes, though very rarely, 
attends Syphilis. As it is impossible to describe the peculiar 
appearance of this ulceration by words only, so as to enable 
the practitioner to detect it upon sight, I refer the reader to 
an excellent delineation of it in Messrs. Carey & Hart's edition 
of Rayor's Plates, PI. xxiv., Fig. 15. 

C/ironie inflammation of the gums may depend upon any of 
the causes mentioned as productive of acute inflammation. It 
nds rather to ulceration than abscess. 

f If there be no specific cause, after removal of any dead teeth, 
, the gums require the aid of astringent and somewhat 
Dulating lotions, such as port wine and water, weak brandy 
1 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, 
ia very improper ; for scurvy is a constitutional affection, de- 
^^^^^eJOding upon long privation of fresh and acescent food, aided 



the ca 
The 




TREATMENT OF INFLAMMATION. 

b; the influence of cold, dampness, kc. It is a disease pecu- 
liar to ships and prisons, and the affection of the gums which 
attends it, ia but one among many symptoms of the disorder. 
It is well, therefore, to abaodon this term, scurvy, as applied 
to the local disease of the gums in question, and, following the 
example of Professor Harris, I will consider it as an idiopathic 
inflammation of the gums, attended by sponginess of structure, 
recession of their margins, and freijuently, destruction of the 
alveolar processes. 

When affected by this disease, the gams present a swollen 
appearance. Their colour is dark-red or purple ; they feel 
elastic under the finger, and when pressed, pus oozes out be- 
tween the teeth and the margins of the gums, which are thick- 
ened and detached. The proper tissue of the gums, having 
become to a certain extent fungus, bleeds upon the slightest 
touch, and is very sensitive. 

The disease progresses with more or less rapidity, according 
to the constitutional health of the patient, and the capability of 
resistance natural to the organs attacked. Sometimes it is con- 
fined to a small portion of the gum, at others, it involves the 
periostea of the fangs and the alveoli, and presents a mass of 
complicated disorder and devastation. A deposition of bony 
matter sometimes takes place in the bottom of the sockets and 
the teeth are loosened and drop out. 

The treatment of this disease does not differ from that of tha 
ordinary inflammatory conditions previously described. Indeed 
it is not speciflcally different. 

All irritating bodies, such as decayed teeth and roots, must 
be removed ; irregularities of denture corrected ; tartar also 
taken away ; the gums depleted ; and after active inflammation 
has subsided, astringent lotions may bo used by way of cor- 
recting the habitual looseness of texture.* 

■ F»r It )Qor« •xtandcd itMcrlpUon of this diseue ftnd its treftUncnt, ihaii 
U oompati bis Kill) llio laopo of this work, see Dr. Harris's Denul Surg«t7. a 
work «hioh 1 wiU t*k* for grmntad i> in tlie huids of eterj scieuUGc dentiat, 
and vrtrj Mndont of dotiltfttj. 




CHAPTER IX. 



OABIBS — MORTIFICATION. * 



E term cariee has different meaninga when applied to the 
at large and to the teeth. Let us first consider the dis- 
ease of the bones thus called. 

Caries in the bones is analogous to ulceration of the soft 
parts, and is very different from necroaia or mortification of 
these parts. 

The bones are vital organs, supplied with arteries, nerves, 
veins, absorbents, and cellular tissue. Like soft parts, thej 
grow and waste, undergo disease and accomplish reparation. 

The denser the texture of a bone the less liable it is to be 
atucked by caries, and for this reason the bones of children 
are more susceptible of it than those of adults. 

In caries, the bone undergoes a change by which its texture 
is softened and broken down; fungous flesh, which bleeds very 
readily, grows up in the interstices formed upon the surface of 
the diseased bone ; fetid, dark-coloured sanies finds its way to 
the surface through a sinuous channel, and a communication is 
thng formed between the diseased bone and the external parts. 

Caries may nevertheless progress for a long time without the 
formation of an ulcer and discharge of matter; and these re- 
sults depend more often on necrosis than on caries. 

The treatment of caries consists in the removal of the dis- 
eased part by surgical means, and, as is often necessary, the 
application of the actual cautery upon the new surface. The 
latter means is not absolutely indispensable ; the former pro- 
bably is, unless, as sometimes happens, the separation of the 



Ki^uu, to abraJc. 




96 CARIES — MORTIFICATION. 

unsound parts may be accomplished by the unaided e£fort8 of 
nature. 

Caries of the teeth, is a chemical erosion of those organs by 
the action of the fluids of the mouth, and the accidental matters 
dissolved in them, upon the salts of which the tooth is mainly 
composed. 

It is yet a mooted question whether the teeth are ever subject 
to true caries, such as affects other bony structures. I have 
already remarked that this disease is not apt to occur in the 
denser osseous structures, and the close texture of the teeth 
renders them particularly unlikely to be thus affected. Yet it 
might be too much to say that they are never subject to the 
active disorganizing process in question. It is certain, how- 
ever, that caries of the teeth, as commonly met with, is a mere 
chemical erosion, resulting from the action of acids upon the 
earthy salts which principally compose them. A human tooth, 
inserted as a substitute in another mouth, will undergo this 
change as readily as a natural tooth ; showing that in this form 
of destruction the organs assailed are passive. 

MOBTIFICATION OB OANaBBNB. 

These two words are commonly used synonymously to express 
absolute death of a part, but by some writers the term gangrene 
is restricted to that condition which immediately precedes death, 
and Sphacelus* applied to the latter condition, while mortifica- 
tion is a general term covering both conditions. 

According to this use of the terms, gangrene represents the 
condition in which there is a sudden diminution of pain, if it 
has previously existed ; a livid discoloration and subsequent 
yellowish or greenish hue of the part ; a detachment of the 
cuticle with effusion of a turbid fluid beneath it, and a solFten- 
ing and crepitation of the part. 

When the part has become cold, insensible, black, motionless, 
without circulation and life, the condition is called sphacelus. 
The state of bone analogous to this is called necrosis, and the 
dead part when detached, a sequestrum. 

* I^Axuu, to destroy. 



CARIES — MORTIFICATION. 97 

Mortification may result from any cause which prevents the 
nutrition of a part. Inflammation may so interrupt the circu- 
lation as to cut off the supply of blood, or the state of the pa- 
tient's digestion may not afford a supply of nutrient fluid suflS- 
cient for those parts which are least vascular or most distant 
from the heart, and certain obscure changes may take place in 
a part which may cause it to mortify, without the precedence 
of appreciable disease. 

When mortification is consequent upon inflammation, the 
quantity of fluids in the part causes a humid state of the spha- 
celus ; where death has taken place from deficiency of blood, 
the mortified parts are dry and shrivelled. These opposite con- 
ditions have given occasion to the distinction so generally re- 
cognised between moist and dry gangrene. This distinction, 
however, is not so absolute as to be without exception, yet it is 
correct to a considerable extent. 

Different parts assume different appearances when gangre- 
nous. ^^ Tendons, muscles, nerve and cellular substance, look 
like dirty shreds of wet tow ; the skin sometimes looks as if it 
had been destroyed by caustic or the cautery." The arches of 
the mucous membrane are often of a grayish or whitish colour. 
Quesnay states that in one case he saw, the gangrened parts 
exhibited a remarkable transparency. The black colour cannot 
therefore be considered as characteristic of gangrene. It may 
exist independently of mortification, and the latter may exist 
mdependently of the other. The principal characteristics of 
gangrene are, 1st. Complete disorganization of the gangrenous 
parts, in which the elementary tissue can no longer be distin- 
guished. 2d. Softness and flaccidity. 3d. The fetid and cha- 
racteristic odour which it exhales. 4th. The sanies, ichor, and 
fetid gas which escape from it. In that variety of gangrene 
termed c2ry, the part presents a black colour, a hardness some- 
times like that of wood, and always a complete disorganization 
of the tissue. 

The treatment of gangrenous parts must be directed to the 
limitation of the mortification, and to the removal of the slough. 

When a part has become dead, it seems to act as a depressing 

9 



98 CABIBS — MOBTIFIOATIOK. 

or devitalizing agent upon the surrounding parts, and even 
upon the general system. If the gangrene take place in one 
of the viscera, the patient generally sinks rapidly and soon ex- 
pires. Immediately upon the gangrenous change, the pulse be- 
comes soft, weak, and frequent, the skin cold, and the nervous 
system seems to labour under a silent, but deadly influence, not 
to be resisted. 

It is difficult to account for this sudden and extraordinary 
result. It is generally supposed that the fluids of the gangre- 
nous part, being absorbed, prove poisonous to life ; but if this 
were the case, similar efiects would result from the much more 
extensive mortifications which frequently occur in the skin, 
muscles, and bones, without those serious constitutional results. 
The eifect must rather be attributed to the powerful sympathy 
which exists between the viscera and the nerves of organic life. 

Where nature makes an efibrt to check the spread of gan- 
grene, which, except in the instances referred to, she almost 
always does, a red line of inflammation is first drawn around 
the afiected part. Ulceration soon takes place along this line, 
and a suppurating furrow separates the dead from the living 
parts. A similar process goes on beneath, and advancing gra- 
nulations gradually push ofi" the gangrenous slough, and supply 
its place with sound flesh. Inflammation and ulceration, there- 
fore, are the means employed for the removal of dead parts, 
and for limiting the progress of devastation. 

In order to effect this, it is necessary that the vitality of the 
adjoining parts be sufficient to produce healthy inflammation, 
support the suppuration, and sustain vigorous granulations. It 
is also necessary, that the inflammation in the adjoining parts 
be not so great as seriously to impede the circulation in them. 

The surgeon takes his suggestion of remedial treatment from 
these necessary conditions. If the parts adjacent to the gan- 
grene be cold and livid, and if they show no disposition to 
throw out the inflammatory cordon sanitaire, he sees the neces- 
sity of stimulating applications to rouse the torpid energies of 
the threatened parts. Cantharides, turpentine, or other reme- 
dies of this powerful class, will then be put in requisition ; and 



CAEIES — MORTrFIOATION. 



Ilboiilil the parts under the i 



It through the n 



tified c 



b be equally torpid, he will 



d covering, and apply his excitants to 
du flesh beneath. 
SDmetimes, though not often, he will find it better to antici- 
L fik the slow process of nature, and at once remove the gan- 
le by his knife. The latter process is fraught with this 
I ItScnlty, — that when the surrounding parts arc feeble and dis- 
[ ptsed to gangrene, the use of the knife imparts to them no 
\ Mrength, while it necessarily inflicts injury. The result often 
liltbe appearance of the disease in the remaining parts. 

When the surrounding parts manifest more excitement than 
u compatible with their security, depleting and sedative treat- 
ment must be instituted. Aa a general rule, however, this 
nil! rarely be required, for the vicinity of gangrene is gene- 
rally abundantly sedative to the surrounding parts. 

Necrosis, or mortification of bone, may take place from simi- 
lar causes to those which produce gangrene of the soft parts. 
As the bones possess less vitality, they are less capable of re- 
sisting disease, and therefore are more prone to die from inju- 
ries and internal causes than other parts. That they are not 
raore frequently necrosed than they are, depends upon their 
protection from external violence by the soft parts, and the 
fact, that their limited vitality and simple functions involve 
leas tendency to disease than is connected with the more ex- 
qaiaite organisation and complicated functions of other organs. 
Necrosed bono is thrown off by a process very analogous to 
that which is instituted for the separation of sphacelus. Where 
the mortification is superficial, it is removed by exfoliation ; 
when it is deeper, a persevering effort is made by the surround- 
ing bone and soft parts, to detach and expel it in the form of 
splinters, or even of large masses, called sequestra. 

Owing to the density of bono 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 bono around it, leaving orifices in this 




100 OABIKS — MOBTIFICATIOK. 

bony case, through which the matter may find a vent. Wlien 
this arrangement has been made, the sequestmm cannot be 
expelled by natural efforts, except in a fluid or very commi- 
nuted state. It is, therefore, generally necessary for the sur- 
geon to cut down to the diseased bone and liberate the seques- 
trum. 

Occasionally, however, nature, though unassisted, will accom- 
plish the expulsion of very large sequestra. In one recorded 
case, a piece of bone seven inches long, was thus expelled ; 
such cases, however, are very rare. 

The presence of necrosis, or caries, may be ascertained very 
satisfactorily after the formation of the external ulcer. Some- 
times the canal will be so straight as to permit a probe to reach 
the diseased part, and when this is not the case, the presence of 
an obstinate ulcer, evacuating dark-coloured and fetid sanies, 
will generally be sufficient evidence of diseased bone. 

It is rarely possible to distinguish necrosis from caries, until 
the sequestrum has become so fully detached as to be movable. 
The cure of necrosis, as of caries, if procurable by art, depends 
upon the removal of the part so diseased. In necrosis, the 
parts surrounding the sequestrum are generally in such a state 
as to return to health after its removal. In caries, the surface 
of the parts exposed by the operation, often require the appli- 
cation of the cautery, as before stated. 

We have already mentioned, that what is called caries of the 
teeth, differs very essentially from the disease of the bones 
which bears the same name. 

Caries of the bones, as we have seen, is a diseased vital ac- 
tion, in which the vessels, &c., are active ; caries of the teeth is 
simply a chemical erosion, which may be imitated upon teeth 
separated from the mouth, and affects dead teeth as readily as 
living ones. 

Caries of the teeth always begins upon their outer surface, 
and does not appear to be in any manner dependent upon dis- 
ease, except so far as it may be favoured by an unhealthy 
structure of the teeth, and a morbid condition of the fluids of 
the mouth. 



OARISS — MORTIFIOATION. 101 

In short, caries of the bones is a vital, that of the teeth, a 
chemical process. 

By instituting a comparison between caries of the teeth and 
that of other bones it will at once be perceived, that there is 
not the slightest analogy between the disease as it occurs in 
the one and manifests itself in the other. In the former, it 
consists simply in a decomposition of the earthy basis of the 
organs, whereas in the latter, it is analogous to ulceration in 
soft parts, and constantly discharges a fetid sanies, and fre- 
quently throws out granulations of fungous flesh. These are 
phenomena which dental caries never exhibits, and they esta- 
blish a wide difference between it and the disease as occurring 
in other osseous structures of the body."* 

The treatment of caries belongs to Surgical Dentistry ; and 
to works on that subject, and particularly to the excellent 
treatise by Prof. Harris, I refer the reader. 

Ifecrosts may take place in the teeth as in other bones, and 
from a similar cause, — the cessation of circulation in them. 

This may be effected by violence. The teeth, especially the 
anterior ones, are very much exposed to be injured by blows or 
falls, and it sometimes happens, that a shock thus inflicted is 
sufficient to break up the vascular connexions of the organ 
without displacing it from its socket. 

More commonly here, as in other bones, the necrosis takes 
place as a result of inflammation ; the pulp having been de- 
stroyed by this process. 

When a portion of bone dies, the surrounding bone sets up 
a process of removal and reparation. Nothing of this kind 
occurs in the teeth ; partly because the evil is generally shed 
over the whole organ at once, and partly because its low vita- 
lity does not permit of such efforts. 

After necrosis has taken place, the tooth having become a 
foreign body produces the usual effect of such causes upon the 
surrounding soft parts. The gums inflame, ulcerate, and de- 

* Harris's Dental Surgery, which see, for a thorough examinatioii and ex- 
position of this subject 

9* 



102 CARIES MORTIFICATIOK. 

tach themselves from the tooth; but not being aBeistcd by 
similar processes in the bone, they are unable to remove the 
evil. Chronic disease is, therefore, commonly the consequence. 
Necrosed teeth lose their colour, and become dark-brown, 
bluish, or dingy ; sometimes when presenting this appearance, 
their vitality is not completely destroyed, and therefore, they 
may remain in the mouth for years without provoking the dis- 
ease of the soft parts which would require the removal of the 
necrosed organs. 




An ulcer ia n running sore ; or, in medical language, a Bolu- 
tion of coDttnuitj in a soft part, with a secreting surface. 

Ulcers present a variety of appearances, depend upon very 
different causes, and exhibit dissimilar conditions of the parts 
implicated in them. 

A great many attempts have been made to classify ulcers. 
Some authors have endeavoured to arrange them by their appa- 
rent phenomena, others by their pathological conditions, and 
I others by the modes of cure to which they severally yield, 
[ while some have seized upon accidental modifying circumatancea 
IB a reason for multiplying subdlviaions already too numerous. 
It is impossible to systematize, in pathological science, so as 
f 'to provide for all the numberless modifications which may be 
I Reduced in disease by the causes which influence vital action. 

■ We must content ourselves with such an arrangement as will 
I ffuble us lucidly to express what we know of the subject. Once 
Fatorc I remind my readers, that medical definitions are not 

jophically complete and accurate. 
An important distinction between ulcers is found in the fact 

■ tliat some of them are the result of local injury or disease, and 
laotinany manner dependent for their existence upon constitu- 
tSonal vice, while with regard to others the reverse is the case, 
l^fite local sore being only a consequence of constitutional dis- 

As the treatment must differ essentially in these diSe- 

mt cases, it is very important to be able to distinguish the 

oe class of nlcers from the other. 

Yc! even this distinction, apparently so obvious and proper, is 

«ilbout difficulty, for local ulcers sometimes involve th« 



104 ULCERS. 

general health, and are instrumental in setting up diseased con- 
stitutional action, in which they themselves participate, and, on 
the other hand, ulcers primarily induced by constitutional causes, 
may continue after the vice of the general system has been 
corrected. 

The causes of ulcers are various, but can generally be re- 
duced to the following classes : 

1. Predisposing causes. All those conditions of the system, 
or of any of its parts, which debilitate structures, or so alter 
their vital action as to impede recuperative processes. Fever, 
scrofula, syphilis, and scurvy, are examples of this kind. 

2. Exciting or immediate or local causes : such as wounds, 
bruises, abscess, suppuration, gangrene, abrasion of the skin 
from any cause. 

3. From the combination of these causes. A slight scratch 
or excoriation, that in a sound constitution would heal without 
any trouble, in a habit tainted with disorders as above mentioned, 
will frequently produce a very disagreeable and tedious ulcer.* 

The prognosis of ulcers, must, of course, depend upon the 
results of a full consideration of the causes and conditions in- 
volved in any particular case. The constitution of the patient, 
his age and habits, the situation and duration of the sore and 
its peculiar condition of sensibility, &c., must all have due con- 
sideration in forming a prognosis. 

It is always proper to attempt the cure of ulcers, except 
such as are of a malignant character, known to be incurable 
through any means yet discovered. 

After ulcers have become chronic, it is sometimes dangerous 
^0 heal them until we shall have provided an artificial drain, by 
seton or issue. The system having once become habituated to 
the discharge of ever so small a quantity of matter, often suf- 
fers severely with a kind of plethora if the discharge be sud- 
denly stopped. 

The simplest, most practical, and most rational of all the 
classifications of ulcers I have seen, is that adopted long since 

♦ Benjamin Bell on Ulcers. 



105 



[by Mr. Benjamin Bell, and generally superseded by more com- 
I plicated arrangements, wLicb beget confusion in the miud of the 
I Student, and are, after all, not more precise and accurate than 
tHie one for which I have professed my preference. 
Mr. Benjamin Bell classifies ulcers as follows : 



1. Tha limpla pamletlt, 

2. The omple vitiated, 
8. Tbe eftlloos, 
4. Tha fangoua. 



w 



a cosatncriosAh. 

I 5. Tlie si 

6. The 01 

T. The ai 

I S. TLe 01 

1. The TCnerekl, 

2. The scwbntic, 
S. The Bcrofuloua. 



It is not my purpose to describe in detail the appearance, 
nature, and treatment of each of the kinds of sore above enu- 
merated ; but I will confine myself to the consideration of 
such aa may occur in the mouth, and thus fall under the notice 
and care of the Dental Surgeon. 

The iimple purulent vleer is the simplest form of sore. It 
is always a local afi'ection ; It Is attended with little pain, and 
but slight inflammation, and furnishes a healthy pus and firm 
granulations. 

A sore of this description needs little or no aid from art, but 
it ia important that the student should be well act]uninted 
%ith ita appearance, because other ulcers, of a less simple 
and kindly character, must be brought to this condition before 
ultimate cure. 

The simple purulent ulcer is always produced by some local 
injury, as wounds, burns, &c., happening to persons of sound 
general health. 

In this kind of sore, the pus is white and thick ; the granu- 
lations small, firm, florid, and pointed. As soon as they have 
reached the level of the surrounding parts, those next the edges 
become smooth, and are covered by a whitish pellicle, or film, 
irhicb afterwards hardens, advances, and forms the permanent 
covering of the parts previously ulcerated. The white, smooth 
margin, lost in the sorroundiug skin or mucous membrane, b 




106 ULCERS. 

one of the surest cbaracteristics of this kind of sore, but it is 
not infallible ; other qualities must be duly considered, before 
a conclusion is formed. 

Such ulcers require no treatment except to be kept clean, 
and protected from any interference with the natural process 
which is hastening to cure. 

A little dry lint will accomplish all that can be done by dress- 
ings. A simple purulent ulcer may very readily be converted 
into an angry and obstinate sore by improper local applications, 
or the occurrence of general constitutional disorder. 

I may remark here that no sores are cured by applications 
of any kind ; nature only can provide the means by which these 
breaches can be healed. Nothing is more incorrect or danger- 
ous than the idea that certain dressings have a specific or ma- 
gical virtue, by which they close wounds, and cicatrize ulcers. 
The surgeon may aid Nature — he cannot supply her place; and 
his business is, generally, so far as the cure of ulcers is con- 
cerned, to aid her in her efforts to bring any particular sore 
into that condition ^' which natural means will suffice to relieve." 

Simple vitiated Ulcer. — When, from any of the causes we 
have mentioned, nature fails to produce such a condition of 
ulcer as we have described, in any part which has been wounded, 
or when, from improper dressings, motion, and fatigue of the 
diseased part, or constitutional causes, the progress towards cure 
is arrested, the discharge from a sore may present one of the 
following appearances : 

1st. It may be a thin, limpid, sometimes greenbh discharge, 
termed sanies. 

2d. A somewhat red-coloured, thin, and generally very acrid 
matter, termed ichor. 

8d. A more viscid, glutinous kind of matter, called sordes.* 

While discharging matter of a kind like any of these, an- 
ulcer will not heal. The granulations become dark and waste 
away ; the matter, especially that called ichor, is very acrid, 
and renders the sore very irritable and painful. It frequently 
excoriates the surrounding parts over which it flows. 

* Benjamin BelL 



ULCERS. 107 

These vitiated ulcers are more apt to occur upon tendinous 
and aponeurotic parts, than in situations abounding with cellu- 
lar membrane, owing to the frequent motion of these parts, 
and the continual agitation of the sore. Wherever an ulcer is 
seated upon a part of this character, absolute rest is necessary 
to preserve its simple and convalescent character. 

The cure of these ulcers depends principally upon removing 
the cause which has operated to change their character for the 
worse. If the vitiated condition depends upon constitutional 
causes, these must be combated by the means found most suc- 
cessful in the practice of general medicine ; if any local irri- 
tant has caused the evil, it must be removed as speedly as pos- 
sible ; if motion of the part has been indulged, it must be re- 
strained. 

The local treatment consists in soothing, emollient applica- 
tions, as it has been found that all those means which allay the 
pain in such sores, tend also to alter their condition to that of 
the simple purulent ulcer. 

When the sore is seated in the mouth, but little opportunity 
is afforded for local applications. The best, perhaps, is warm 
water, frequently taken into, and held in the mouth ; or the 
vapour of hot water received into it repeatedly and for a con- 
siderable time. The dentist should look closely in such cases 
for causes of irritation in diseased teeth and fangs, and also 
ascertain whether constitutional causes are interested in the 
production of the troublesome sore. When the ulcer is small, 
it would be well under these circumstances to destroy its sur- 
face at once, with caustic. 

The difficulty of protecting ulcers in the mouth from the con- 
tact of its secretions, and the food and drink, and the imprac- 
ticability of dressing them with applications elsewhere service- 
able, should make the dentist extremely cautious lest a careless 
or awkward movement of an instrument in his hand, should 
produce a wound and sore extremely painful to the patient, 
and difficult of cure. 

The callous Ulcer. — ^When ulcers become inactive and sta- 
tionary, rather than progressive, secreting but little, and that 



108 DLcass. 

of bad qnality, and being little sensitive, they are called in- 
dolent; if, in addition, the edges become hard and thickened, 
they are called callous. 

Very often these callous ulcers are attended with an enlarged 
condition of the veins of the part, which is called varicose. 
This condition of the veins ia very embarrassing to the surgeon, 
and sometimes produces fatal hemorrhage. 

Callous ulcers arc most common upon the extremities, and 
owmg to the mechanical difficulty in the return of blood from 
these parts, they are, in these situations, moat frequently at- 
tended with varicose veins. 

The callous condition of ulcers is the consequence of neglect 
and bad management. Their cure consists in restoring them 
as soon as possible to the condition of a simple purulent sore. 
This can only be done by removing the indurated surfaces. 
The moat expeditious way of effecting this, is to pare away the 
edges and surface of the sore with a scalpel, thus converting 
the lesion into a wound of the simplest kind ; but as few patients 
will submit to the pain of this procedure, the application of 
caustic is generally preferred. 

By freely touching tho surface of the ulcer with nitrate of 
silver or caustic potassa, a slough is produced, which, coming 
away after some considerable time, leaves after it a healthy, 
granulating surface. 

Fungovs Uloer». — When granulations are large and pale, 
grow vapidly and rise above the level of the surrounding parts, 
bleed freely upon touch or slight presBurc, and make no at- 
tempt at cicatrization, tlioy are called fungus or proud flesh. 
Oencrnlly they are soft and spongy, but by very long continu- 
ance they may acquire considerable hardness. Fungus is not 
uniformly sensitive : generally it is not at all remarkable in this 
respect ; occasionally, however, it is very sensitive. It is but 
imperfect granulation, and may arise from any cause which 
tonda to interrupt the convalescence of an ulcer. Long-con- 
tinued inflammation of cellular structures and caries of the 
bonca are very apt to he attcndetl by fungus. It sometimes 
occurs in young and vigorous subjects merely as a kind of 



ULCERS. 109 

«XDberant growth, which can hardly be considered as giving 
an onfurourable appearance to a Bore, as it ia readily removed 
by mild eschuroticB. 

Where fungus depends upon a mere defect of action of the 
ressels of a part, and not upon the presence of any irritating 
c&ose 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. Fungua has not sufficient vitality to 
resist the impression made by agents of this class, and gene- 
rally the application of the eseharotie will excite the surface 
of the alcer sufficiently to cause the growth of firmer granula- 
tions. 

The Simioua Uleer, — This name is given to « sore communi- 
cating with long and narrow canals, penetrating the cellular 
membrane and running irregularly under the skin or between 
the muscles. These sinuses generally have more than one 
opening through which pus is discharged. 

Originally they are the artificial channels through which the 
conientB of abscesses or the fluids produced from carious parts 
CBcape from situations deeply seated, or so placed as to be unable 
to pass off matter in a straight line ; but the sides of the canals 
themselves becoming iufiamed and secreting matter, the whole 
presents the appearance of an irregular ulcer, connected with 
Bome primary source of matter, and forming openings wherever 
the nature of the part causes a determination of matter to the 
surface. 

Should the sinus remain for a long time without cure, its 
sides and the edges of its orifices become hard, and it is then 
called a fistula.* This term, however, is most frequently ap- 
plied to artifidal canals which connect with some natural pas- 
sage. 

The cause of sinuses is the want of a free passage for matter, 
which, seeking the moat dependent point, readily penetrates the 
yielding texture of the cellular membrane, and ultimately pro- 
duces ulceration at a point distant from its source. 



* FiatDlB — a pip*. 



110 ULOERS. 

The cure of these sinuous ulcers depends upon making a free 
passage for the matter in a direct line from its source, and then 
bringing the edges of the canals together and causing them to 
unite. 

If the edges and sides of the ulcer be too hard to undergo 
the necessary adhesive process, stimulating or caustic applica- 
tions may be used with advantage. Sometimes it is necessary 
to lay open these tortuous canals to the primary abscess, a 
process which at once gives free escape to the matter, and by 
exposing the sides of the sore to the influence of the air and 
proper medicinal applications, generally causes a wound which 
readily heals from the bottom with healthy granulations. 

Sinuses situated in the mouth should always be treated in 
this way, unless they are connected with diseased bones or 
teeth, or are so situated as to make the free use of the knife 
dangerous. 

Carious Ulcers are those which are connected with caries or 
necrosis of bony structures. They are often sinuous, but may 
be seated immediately upon the caries which causes them. 

The discharge from carious ulcers differs from good pus. It 
is thinner and fetid, and at last becomes blackish, and often 
very acrid and irritating. Mr. Bell thought that the fetor of 
carious ulcers always afforded a su£Bcient means of diagnosis. 

The surfaces of carious ulcers are usually softer and more 
flabby than natural ; and instead of a florid red, they have ra- 
ther a dark brown with somewhat of a glassy complexion. 

The granulations generally grow rapidly, but are exuberant 
and fungoid. Should the orifice heal, either by the efforts of 
nature or the appliances of art, the apparent cure is of short 
duration, for the pent-up matter soon finds another vent and 
produces another ulcer. When a probe is pushed down to the 
bottom of a carious ulcer, it generally encounters a roughness 
of the surface of the bone, which plainly indicates its eroded 
condition. 

When obstinate sinuses are observed in the gums, discharging 
fetid matter, and containing fungous granulations, we may al- 
ways be assured that the cause is to be found in the presence 



ULCERS. Ill 

of some decayed tooth or root, or to caries of the alveolus, jaw, 
or some other bony structure. 

As a carious ulcer is nothing more than an accident attend- 
ing caries, the treatment of it must always be secondary to that 
of the disease which produces it. The removal of the carious 
or necrosed part, and the employment of the means which will 
best prevent a return of it, are to be regarded as the proper 
means of curing the carious ulcer. When the caries is seated 
in the cancellated structure of bone, it can only be thoroughly 
eradicated by the terrible energy of fire, and the actual cautery 
must sweep over the diseased surface and rouse it to the exer- 
tion of its vitality. When a tooth is the subject of caries, no 
such frightful treatment is necessary. The tooth being passive 
in the matter, and being acted on by chemical agents only, all 
that is required is to remove the caries and interpose between 
the fluids of the mouth and the parts of the tooth thus exposed 
a barrier which must be impenetrable to the action of the fluids 
which caused so much mischief. The only substance by which 
a cavity in a tooth can be successfully filled is gold, as it only, 
of all the metals, possesses both the physical and chemical 
qualities necessary to the purpose. If gold cannot be used, 
tin, though far inferior, is the best substitute. All the mercu- 
rial amalgams, are exceeding deleterious, both locally and con- 
stitutionally, and ought never to be used as dental fillings. 

The Cancerous Ulcer. — Cancer, or Carcinoma. This terrible 
affection occurs under two forms, called occult and open, or 
schirms and ulcerative. The former variety generally, though 
not always, precedes the latter, and presents itself in the form 
of a hard, dense tumour, of slow growth, generally seated in a 
glandular structure, at first, in most cases, nearly insensible 
and subsequently causing very sharp darting or burning pain 
or twinges, which radiate from the schirrus as from a centre. 
As the disease progresses, the skin adheres to the tumour, cor- 
rugates or puckers, changes colour, becoming of a livid or 
leaden hue, then ulcerates and ushers in the second stage of 
the disease, the open or ulcerating cancer. 

The ulcer thus produced is exceedingly painful and irritable. 



It discharges a thin, fetid ichor, sometimea very excoriating. Its 
edges are hard and irregular, reversed and contorted. Its sur- 
face ia generally irregular, showing depressions or excavatioDS. 
The Bore manifests no tendency to form healthy granulations, 
hut spreads among the surrounding tissues, which aucceasively 
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 profuae, occurs. 

Cancer, however, presents various appearances. I have seen 
it occur without preceding schirrus, present an even smooth sur- 
face with little secretion ; and many other appearances of this 
ulcer have been observed, as it has been modified by accidental 
circumstances. 

The characteristics of cancer may be considered to be an 
irregular phagedenic sore, with hard reversed edges, exceed- 
ingly irritable under all common dressings, and causing a burn- 
ing pain. When such a sore has resisted the treatment which 
is found to be successful in ordinary irritable ulcers, and espe- 
cially when it is seated in a glandular part and follows a schir- 
ms, there can be no doubt of its malignant character. 

Cancer, in all its stages, is altogether intractable to any 
treatment which has yet been devised, and' all hut the most 
soothing applications are found to accelerate its progress and 
add to the iotolorable acutencsa of its pain. 

The only mode of cure now attempted is thorough extirpation, 
and this is confined almost entirely to the latent or schirroua 
state. The open cancerous sore rarely yields even to surgical 
remedies. It is even a mooted (luestion whether the removal of 
Bch.rrouB tumours is advantageous. Some surgeons contend that 
where true schi.Tus is removed, cancer soon makes its appear- 
ance elsewhere, often in a more maUgnant form and v 



a a worse 



ULOBBS. 113 

location, and that the life of the patient is often shortened by 
the painful operation endured in hope of cure. 

It is not by any means easy to settle this question. Surgeons 
are in the habit of removing all chronic tumours which are hard 
and painful, whether they present decidedly carcinomatous 
symptoms or not. Many of these are probably not cancerous, 
yet the operations by which they have been removed enter into 
the statistics of cancerous extirpation. 

Where but one possible hope is left, we should be very care- 
ful not to extinguish it, and we therefore may recommend the 
exsection of schirrous tumours. To be successful, however, the 
operation must be performed before the disease has manifested 
activity by changing the surrounding parts into its own pecu- 
liar texture. 

The cause of cancer is also a matter of controversy. It is 
often excited by a wound, especially a bruise or pinch ; but this 
can only occur where there is a constitutional tendency to the 
affection. On the other hand, it frequently appears without any 
exciting cause. Some writers, in view of these facts, contend 
that cancer is primarily a local affection, having a strong 
tendency to infect the whole system with its own poison. 
They, therefore, very rationally conclude that if it be extir- 
pated in its latent state, the patient may be entirely relieved 
from it. Others belieye that carcinoma is a constitutional dis- 
ease, manifesting itself in local changes of the kind described ; 
that it is, therefore, useless to remove the local effect, and the 
constitutional cause being beyond our control, they prefer, in 
the present state of medical science, to refrain from all at- 
tempts at cure of the disease. 

On each side of the question are presented observations and 
pathological demonstrations, and authoritative names, and with- 
out troubling my readers with a recapitulation of the facts and 
arguments brought to bear upon this subject, I will content my- 
self with suggesting the practical inference which seems most 
rational upon the whole ; which is, that eradication of schirrus 
may be attempted with good hope, though not with certainty of 

success ; that the excision of open cancer will be an experiment 

10* 



114 ULCBRS. 

Tery doubtful, jet if the reports of surgeons are to be believed 
not absolutely hopeless ; and finally, that under all circum- 
stances the operator must be prepared for a recurrence of the 
disease. 

Many specifics hare 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 sufiering and violence 
of the disease, and probably often produces most serious con- 
stitutional effects. 

I attribute to the improper application of this poison, the 
sudden death of one young lady, who, having a sore, probably 
of an ordinary kind, upon her leg, was induced through exces- 
sive modesty, to subject it to the treatment of a famous female 
empiric. 

Although arsenic is useful in certain obstinate cutaneous 
afiections, it does not control cancer when given internally. 
When externally applied to a surface so irritable as that of 
cancer, it necessarily does great mischief. 

Cancer sometimes attacks the tongue. I have seen a case 
of this kind, which seemed to have been provoked by the abra- 
sion of the organ against fractured teedi. The sides of the 
tongue presented a jagged edge, which gave out sanious matter. 
The whole body of the organ was schirrous, and the neighbour- 
ing glands manifested a similar condition. 

A cause so slight as the retention in the mouth of a broken 
or eroded tooth, seems, in this case, to have been sufficient to 
excite this fearful malady, in a part, too, where the greatest 
possible inconvenience and distress must result from its pre- 
sence. I have recently seen another instance of this kind, in 
which, the whole glandular structures about the lower jaw 
were frightfully involved, in which the first impulse to the dis- 
order was given by a diseased tooth. 

The lips, too, are very frequently the seat of cancer, and the 
dentist should be careful not to wound these very vascular and 



CLCSKS. 115 

Mnsitive parts by careless or airkward handling of the sharp 
tiutniments he wields. 

As the several varieties of cataoeous ulcer are not likelj to 
require treatment from the Deatal Surgeon, I will not consider 
tbem, but refer the curious reader to the several surgical works 
in which they are accurately deacribed, and their proper treat- 
ment pointed out. 



Venereal or SyphiUtic Ulcers. — Impure sexual intercourse 
his engendered a poison which is capable of producing local 
ud constitutional disease of a distressing and dangerous cha- 
racter. With the consideration of local or primary ayphilis wo 
have nothing to do, but as the secondary or constitutional dis- 
order often developes itself in the structures of the mouth, it is 
necessary that the well-instructed dentist shall be prepared to 
detect and treat it, when thus manifested. 

Syphilis nsuallj presents itself in the form of ulcers, which 
are colled chaneret; it also causes cutaneous eruptions, swell- 
ing of glands and disease of the periosteum, fascia, and booea. 
The ulcers vary considerably. Generally they are remark- 
able for their hardened base, feeling like cartilage under the 
■kin ; the borders are red and sharp, the bottom grayish, and 
the sores painful and not tending to heal. 

In the throat, tonsils, and mouth, the disease generally shows 
itself at once, without much previous tumefaction, so that the 
tonsils are not much enlarged; for when the venereal iuflam- 
nation attacks these parts, it appears to be always upon the 
■nrface, and it very soon terminates in an ulcer. 

These ulcers of the throat are to be carefully distinguished 
from all others of the same parts. The disease in the throat is 
Tiniformly ulcerative ; this being the first appearance of disease 
in that part.* 

The syphilitio ulcer always begins auperficiallj/, and is not 



inter on the Venereal Diseisc. 



116 ULCSB8. 

preceded by observable, or at least, by any notable degree of 
inflammation. This fact will be safficient to distinguish these 
sores from the ordinary open abscess of the suppurating tonsil. 

There is also an indolent swelling of the tonsil, accompanied 
by an exudation of lymph, which at first sight might be mis- 
taken for an ulcer ; and indeed such exudations, when they ac- 
company scarlet fever, are often miscalled sloughs. They may 
be detached from the subjacent membrane, which is found un- 
broken. 

There is another complaint of those parts often mistaken for 
venereal, which is an ulcerous excoriation running along the 
surface of the parts, becoming very broad and sometimes foul, 
having a regular termination, but never going deep into the 
surface of the parts. Mr. Hunter says that there is no part of 
the inside of the mouth exempted from this ulcerous excoria- 
tion, but it occurs most frequently about the root of the uvula, 
and spreads forward along the soft palate. 

The same writer observes that the true venereal ulcer in the 
throat is a ^'fair loss of substance, part being dug out as it 
were from the body of the tonsil with a determined edge, and 
is commonly very foul, having thick white matter adhering to 
it like a slough, which cannot be washed away." These ulcers 
never heal spontaneously, and generally spread rapidly. 
When the sores are seated upon the pharynx, they produce 
great distress in deglutition, cough and puriform expectoration, 
and rapid sloughing of the soft parts, exposing the bones and 
destroying them even as far as the vertebra by caries. The 
palate is frequently destroyed, throwing the nose and mouth 
into one cavity, preventing distinct speech, and causing great 
discomfort and distress. The dentist will often be required to 
supply this serious loss of bone by an artificial substitute. 

^'At other times, especially in cases of long standing, these 
sores extend not by sloughing, but by rapid ulceration. The 
aspect is less formidable, but its progress is scarcely less de- 
structive. This variety is most commonly seen on the soft 
palate. The surface is foul, but the slough which occupies it is 
of little depth. The sore is edged by a very narrow fringe of 



I 



moiBs. 117 

jellow sIoDgli, and beyond this for the extent of a quarter of an 
iDcb, there is an inflamed margin of a deep crimson colour ; but 
there is not mach general sloughing of the surrounding parts. 
Yet the sore extends daily with extraordinary rapidity. The 
■uhsiaace of the part seems to melt away under the ulceration, 
■nd the greater part or the whole of the soft palate, is often 
destroyed before it can be arrested, though no distinct slough 
can he seen to separate through the whole of its course."* 

Phagedenic venereal ulcers, like cancerous sores, have thick- 
ened edges ; a characteristic rather of an unhealthy character 
ind spreading tendency, than of any specific quality of the 
lore itself. 

There are several kinds of venereal afiections observed in the 
bones. The periosteum may be thickened and inflamed. This 
IB a very painful affection, the pain being greater at night ; and 
may be mistaken for rheumatism, when the hone is so deeply 
■eated as to prevent the distinct feeling of the swelling. This 
periosteal disease generally ends in permanent enlargement of 
llie bony structure from deposition of osseous matter. Sometimes 
tile periosteum suppurates and causes exfoliation of the hone. 

Caries of the bone frequently commences in the cancellous 
ftnictare, and gradually perforates the external plate, and then 
spears as a soft tumour, which may he seen and felt externally, 
Zf this tumour be laid open, a glairy fluid Is evacuated ; the 
'periosteum is found to be somewhat thickened, and the bone 
beneath is denuded, and in the centre of the denuded part, ia 
found a small hole which perforates the cortical plate and com- 
municates with the interior of the bone. This afl'ection is very 
eommoD in the skull, and may be seen in the tibia, Jaw, and 
sink. In itB worst forms, it constitutes the worm-eaten Ga- 



in determining whether a sore in the throat or a caries of 

the bones be syphilitic, it is absolutely necessary that the ob- 
server shall obtain all the collateral information which may aid 
' the diagnosis, for it is often impossible to decide positively 

* Babiagtou. 




118 ULCERS. 

from the mere appearance of the ulcer, whether it be venereal 
or not. 

Very often cutaneous eruptions of a syphilitic character 
attend the venereal sore throat, and the presence of such erup- 
tions would be sufficient to decide a doubtful case. 

Unfortunately, however, it is not easy to detect with cer- 
tainty all forms of syphilitic eruption ; yet, when suspicion is 
aroused by the appearance of the throat, and corroborated by 
that of the skin, or vice versa, there must be extraordinary 
reasons for inferring the cause not to be venereal. 

Syphilitic eruptions may be tubercular. That is, they may 
appear in the form of hard lumps, covered by red inflamed 
skin, and often by dead cuticle. These often ulcerate and 
leave behind them a peculiar copper-coloured blotch. 

Another form of syphilitic eruption, is that of small, red, 
accuminated pimples, sometimes scattered regularly over the 
surface, at others arrayed in groups. 

Scaly eruptions are also common, and sometimes a pustular 
affection, attended with a large, hard, conical scab or crust 
(rupia), is observed. These may all be due to other causes, but 
when occurring together with a suspicious sore throat, they 
very much strengthen the probability of venereal origin. 

Mr. Hunter says, when syphilis attacks the tongue, it some- 
times produces a thickening or hardness in the p^rt ; but this 
is not always the case, for it very often ulcerates, as do the 
other parts of the mouth. 

If the character of the disease be clearly venereal, or if it 
be probably so, it is important that proper remedies be at once 
administered ; for, when the virus has become so generally dif- 
fused as to produce the remote symptoms observed by the 
Dentist, the life of the patient is in imminent peril. 

There has been much controversy as to the means of curing 
syphilis, one party contending for the use of mercurial prepa- 
rations, and the other denying the necessity of these medicines. 

Without pretending to any claim to decide a question so ably 
supported on either side, I will briefly remark, that mercury 
will certainly cure the disease, except in a few uncommon cases, 




irliere it exists in a kind of combi nation ^itfa scrofula; and 
secondly, that mercury will do this without injury to the pa- 
tient, and generally with as little inconvenience as can attend 
the use of less certain remedies. Without hesitation, there- 
fore, I recommend its use ; especially in constitutional or ae- 
Kmdary syphilis, where no time must be lost, and no risks must 
be run. 

As to the particalar preparation of mercury most proper for 
the purpose, there also is difference of opinion. As a general 
rale, however, I prefer the proto-chloride, or calomel, to any 
other preparation. It is more certain than blue pill, and per- 
htps than any other mercurial medicine, and can be used with 
more safety than the deuto-chloride (corrosive sublimate). My 
common practice is to give a grain of calomel, to which is added 
one-twelfth of a grain of opium, night and morning, until the 
ulcer disappears, or the gums get sore. It is rarely necessary 
to produce salivation : a mere tenderness of the mouth will 
geoerally 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. 

Corrotive Sublimate, in the dose of a twelfth part of a grain 
three times a day, will often succeed ; and in secondary syphilis, 
is thought by some to be superior to calomel. 

When calomel acts too freely upon the bowels, as it some- 
times does, even when administered together with as much 
opium as it is prudent to give, corrosive sublimate or blue pill 
may be tried. Should these purge also, resort must be had to 
inunction; the patient being rubbed with mercurial ointment, 
until his mouth begins to acknowledge the mercurial influence. 
When scrofula exists in union with syphilis, the iodide of mer- 
cury may he used. 

When after several successive constitutional impregnations 
with mercury, the periosteal swellings, and other chrenic syphi- 
litic conditions remain, I have found great benefit to ensue upon 
the tiae of led. Potass. 

Scorbutic Ulcers. — Scorbutus is a barbarous half Latin name, 
^ren by medical writers to tcurvy, a constitutional afTcction 



i 



120 ULCERS. 

depending upon privation from vegetable food, under circum- 
stances calculated to weaken the energies of the system, and 
which was long a terrible scourge to seamen, soldiers, and the 
inmates of prisons. It has frequently been confounded with 
other affections, a mistake which has led to serious conse- 
quences. In the year 1700, the celebrated Boerhaave treated 
with mercury four hundred soldiers thus affected, and killed 
them all. 

The term scurvy, is applied to sponginess and ulceration of 
the gums from any cause, but this is an impropriety. Scorhu- 
tiMj or true scurvy, is always a constitutional affection, never 
occurs when patients have lived upon diet sufficiently yegeta- 
ble, and in short can only be expected to occur in ships, camps, 
or prisons. Happily, since its character has become known, it 
is rarely seen now even in these places. 

As it would be of little use to my readers, I will not intro- 
duce here a full discussion of this subject, which has ceased to 
be of much interest, even to the general practitioner ; but will 
content myself with a very few remarks upon it, referring 
those who may be curious to know more of ,it to a very in- 
teresting article in the Cyclopaedia of Practical Medicine, writ- 
ten by Mr. Kerr. 

Scurvy is a general disease, characterized by debility, foetor 
of the breath, sponginess and turgidity of the gums, livid sub- 
cutaneous spots, particularly of the roots of the hair, ecchy- 
moses, spontaneous hemorrhages, and frequent contraction of 
the limbs. 

The face becomes bloated, early in the disease, and the lips 
are of a pale greenish hue. The countenance looks sad ; the 
patient complains of extraordinary lassitude, and becomes 
breathless after slight exertion. The gums soon become swol- 
len, itch and bleed upon touch ; they are deep red, soft and 
spongy ; icon fungous and putrid. Bleeding occurs frequently 
from the mouth and other parts, and the breath is very offen- 
sive. The skin is usually smooth and shining, with a suffusion 
of black or livid spots. Old wounds or sores break out afresh, 
and ulcers frequently occur. 



These sores secrete n thin Tetid sanioiis fluid; their edges are 
geuentlly livid and puffed up ; a coagulum soon forms, which, 
Kith great difficulty, can be wiped away or separated from the 
suhjicent 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 lirid and 
[iiiaful swellings break and assume the fungous appearance 
characteristic of scorbutic ulcers. The hemorrhage becomes 
more profuse and general ; the increasing dyspntoa is accom- 
panied in some cases with pain under the sternum, but more 
frequently in one of the sides. In others, however, without 
iny complaint of pain, the respiration becomes suddenly qnictc 
lod laborious, and death unexpectedly puts a period to the 



The prevention and cure of scurvy consist simply in provid- 
ing a proper vegetable diet, and keeping the patient warm and 
iItj. Where this cannot be done, aa is the case at soa, the 
parpose can be effected by administering lemon juice freely, 
ind making the men as comfortable as possible. Medicine has 
little to do in the matter, though it may render occaaioDal aid. 
It is always important to distinguish the symptoms of scurvy 
from those of other diseases ; fortunately there is no longer 
much danger of mistakes in this respect. The subject does not 
belong to practical dentistry, though the disease of the gums 
eonnectcd with it makes it proper for me to mention it ; my 
chief purpose in doing so, however, is that my readers may 
bave a proper knowledge of the meaning of a word which is 
continually misused by dentists by applying it to a local fungous 
ftffection. 

Serofulom ITlner, — 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"'?°*) signifying a hog. 

Whether those who originally described the disease were 
•ware [hat swjne are subject to it, or whether, as is most pro- 



• Cjclop. Pne. Med. 



122 ULCERS. 

bable, they intended to portray the dirty appearance of those 
afflicted by it, we have no means of determining. Scrofula is 
also known as Struma, and the word Strumous is frequently 
used instead of Scrofulous. 

Scrofulous tumours and ulcerations are also yulgarly called 
King's Evil, from the loyal superstition which for many years 
attributed to the touch of a sovereign the miraculous power to 
heal the disease. Multitudes of cases were touched by the 
monarchs of England, from Edward the Confessor to Queen 
Anne. A similar practice existed in France. Many got well 
after this process, as they do after all quackery, except the 
severer kinds. The king's physicians took care of the royal 
reputation by selecting from the candidates for the manipda- 
tion, the best-looking cases. 

Scrofula is a constitutional disorder which manifests itself 
in a great variety of local affections, and is among the most 
distressing, and in some of its forms, the most fatal of all the 
ills that flesh is heir to. 

The pathology of scrofula is not well understood. It seems 
to affect particularly the lymphatic system ; the glands, espe- 
cially the subcutaneous and mesenteric, being most frequently 
the parts which first manifest the local influence of the consti- 
tutional vice. Very often, however, its ravages are confined 
to other organs. The lungs are especially liable to be affected 
by it, assuming that well known and so far incurable cUseased 
condition, which is called phthisia* or pulmonary consump- 
tion. 

Although persons of all temperaments are subject to scrofula, 
yet those who possess what is called the lymphatic tempera- 
ment, are much more liable to it than others ; and as this sys- 
tem is predominant in children and women, they are more ex- 
posed to serofula than adults and men. 

* Phthisis, fipom ^um — I oonsume— Consumption. There are seTeral 
chronic diseases of the langs, which are Tnlgarlj known as consumption. 
Most of these are inflanunatorj affections and their consequences. Phthisis, 
or consumption proper, im an entirely different disorder in its cause and 
character. It is, with few exceptions, incurable from the commencement 
The inflammatory affections are all cnrable if promptly and rightly treated. 



Yet meo are by no meanB exempt, but those of the male sex 
b whom the Ijmphatic temperament predominates, are most 
liable to it. 

It is common to distinguish tbe scrofuloaa disposition by 
cerCtin external marks which doubtless indicate, with con- 
siderable accuracy, the presence of the constitutional vice. 
These appearances, from the strong disposition to phthisis 
"iiich they manifest, are frequently called "consumptive." 

These marks are a fine white skin ; light hair ; rounded 
plnmp figure; delicate complexion, with rosy cheeks; large 
lips; large lower jaw ; yellowish teeth, or teeth, whatever their 
colour, which are soft and easily attacked by caries ; a large 
bead ; straight and narrow chest ; large abdomen, and soft and 
flabby flesh. Persons presenting these external appearances 
ire generally amiable, and often very sprightly and intelligent, 
ni among them are found the loveliest and most attractive of 
the female sex. 

The strumous diathesis is exhibited, in another class of per- 
Kns, very differently. In these the complexion is dark, the 
skin harsh, and the habit indolent; the countenance is swollen 
&nd pasty, and all tbe functions of the body are slugg'ish and 
imperfect ; tbe nervbus energy is feeble ; the feelings are ob- 
tuse, and the moral and intellectual powers occupy a very loir 
rank. Scrofulous cases of this character are not by any means 
uncommon in Britain or the United States, althoagti far more 
rare than the other variety, but extreme instances are frequent 
m some districts of Switzerland and France ; and in these, 
human nature appears reduced almost to the level of tbe brute 
creation, assuming forms which awaken feelings of hunullation 
and disgust.* 

Appearances, such as described as characterbtic of either of 
the two classes of scrofulous subjects, are not necessary to the 
development of scrofula ; but when these marks present them- 
Belves, nothing bat the action of circumstances most favourable 
to counteract the threatened evil, can prevent its appearance. 




124 ULCERS. 

Scrofula is the conseqaence of damp, cold climates, bad diet, 
and ^ant of exercise and fresh air. These circumstances, when 
combined, may engender the disease in any child, but in most 
cases it is hereditary, being transmitted from the parent ; whole 
families being frequently destroyed by this fatal legacy. In 
one recorded instance, in which the father and mother were 
both strumous, eight children out of nine died in childhood, of 
scrofulous affections. 

The scrofulous disease manifests itself in a variety of ways ; 
in glandular swellings, sluggish ulcers, distorted bones, cu- 
taneous eruptions ; but the most common and the most cha- 
racteristic attendant upon scrofula, is the production of a soft, 
cheesy, unorganized matter, which is found mixed with the pus 
of abscesses or deposited in rounded masses of different degrees 
of firmness, and of various sizes, called tuberculous matter. 
Sometimes this is enclosed in cysts, sometimes diffused through- 
out a part, and sometimes it is found in the natural canals or 
cavities of the body. To the depositions of this matter and the 
irritation and inflammation which it produces, are due the most 
serious consequences of scrofula. 

Scrofulous ulcers are generally consequent upon tumours of 
the same character. These, after having 'been indolent for a 
considerable time, at last ulcerate and discharge their softened 
contents. Instead of healing, the orifice enlarges, and an ulcer 
is established, discharging a thin glutinous fluid, occasionally 
intermixed with the peculiar cheesy or curdy substance already 
described. 

Commonly, scrofulous sores are not painful; occasionally 
they are so. The skin around them is livid and slowly ulce- 
rates ; the granulations are flabby and pale, and their margins 
are usually overlapped by the thin unhealthy looking skin. 
The matter often hardens about the sore, and presents a dis- 
gusting appearance. The ulcer heals slowly, and the cicatrix 
is irregular, puckered and wrinkled, ^^ with small portions of 
projecting skin and even complete bridges, admitting a probe 
to pass beneath them ; features by which their origin, long 
after a cure, may be readily discovered." 



ULCIBS. 125 

As one ulcer heals, another is often ready to break out, and 
the patient is gradually debilitated and worn down by the in- 
cessant irritation and drain. Sometimes the disease manifests 
itself in a vital organ, and by speedy death curtails the suf- 
ferings of the patient. 

To scrofula seems properly to belong a very serious ulcera- 
tion of the lips, nose, &c., which is called lupus, or nolle me 
tangere. 

This disease commonly commences by the appearance of a 
hard, livid tubercle, which, after being indolent for a longer or 
shorter time, ulcerates, and produces ichorous, wasting, ill-con- 
ditioned sores, which, in some instances (lupus exedens), rapidly 
destroy the adjacent parts ; in other cases, lupus induces a sort 
of hypertrophy of the skin. Sometimes the first appearance 
of the disease, is a mere violet red colour, tending rapidly to 
ulcerate and destroy the surrounding parts. 

The tonsils of scrofulous persons are very prone to chronic, 
indolent swellings, which, upon slight provocation, take on 
acute inflammation. The glands in the neck, and the sublin- 
gual and submaxillary glands, are often afiected by scrofula, 
forming hard, painless, indolent tumours, which sometimes 
suppurate, causing intractable ulcers, which, after pouring out 
the glutinous and flocculent matter peculiar to this kind of 
sores, heal with the irregular, puckered, ugly cicatrix before 
described. 

Dr. Cumin says that scrofula occasionally attacks the tongue. 
It sometimes assumes the form of aphthous ulcerations, and 
fissures of the margin, but its most characteristic features are 
small knots or nodules, superficially imbedded in the substance 
of the organ, varying in size from that of a small shot to that 
of a horse bean. They cause no uneasiness, unless when firmly 
pressed, and then the pain is slight and pricking. The mucous 
membrane covering them, is red and prominent, and soon 
breaks in the centre, giving rise to an ulcer, which spreads 
and destroys by sloughy erosion, with much pain, profuse sali- 
vation, furred tongue, and fetid breath. The ulcers, under 

proper treatment, become clean, contract and heal ; but the 

11* 



hardness remains : fresh nodalea form in other parts of the 
organ, and the same train of Buffering is gone through, after a 
longer or shorter interval, according to the state of the pa- 
tient's health and the regularity of Lis mode of life, until a 
decided improvement be produced on the constitution by time, 
change of climate, or the employment of remedies. 

The mucous membranes of scrofulous persons are apt to in- 
flame, and generally pour out mucus in large quantity, and 
often of an acrid quality ; not unfrequently the mucous mem- 
brane of the mouth presents aphthous exudations, excoriations 
and small ulcers. 

I have already mentioned that the texture of the teeth of 
scrofulous persons is of that character which makes them an 
easy prey to caries. When we remember that teeth thus little 
capable of resistance arc continually exposed to the action of 
unusually abundant and acid mucus, we may readily account 
for the ravages of caries upon the mouth of persona of scrofu- 
lous taint. 

Scrofula sometimes attacks the bones of the face, especially 
the nose, causing, when the disease is confined to a very small 
portion of the osseous tissue, the intolerably fetid sore called 
ozena, and when acting upon a large surface, horrible devasta- 
tion and deformity. The bones of scrofulous subjects are 
more slender, the outer vatl thinner, and the inner softer &nd 
more vascular than the bones of others. 

Syphilis, however, is the more common cause, both of oiena 
and osseous destruction, but it is in subjects of scrofulous 
constitution that it produces its most fearful and irresistible 
effects. 

The cure of scrofula depends much upon hygienic treatment. 
As experience shows that cold, humid climates are most favour- 
able to it, one of the best means for preventing and curing its 
disorders, is evidently removal to a warm, dry climate. Be- 
sides this, which is often impracticable, exercise in the open 
air, generous diet, and the use of such medicinal remedies as 
aro calculated to invigorate the frame, are the best means by 
which to combat this obstinate and most serious affection. 




■dine is the best medicine we possess for removing tho 
>cr£cial glandular obstructions, and healing the ulcers of 
■erofula. It often exerts a sanitary influence upon these and 
similar external manirestations of scrofula. Unfortunatel; the 
high hopes entertained at one time of the power of this medi- 
cine to cure the radical constitutional evil, or even the most 
fatal form of its development, tubercular phthisis, have been 
totally disappointed. This terrible form of scrofulous malady 
yields little to therapeutic agents, and, for the most part, is 
checked only by the hygienic means before referred to. Cod- 
liver oil is now much used in scrofulous, and especially phthisi- 
cal cases, and seems to benefit them, either through some un- 
known medicinal principle, or, as is more probable, through 
the concentrated and highly nutritious aliment it affords to the 
iwaflting tissues. 




128 



CHAPTER XL 



TUMOURS. 



The term tumour,'*' literally means a swelling, and is often 
used in this wide sense, but it is more properly restricted to 
such enlargements as depend upon morbid growth, either of 
the natural parts, or of organizations not natural, formed in the 
tissues of the body. This definition rejects such swellings as 
are produced by the presence of free fluids and gases. 

Tumours may be divided into malignant, and those which 
being comparatively innoxious, may, for want of a better term, 
be called benign. 

The malignant tumours are such as depend upon some con- 
stitutional vice, and, resisting all remedies, tend to convert the 
surrounding tissues into their own substance. These spread 
rapidly, ulcerate, destroy the blood-vessels of the part, pro- 
duce frequent and exhausting hemorrhages, are sometimes very 
painful, and if permitted to remain, ultimately fatal. 

Cancer, or carcinoma, and fungus haematodes, or bleeding 

fungus, are the general names for these tumours, though distinct 

N names have been given to varieties of each of these disorders. 

rUMOUB BiBMATODBB, BLBBDINO lUNQUS, BPOMOOID IHILAM- 
MATION, 80IT OANOBB, MBDULLABT 8AX00MA. 

This disease is almost uniformly, perhaps always, a constitu- 
tional one, and therefore beyond the reach of any local means. 
Unfortunately we have no antidote to the poison shed through- 
out the whole body, and, therefore, there is no disease more 
intractable and hopeless. 

♦ Tumeo, I swell. 



TUMOURS. 129 

It generally makes its appearance in the form of a small 
elastic tumour ; at first painless, but subsequently very pain- 
ful. As it grows, its elasticity becomes more remarkable, a 
peculiarity which has originated the term spongoid inflamma- 
tion. When ulceration takes place, fungus shoots forward, and 
the bleeding which results from these irritable and morbid 
granulations, has occasioned the name of the disease. 

Patients who suffer from fungus hsematodes, have frequently 
a peculiar appearance which indicates their constitutional 
prayity. Their skin is sallow, or has a greenish cast, they 
are often bedewed with clammy perspiration, and are troubled 
with cough and dyspnoea. 

Should the tumour be extirpated, the disease soon appears 
in some vital organ and proves fatal. 

When the tumour is examined after death, it is found full 
of a grayish greasy substance, somewhat like that of the brain, 
mixed with a thin bloody matter. 

Polyjpu9,* — This is the name given to a variety of tumours 
which have their seat in certain cavities, particularly the nose 
and uterus, and by their growth distend and break up the sur- 
rounding parts, and otherwise mechanically impede the per- 
formance of function, even to a fatal extent. 

Some surgeons distinguish polypi as benign and malignant. 
Others deny that any such essential distinction exists. Pro- 
bably the disease is never malignant in the proper sense of that 
term, unless the constitutional tendency of the patient to some 
of the forms of carcinoma engrafts the latter disease upon the 
polypoid tumour, in which case it may present the appearance 
of cancer or fungus hsematodes. 

As a general thing, polypus, however dangerous, has no ma- 
lignancy about it. The harm it does is due merely to its bulk 
and unfortunate position. 

Polypus is very often seated in the nose. According to Mr. 
John Bell, every polypus, here seated, is in its early stage a 
small movable tumour, attended with sneezing and watering 

* Polypus — rox»(, many — irovc, a foot — from a supposed resemblaQce to 
the radiated animal so called. 



180 TUMOURS. 

of the eyes ; swelliDg in moist weather ; descending with the 
breath, but easily pressed back with the finger. It causes no 
pain, and generally begets no alarm ; yet this small, innocent 
looking tumour may become most distressing and fatal. As it 
increases, the pressure it exercises upon the delicate structure 
of the cells, &c., where it is seated, begins to cause serious 
suffering. It fills the nostrils and obstructs the breathing. 
The eyes become watery from the pressure upon the lachrymal 
sac ; the hearing impaired by the obstruction of the eustachian 
tube, and the voice changed by the stoppage of the nostriL 
The swallowing begins to be impeded by the depression of the 
palate ; the bones become carious from the steady and increas- 
ing pressure ; the tumour projects from the nostril before and 
over the arch of the palate behind; the nose is twisted; the 
countenance distorted ; the patient suffers with terrible head- 
aches — a foul and fetid matter is discharged from the nostrils; 
alarming hemorrhages ensue ; the floor of the antrum begins 
to give way ; the teeth fall out and matter issues through their 
sockets; the still increasing pressure constantly aggravates 
the sufferings of the patient until death closes the scene. 

Though all polypi, from their tendency to grow, may in time 
produce the terrible train of symptoms above enumerated, yet 
I cannot agree with Mr. Bell, that all are essentially similar. 
They differ very much in colour, density, and tendency to re- 
turn. Some are pale and so loose in texture as to be almost 
vesicular ; others are red, hard and resisting, &;c. But in all 
cases they must be removed, and it is of little use to distinguish 
between them. 

There are four ways of extirpating nasal polypi : extracting 
them with forceps ; tying them with ligatures ; cutting them 
out, and destroying them with caustic. The manner of per- 
forming these several operations is described in the books on 
general surgery. It is not within my province to recapitulate 
them. 

Benign Tumours.-^Axe those which have no tendency to 
spread by converting adjacent tissues into their own substance ; 
which do not depend upon constitutional vice, and may be con- 



TUMOURS. 131 

sidered as mere local aberrations from healthy growth. Of these 
there are several kinds, which may be reduced to two classes, 
the Sarcomatous'*' and Encysted Tumours, and Exostoses. 

SareomatouB or fleshy tumours are known by their firmness, 
redness, and fleshy feeling. (Some of the malignant tumours 
are arranged by Mr. Abemethy under this class.) There are 
several varieties of them, of which the common Vascular and 
the Adipose or fatty are, by far, the most common. 

These tumours grow to great size ; are not painful, and may 
be handled with impunity. Their size and situation, however, 
often make it necessary to remove them. If permitted to pur- 
sue their natural course, they sometimes suppurate, and then 
subside. This mode of cure, however, involves so much incon- 
venience, that it is commonly better to extirpate them. 

EncyBted TSinumrSj or as they are commonly called, Wen9j 
have this peculiarity, that their contents are contained in a 
cyst or sac, or bag. The contents of the cyst are various. 
Sometimes the contained matter is fatty, in which case the 
tumour is called a SUatoma,^ Sometimes it is a yellowish, 
thick substance, somewhat like honey or a mixture of honey and 
wax. Tumours of this kind are called MellicerU.X When the 
contents are like fluid cheese or pap, the tumour is called Athe- 
roma.% 

The contents of these tumours, however, are not always of 
such a quality as will permit them to be classed under the 
names above mentioned. It is not necessary, however, to be 
more precise. Perhaps, for all practical purposes, it had been 
as well to have permitted them all to wear the popular desig- 
nation. Wens. 

These encysted tumours are common about the head, and 
frequent upon the eyelids. They are generally globular, not 
sensitive, and cause no inconvenience beyond what is insepa- 
rable from their weight and size; and the trouble from these 
causes will, of course, depend upon their location. They 
usually grow slowly, but sometimes attain great size. Some- 

♦ 2«(f— fleth. t i'««{— fat 

I M»A/, honey, and K»^6f» wax. { a6/:{« — pap or pulp. 



132 TUMOURS. 

timoa the skia above thorn ulcerates, and the ttunonr is thns 
evacuated. This does not very frequently occur. These 
tamours should always he removed by diaaecting them oat, be- 
ing careful not to leave any portion of the cyst behind — for if 
this caution be neglected, the disease is liable to return, and 
does not always present, upon its second appearance, the 
benign character which characterized it originally. For 
obvious reasons, the operation should always be performed 
when the tumour is small. 

The mode usually adopted in the extirpation of these tumours 
is to dissect out the sac with the contents entire. Owing to 
the yielding nature of the contents, this is a tedious and trou- 
blesome process. Sir Astley Cooper recommended to cut 
through the sac at once, and then to dissect it out ; and doubt- 
less this is the more easy method, inasmuch as the divided 
edges of the cyst may then be held by the forceps. Encysted 
tumours occurring in the mouth should be attended to as soon as 
they are perceived. 

Boni/ Tumours — Exostosis.* — An enlargement of the bone 
by the addition of osseous matter within its cavity or upon the 
surface. There are several varieties, denominated ivory, lamel- 
lated, kc, according to the density of the tumour and the dis- 
position of its particles. 

The bones are liable to other forms of tumefaction, which 
differ from exostosis, although often confounded with it. 
When the bones are enlarged by mere distension or separation 
of their parts, the disease is not at all similar to the dense 
tumour produced by the presence of an unnatural quantity of 
bony substance. 

Thickening of the periosteum sometimes occasions an appa- 
rent enlargement of the bone, when in fact the osseous matter 
is not at all increased or distended. 

Sir Astley Cooper described exostosis as having two different 
seats, vis,: between the external surface of the bone and the 
periosteum, constituting periosteal exostosis; and in the me- 
dullary membrane and cancellated structure, forming medal- 



TUMOURS. 188 

)r exostosis. Soractimea he found the production of bone 
'preceded bj cartilage, in wbich it was deposited; at otber 
times connected with a fungus of a malignant character, con- 
taining spicula. This latter form of disease seems to have been 
1 Tarietj of osteo-sarcoma. 

Eiostoeis may occnr upon any of the bones, and the cause 
t the disease is generally inscrutable ; depending upon irregu-. 
hrity of ultimate nutrition, a process nhicb cannot be compre- 
hended. 

The structure and consistence of exostosis present great dif- 
ferences. Sometimes, especially when the tumonr is not very 
Urge, and when situated on the surface of a cylindrical bone, 
one may trace with the eye the diverging of the osseous fibres, . 
in the interspaces, of which we might say that there is deposited 
a new bony substance, the organization of which is less distinct. 
Sometimes the tumour is entirely cellular, and formed of a few 
broad, laminal, intercepting, extensive spaces, which are filled 
with matter, different from the medulla, and of various quality. 
This case is denominated the laminated exostosis. Sometimes 
the enlarged portion of bone makes a sort of hollow sphere, 
with thick, hard walls, the cavity of which is filled with fungous 
granulations, more or less extensive and indolent. According 
to Boyer, this variety of the disease differs essentially from 
oeteo-sarcoma, notwithstanding external appearances. The 
case here alluded to, Mr. S. Cooper considers the same as that 
wbicb Sir Astley has named cartilaginous exostosis of the me- 
ullary membrane.' 
n this last-described form of exostosis, Sir Astley Cooper 
s that the original shell is absorbed and a new one deposited, 
ind within the ossified cavity thus produced, a very large mass 
t elastic, firm, and fibrous cartilage is formed. This form of 
i is not malignant, but often ends in very extensive dis- 

L true exostosis, consisting of dense bony matter, and of 

>derate size, may exist without much inconvenience to the 

rroonding parts, provided they be of a kind to endure the 

• Cooper, Surg. Diet. 




tH TUMOURS. 

degree of pressure ■without distroas. But where the exoetoab 
ie so situated that its bulk can only be accommodated by prees- 
ing upon dense and unyielding structui'cs, or upon nerves or 
blood'Tesscls, or where the enlargement impedes muscular mo- 
tion, these tumours may occasion very serious consequences, 
The action of the flexor muscles of the leg has been seriously 
interfered with by an cxoatosia in the neighbourhood of the 
knee. An exostosis of the orbit has displaced the eye. Sir 
Astley Cooper narrates a case of this kind, where two exosto- 
ses, growing from the antra, pushed out both eyes, and finally 
produced death by pressure upon the brain. In another in- 
stance an exostosis of the sixth or seventh cervical vertebra, 
stopped the circulation in the radial artery by pressing npon 
the subclavian, and in another a cartilaginous exostosis of the 
medullary membrane of the lower jaw estecded so far back, 
that it pressed the epiglottis down upon the rima glottidls, and 
destroyed the patient.* 

The causes of exostosis are various, nnd, for the most part, 
little understood. The venereal disease is frequently attended 
with the formation of bony enlargements, or nodes, but this 
cannot by any means be considered the ordinary, or indeed a 
frequent cause of other forma of exostosis. 

In some individuals there is an unusual tendency to the ir- 
regular deposit of bony matter, and provocations, otherwise 
trivial, will often determine local osseous enlargements. Some- 
times these provocations are perceived, as when they consist in 
some form of external force, as blows, pressure, &c. ; more fre- 
quently the determining cause is as obscure as the constitu- 
tional vice. 

Exostosis is always very hard, sometimes painful, often in- 
sensible. The firm resistance of the tumour, and its adhesion 
to a bone, will generally enable us to distinguish it from other 
tumours. 

Exostosis is commonly gradual and slow in its growth, but 

the fungous, or medullary swelling of the bones, is often rapid 

in its development. The latter form of disease is attended 

'* Surgical E«saf9. 



TUMOURS. 135 

with very severe pain, and often with much constitutional irri- 



^e fangs of the teeth are more frequently the seat of exos- 
t than any other part of the osaeoua Btructurea. This 
g often causes great suffering to the patient, and the 
t finds in it one of the most common and trouhlesome im- 
pe^bnent^ to safe and easy extraction of the teeth. 

The disease is always developed upon the root ; generally at 
the extremity, sometimes at the sides ; frequently the whole 
fang ia involved, though not so equally as to present a symme- 
trical enlargement. 

Mr. Thomas Bell says that the substance thus added, differs 
from the natural bone, being harder, yellowish, and slightly 
transparent. As the swelling progresses, the pressure on the 
•Ireolos 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, 
Boon exposes the cavity to the action of external agents, and 
toothache leads to extraction. Mr. Bell says that the con- 
tinued irritation sometimes occasions thickening of the peri- 
steum 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 canse of which is 
r»rely discovered by an ordinary observer. Sometimes the 
adjacent parts become functionally distnrbed, and multiply the 
points of suffering. Mr. Fox relates the case of a young lady, 
who had suffered long with this affection of the fangs, which 
her medical attendants had entirely overlooked. The eyelid 
of one eye had not been opened for two months, and the secre- 
tion of saliva was so abundant from the irritation that it flowed 
out whenever the mouth was opened. 

Professor C. A. Harris has recorded the following case:* 

Mr. S., of Baltimore, having suffered from pain in the left 

Boperior Mcuspis, applied to a dentist in 1843, for the purpose 

■ UialioDsrj af Donlal .Science, article Exostosis. 



i 




of having his tooth removed. In the operation the root was 
fractured, about three-sixteenths of an inch from its extremity, 
and the upper part left in the socket. The pain continued, and 
at the expiration of twelve months the gum over the upper part 
of the alveolus became very much swollen, puffing out the up- 
per lip to half the size of a ben's egg. The tumour was opened, 
and a large quantity of dark-coloured, very fetid matter was 
discharged, which for a short time afforded considerable relief. 
The tumour, however, soon re-appeared, and was opened four or 
five times in as many months. 

In the fall of 1845, he called on Dr. Harris for advice. The 
gum was swollen, and the lip and cheek protruded in the man- 
ner above described. The tumour was opened again, and about 
three tablespoonfuls of black matter, resembling thin tar, 
were evacuated. Upon farther examination, the outer wall of 
the antrum, immediately over the upper part of the alveolus of 
the bicuBpis, which had been fractured, was destroyed, leaving 
an opening large enough to admit the end of the forefinger- 
Believing that the extremity of the root left in the socket 
was the cause of the mischief. Dr. Harris cut away the outer 
wall of the alveolus, and removed the fragment. The root of 
the tooth was found exostosed. The patient recovered com- 
pletely in a few weeks. 

A great number of cases, illustrating the variety and extent 
of mischief occasionally resulting from oxostosia of the teeth, 
are recorded by writers upon the subject. The dentist when 
consulted for the relief of pain in the teeth or jaws, especially 
if of long continuance and obstinate persistence, should always 
seek carefully for evidence of bony enlargement of the fang. 
It is a very common disease, and in some individuals affects 
many, or even all their teeth simultaneously. Sometimes ex- 
ostosis unites several teeth together. In a specimen presented 
to the Baltimore College of Dental Surgery, by Dr. G. R. 
Hawes, of New York, the three superior molar teeth of one 
side, are thus united. In another specimen, presented by Dr. 
Blandin, of Columbia, S. C, two upper molars are united ; and 
in a third, prescnied by Dr. Ware, of Wilmington, N. C, there 
is a deposition of bone on the roots of a first superior mo- 



TUMOURS. 187 

Ixris, OS large as a hickory nut. Similar epccimens are in the 
moseam of the Institution. 

The disease admits of no cure, and tho exostosed tooth must 
be extracted. In performing the operfttion, caution is neces- 
B»ry lest in the effort to tear away the enlarged bulb, the alve- 
olus, or adjoining teeth, or a fragment of tho maxillary, be 
brought with it. It is often necessary to cut away the socket 
in order to liberate the root. 



By 0Bt«o-8arcoma, is meant a malignant disease of a bone, in 
which there takes place within it a growth of fleshy matter, which 
distends the bony walls, and gradually converts the structure 
into a medullary, cartilaginous, or eanceroufi-Iooking substance. 

Osleo-sarcoma announces itself by severe, deep-seated pain, 
which is often felt for a considerable time before any swelling 
of the bone is perceived. Sometimes the pain is so great 
and unmitigated as seriously to impair the patient's health, 
before there is any perceptible disease. 

The tiimour is at first deep-seated, general over the part, 
hard and tuberculated. It does not yield to pressure, nor ie 
the pain aggravated by it. The soft parts, for a considerable 
time, may manifest no diseased condition ; indeed, it is not 
necessary to a fatal result that they should be implicated. 
Sometimes, however, as the swelling advances and the pain 
increases, the skin inflames and ulcerates, and assumes a caa- 
cerous appearance. 

As the disease progresses, hectic fever is set np, and the 
patient soon succumbs under accumulated suffering. When the 
sarcomatous bone is examined after such a termination, it ia 
found transformed into a yellowish, cheesy or lardaceous aub- 
Btsnce, and all the surrounding parts which have participated 
in the disease, are found to be changed into the same hotnogo- 
neons matter. 

The prognosis of osteo-sarcoma is decidedly unfavourable. 
No medical treatment is of avail in checking it. Extirpatioa 
a the only means which promises relief. 



k 



UN£ LIBRARY. SII^WWO > 



138 TUMOURS. 

Spina Ventosa is a swelling of the bones with diminution of 
their density. It is most common in the lower jaw, and in the 
metatarsal and metacarpal bones and phalanges of the fingers 
and toes. 

These tumours are the result of inflammation or of scrofulous 
degeneration in the cancellated structure of the bones, produc- 
ing matter, generally fluid, purulent, and mixed with the dark- 
coloured matter of osseous disorganizations. Sometimes, ac- 
cording to Dr. Gibson, the contents are cheesy, and Mr. Liston 
says, curdy. It is questionable whether these scrofulous swell- 
ings of the bones are reducible to the same pathological de- 
nomination as the fluid tumours properly known as spina ven- 
tosa. They are not malignant, but for the most part require 
to be removed by an operation. 

ANKUBI8MAL* TUM0UB8. 

A tumour caused by the distension of the walls of an artery, or 
of the heart, is called a true aneurism ; if the swelling be due 
to the rupture of an artery and the extravasation of blood in 
the surrounding tissue, it is called a fdUe aneurism. If an 
artery be wounded through a vein, so as to permit the arterial 
blood to pass into the vein, the condition is called varicose 
aneurism. 

An aneurismal tumour may generally be detected by the 
throbbing or pulsating sensation which it communicates to the 
hand upon pressure. Sometimes, however, when an abscess 
happens to be seated over an artery, the pulsation of the latter 
will be communicated to the former. The pulse often indicates 
the existence of an aneurism of the heart, or some large artery, 
by a peculiar thrilling sensation, which has been aptly com- 
pared to the feeling of a ^^ shattered quill." As fatal acci- 
dents have occurred from thoughtlessly opening tumours of this 
description, it is always important to examine every tumour 
carefully before thrusting a lancet into it. 

The pathology and treatment of aneurism does not come 
properly within the scope of the present work. 

* AfUffvfUf, to dilate. 



189 



CHAPTER XIL 

DISBASES 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? I answer that they are|; yet the distinction 
between neuralgic and other pains, is that in the case of the 
former the nerves are concerned primarily rather than as in- 
struments; or in other words, they transmit intelligence of 
their own suffering (for such is pain), not that which is only 
shared by them with adjacent parts. We must not expect 
philosophical definitions in medicine. The term neuralgia is 
not precise, but it is sufiScient for practical distinction. 

The superficial nerves being by far the most sensitive, and 
withal the most exposed to injury, are very much more fre- 
quently affected with neuralgia than those which are deeply 
seated. It is not certain whether the seat of the disease is in 
the neurilemma or the nervous pulp. In fact the ultimate na- 
ture of the nerves is too little known to permit us to hazard an 
opinion upon this subject. 

Neuralgia is a very acute pain, which generally commences 
suddenly, and occupies a single spot, from which as the attack 
progresses in violence, it radiates by pangs or fiashes to the 
surrounding nerves. The pain is generally sharp and darting 

* Niv^cy, a nenre, and «tA>ec> pain. 



140 NEURALGIA. 

or burning, and may be distingnishedy among other character- 
istics, by this, that in its radiations it follows the threads of 
the nerves without extending to the adjacent structures. There 
is no heat, redness, or swelling, the absence of which is suffi- 
cient to distinguish the disease from inflammation. The pain 
after continuing for a longer or shorter time, rarely longer than 
a few hours, abates, generally suddenly, and disappears, to re- 
turn with equal rapidity if the proper provocation be re- 
peated. 

The proximate cause of neuralgia is unknown, as indeed is 
its pathology. 

There are two varieties of it, which may be termed pure and 
intermittent. 

By pure neuralgia we mean that variety which is not, so far 
as we know, connected with or dependent upon any other affec- 
tion, general or local. 

This disease generally occurs in pale, thin, and feeble per- 
sons, and seems to be a disease of debility. The pain for the 
most part comes on suddenly, and gradually increases to great 
intensity, when either through the efficacy of remedies, or in 
obedience to unknown laws, which regulate the ebb and flow of 
nervous influence, it abates rapidly and leaves the patient en- 
tirely free from sufiering. It does not return until some pro- 
vocation be applied, when it will suddenly reappear, and will 
not be appeased for several hours. Nor is it necessary that 
any powerful irritant be applied in order to rouse the nerve to 
renewed agony. Often the slightest cause will be sufficient; 
the gentle movement or touch of the part, and especially the 
slightest breath of cool air, will often be sufficient to renew the 
terrible pain. 

The intermittent neuralgia is a symptom, and often the only 
one, of ague, or intermittent fever, as it is commonly called, but 
which in this case must drop the latter word, as there is no 
fever present. Of this disease I must speak at length pre- 
sently. 

Neuralgia of each kind may be located in various nerves. 
The scope of this work makes it necessary for me to notice but 
one speciality of the disease. 




To this subject I would particularly invite mj readers, as it 
is one which it is most important for all dentista to understand. 
The reason will be seen in the sequel. 

Neuralgia faciei is sometimes called tic douloureux. The 
word tic tneans a sudden twitching or convulBive movement, 
ud BS this is sometimes noticed in the faces of persons suffer- 
ing with neuralgia of that part, the term tic douloureux or pain- 
ftil tic, was given to the affection. 

Neuralgia faciei occurs in some of the branches of the fifth 
pair of nerves, and the first and second branches are more com- 
monly its seat. The pain is therefore more frequently suffered 
l»Tcr the orbit, in the cheek, mouth, lower jaw, and lower 
teeth. 

It will be perceived at once that the dentist must often be 
called upon to discriminate between this disease and ordinary 
toothache, and that, unless he be properly informed upon these 
Vabjects, he may add to the terrible suffering of his too confi- 
dent patient, the additional anguish of tooth extraction, and the 
injury of losing sound and most valuable organs. 

Id most cases the neuralgia of the nerves of the jaw b at 
Srst mistaken for toothache, and frequently ignorant dentists 
kave extracted tooth after tooth, and have at last relinquished 
tbe 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 
"febsence of all the other symptoms of inflammation eiccept pain, 
and by the peculiar character and direction of the pain. The 
fact that it subsides, disappears, and returns, will also serve to 
distinguish it from the continued pain of inflammation. 

From toothache depending upon exposed nerves, it may be 
diagnosed by the evident centralizing of the pain in a certain 
tooth, by the aggravation of it when the tooth in fault is struck, 
and by the positive evidence of a cavity in it, with an exqui- 
sitely sensitive pulp exposed. 

h i 



142 KSUBALGIA. 

The treatment of pure neuralgia faciei is palliatiye and cura- 
tive. 

The palliative treatment consists in the use of such means as 
are calculated to allay the pain of the paroxysm. The cura- 
tive consists in the employment of such remedies as experience 
has shown to be most useful in restoring the health of the pa- 
tient. Of palliative means, warmth is one of the most impor- 
tant. Gold aggravates the pain intensely, and will almost 
always excite a paroxysm of pain in a patient subject to neu- 
ralgia. Warm or even hot applications to the face are there- 
fore important aids in allaying the suffering. Counter irri- 
tants, such as mustard plasters, blisters, cupping, &c., are also 
occasionally useful. 

But our main reliance for the relief of neuralgic pain, is in 
the use of narcotics* or anodynes,t and especially of opium, 
which is vastly superior to all the rest. 

It is necessary to give this medicine in full doses, if we would 
benefit the patient under these circumstances. An adult should 
take two grains of opium, or sixty drops of laudanum, and in 
some severe cases, or when the patient has become accustomed 
to the effects of the drug, this dose will require increase or 
repetition. 

Aconite, another powerful narcotic, which has a remarkable 
quality of lessening sensibility, is now much used, both exter- 
nally and internally, for the relief of neuralgic pain. It must 
be used with great caution, as it is eminently a dangerous article. 

The curative treatment of pure neuralgia will be modified 
by circumstances. If the patient be plethoric, with a red face 
and active pulse, even general and local bleeding may be pre- 
mised. Such, however, is rarely the case, and when it is, we 
have reason to believe that the disease is rather rheumatic than 
neuralgic. 

If the digestion be bad, which is often the case, correctives 
must be directed to the organs involved. But in most cases 
the restoration of healthy digestion will not be sufficient to 
procure permanent relief. 

* KarcoticSy Aram Ht^msm, I stapifj. f Anodyne, from «, primitiTe, o^?!/, pain. 



NBURALQIA. 143 

Generally, neuralgia is a disease of debility, and is found in 
the cold, pale, and feeble, and in persons of evidently broken 
health. In such cases the tonic medicines offer most advan- 
tage, and of these none are found to be so useful as the salts 
of iron. 

There are several preparations of this medicine. The carbo- 
nate, if properly prepared, is a good form of administering 
iron, but by far the most valuable preparation is the sulphate. 
This has also the advantage of being generally good as found 
in the shops, and of being always readily procured. It is, I 
think, much more certain and efficient than the other ferrugi- 
nous preparations. 

It may be given in doses of a grain two or three times a day, 
and must be continued for several weeks. Under its use the 
patient will generally improve in strength and colour, and with 
the invigoration of the general system, the neuralgic affection 
will frequently disappear. If this medicine should disagree 
with the patient, or it should fail after a fair trial, recourse may 
be had to other medicines of the tonic class, of which there are 
many, mineral and vegetable. 

It is a very common thing for authors and practitioners to 
confound the pure and intermittent neuralgias, through want 
of discriminating periodicity, from a tendency to return upon 
slight provocation. Yet the distinction is plain and very im- 
portant, for upon proper diagnosis of the form of the disorder 
depends the rational treatment of it. 

In pure neuralgia the nerve after the subsidence of a parox- 
ysm is left in an exceedingly irritable state, so that it will be 
excited to another by causes of irritation in themselves exceed- 
ingly slight. But this return is merely accidental and occa- 
sional, and of course, obeys no law of regular occurrence. In 
some instances the exciting cause may be so trivial as to escape 
notice, but after long and painful experience, the patient learns 
to perceive potent agents for evil in things which previously 
eluded observation altogether. 

Periodicity, is the regular return of paroxysms in accord- 
ance with a law of the disease and independently of provoca- 
tion. It generally observes fixed periods of return and depar- 



144 KEURALQIA. 

tare, and when irregular as to the common law which governs 
the type to which it belongs, it obeys some regulation of its 
own, by which some well-defined proportion of paroxysm to 
intermission is preserved. It does not follow then, that be- 
cause the neuralgic pain abates, either of itself or under narco- 
tics, and recurs in a few hours or days, that consequently it is 
periodical, and must be treated by quinine. 

Intermittent Neuralgia. — In order to understand the charac- 
ter and treatment of this disease, it is necessary to have a cor- 
rect knowledge of a particular class of fevers, which present 
very curious phenomena. 

These fevers belong to the class which we have designated as 
idiopathic ; and to the family of malarious or marsh fevers. 
They are commonly known as agiteSj from the fact that each 
paroxysm is preceded by a chill. Hence, also, they are known 
popularly as chills and fevers. 

The cause of these affections is always malaria ; no other 
agent or combination of circumstances produces them, and this 
is so true that the fact of exposure to malaria is most impor- 
tant in deciding upon the character of the disease in mooted 
cases. 

Malarious neuralgia always assumes the intermittent, never, 
as far as I know, the remittent type. It may appear as a quo- 
tidian, tertian, or quartan, or it may be irregular in its periods. 
Its paroxysms are rarely preceded by chill, accompanied by 
fever, or perceptibly finished by a sweating stage. Though 
evidently depending upon the same cause as intermittent fever, 
it has no phenomena in common with the former, except its 
paroxysmal character, periodicity, and curability by certain 
specific means. 

In endeavouring to ascertain the cause of violent intermitting 
pains in the face, it is all-important to learn whether the pa- 
tient has previously been exposed to malarious influence. If it 
shall appear in any instance that he has not been out of the 
central part of a large city, known to be free, at least in such 
part of it, from all emanations of a malarious kind, this fact is 
abundant evidence that the patient has not intermittent neural- 



NBURALGIA. 145 

gia, however strong appearances may be to the contrary of this 
opinion. On the other hand, if he lives in a marshy or ma- 
larious country, or if he has visited such a locality during the 
latter part of the preceding summer or early part of the fall, 
and especially if the patient has had well-marked ague pre- 
viously to the facial suffering, then the presumption will be 
very strong in favour of the malarious origin of the disease. 

Besides this historical kind of evidence, the attending cir- 
cumstances will shed much light on the case. If there be no 
apparent cause in the condition of the teeth of the affected jaw 
for 80 much suffering, if no other disease can be detected in the 
bones or soft parts, if the pain intermits perfectly and returns 
periodically, or even if not with entire regularity, yet obviously 
with some obedience to the law of type, and without provoca- 
tion, all these circumstances taken together will leave little 
doubt as to the nature of the malady. 

Cure. — This distressing disease, which, if misunderstood, is 
one of the severest and most difficult to alleviate or endure, is 
when properly diagnosed a very manageable affection, and often 
yields to the very first dose of well-directed medicine. 

We have previously remarked that the pathological cause of 
intermittent febrile phenomena is not known ; fortunately for 
the world, experience has not waited for pathology, but has 
pointed out the means of relief and the mode of applying it. 

Certain medicines are known to be positive antidotes to in- 
termittent malarious fevers of all kinds. These agents, if ex- 
hibited freely during the intermission, rarely fail to prevent 
the return of the paroxysm. Owing to the fact that most of 
these medicines possess tonic or roborant qualities, it has been 
supposed that they check intermittents, through this quality. 
Hence, tonics are said to cure ague. 

I am convinced, however, that the supposition which attri- 
butes the prevention of intermittent paroxysms to the common 
roborant quality of tonics is a mistake, and a mistake which 
probably has led to unfortunate consequences in practice. 

The medicines which possess in the greatest degree the anti- 

18 



146 NBUBALGIA. 

dotal power to intermittents, are not those which are the best 
tonics ; while the best of all roborant medicines have but little? 
if any, power to check intermittent paroxysms. 

Cinchona, or Peruvian bark, is by far the best anti-intermit- 
tent remedy we have, yet as a pure tonic it certainly is vastly 
inferior to iron, and hardly equal to some of the vegetable bit- 
ters ; while arsenic, which, next to cinchona, is the most pow- 
erful anti-paroxysmal medicine of which we have any know- 
ledge, has no tonic property at all. 

The anti-intermittent quality is therefore obscure, and the 
medicines under consideration are prescribed for the cure of 
these diseases, simply because experience has clearly proved 
their preventing quality, and not because we perceive any ra- 
tional relation between the physiological 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 for an efficient remedy. 

The best mode of administering cinchona, is in the form of 
the sulphate of quinine, because the dose b very much smaller, 
and sits better upon the stomach, and because, moreover, the 
cinchona in bulk is uncertain in strength. The best form of 
administering the quinine, is in solution, although piUs of it 
are often given. 

In order to dissolve it perfectly in water, it is necessary to 
add a few drops of sulphuric acid or elix. vit. 

The dose varies very much with the circumstances of the 
case. Thus if the intermission be long, a considerable time is 
afforded between the paroxysms, for the introduction of the 
antidote, and small doses, frequently given, are preferable ; if, 
however, but little intermission is afforded^ the dose of the me- 
dicine must be proportionably greater. 

The dose, also, must vary with the urgency of the case, and 
the condition of the patient. If he has already suffered long, 
has been much reduced, and has but little power of resistance 
left> the dose should be very decided. 



NEDR4LQL4. 147 

There is alao considerable difference of opinion among prac- 
titioners upon thia subject. Some prefer giving large single 
doses, or at least rarelj repeated; others, small doses, fre- 
qaently repeated. 

Generally speaking, either mode will effect the desired re- 
Bolt ; bnt as it is plain that we shonid give the least quantity 
of medicine that will be sufficient, I am in the habit of pre- 
scribing moderate doses of quinine, and have never found them 
to fail except when the stomach refused to bear them ; in which 
cases larger doses would have been yet more objectionable. 

The prescription of quinine which I generally give, is a so- 
lution of ten grains, dissolved in an ounce of water. A tea- 
ipoonfol, containing a grain and a quarter of quinine, being 
given as 8 dose to an adult. 

This quantity is given every two hours, if there be an inter- 

nuBsion of considerable duration, or every hour if the time for 

tdministering be short. 

In very serious cases of intermittent, involving great danger 

I to the patient, and when the powers of life were low, I have 

Tery much exceeded the quantity above named. Some practi- 

I tioners always give it in doses of ten or twenty grains ; but 

I (his quantity is unnecessary, and Tiardly safe ; for though many 

I pftlients would bear it without inconvenience, some would suf- 

] fer from its action upon the brain. 

The dose of quinine to young children, must always be very 
•mall, as their nervous system is more excitable, and their brain 
■ore easily disturbed, than is the case with adults. 

Kext to quinine, arsenic is our most certain antidote to in- 
(erroittent affections. It is given in the form of arsenias po- 
se, or Fowler's mineral solution, in which form it is 
I manageable, and in proper doses entirely safe. The viru- 
lently poisonous character of arsenic, renders it improper to 
tttempt its administration in any but a diluted form. 

There are many coses in which the arsenic appears to exer- 

eise the anti-intermittent power quite as efficiently as cinchona, 

and the small bulk of the dose, and the readiness with which 

its flavour may bo covered, make It far preferable for admi- 

I uAtration to children. 



148 NEURALGIA. 

It ma J be given very advantageously in alternate doses with 
quinine. After it has been persevered in for a long time, it is 
apt to produce oedema, which readily subsides when the medi- 
cine is withdrawn. The dose of Fowler's solution, to an adult, 
is eight or ten drops, every one, two, or three hours, or alter- 
nating every four hours with quinine. Sometimes it produces 
nausea and irritation of the bowels. In such cases the dose 
should be lessened. It not unfrequently produces oedematous 
swelling of the face and hands, which disappears when the 
medicine is suspended. 

There are many other remedies, which are more or less effi- 
cacious in the prevention of intermittent paroxysms, but it is 
not necessary to mention them here. 

The quinine and arsenic should be given only during the in- 
termission ; though if this be very short, the administration of 
remedies, and especially of the arsenic, may be recommenced 
before the fever has entirely subsided. 

In the treatment of intermittent neuralgias, as in other in- 
termittent affections, the prevention of a paroxysm will be 
more certain, if a full dose of opium be given an hour before 
the expected return. 

In cases of intermittent neuralgia, where the patient has 
been exposed to malaria for successive years, and has suffered 
much from the diseases attributed to this cause, the liver and 
other abdominal viscera are generally deranged, and the neu- 
ralgia cannot be permanently relieved until these visceral ob- 
structions are overcome. The purgative preparations of 
mercury are very useful in such cases. 

Of course, no permanent cure can be expected, while the 
patient shall continue to reside in the unhealthy location, as he 
must, of necessity, be exposed to continual renewal of the dis- 
ease. Unfortunately, the advice of medical men is rarely of 
much avail in directing the choice of residence. This is deter- 
mined, for the most part, by considerations entirely indepen- 
dent of health ; and there is great difficulty in persuading a 
man that it is unsafe for him to live where it is most profitable 
or pleasant, and that his own property is situated where no- 
body ought to dwell. 



149 



CHAPTER XIIL 

MORBID SECRETIONS OF THE MOUTH. 

Six glands, the parotid, submaxillary, and sublingual of each 
side, pour their secretions into the cavity of the mouth. The 
mucous membrane, which lines the organ, also contains upon its 
surface a great number of crypts, or follicles, which prepare 
and pour mucus into the mouth. The secretions from the 
glands and mucous membrane form saliva, which lubricates the 
facial cavity, and in mastication is thoroughly mixed with the 
food, the subsequent digestion of which it materially aids. 

The mucous membrane of the mouth is continuous with that 
which lines the pharynx, oesophagus, stomach, and intestines, 
and sympathizes greatly with any diseased condition which 
affects those organs. Hence the furred tongue in fever, the 
red tongue of intestinal irritation, &c. 

The fluids of the mouth are readily changed from their nor- 
mal condition, when the digestive organs are feeble, and per- 
form their functions badly. When such is the case, the secre- 
tion of the stomach and its appendages are so changed as to 
unfit them for the perfect performance of their work ; they be- 
come, to a certain extent, foreign substances, and are capable of 
exciting irritation, and also, by mixing with alimentary matters, 
of converting them into deleterious agents. Generally the 
change produced upon the fluids of the stomach, &c., under 
Buch 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 

18» 



MORBID SECRETIONS OF THE MOUTH. 

about the teeth, especially of the lower jaw, forming the seve- 
ral yarlctles of lartar. 

The saliva of healthy persons ia only sufficient for comfort- 
able luhi'icatioQ of the mouth, and being passed into the sto- 
mach as fast as it forms, it does not collect in the mouth, or 
require to be frequently excreted. When healthy, it is light, 
frothy, and but little viscid, without odour, floats upon, and 
mingles readily with water. In this condition it ia slightly 
alkaline. 

The saliva is acid in dyspepsia, and cousequently caries is 
apt to prey upon the teeth of persona suffering with indigestion. 
Nor may the dentist expect to arrest the devastation, unless he 
can remove the cause that is continually decomposing the bony 
structures of the teeth. 

That the saliva is acid in certain diseases, is abundantly 
shown by Mr. Donut?, of Paris, — who was so struck with the 
changes in the chemical character of the fluids of tbe mouth, as 
responding to disordered states of the stomach, that he sug- 
gested the U30 of this fact, as tbe best means of deciding upon 
doubtful cases of such disorders. 

MM. Tiedcmann and Gmelln had previously found the 
Baliva to be alkaline in man, and all other animals whose secre- 
tions they had examined. Wagendle, with his usual careless- 
ness of facts, and boldness of theory, taught that the saliva was 
sometimes strongly alkaline, sometimes neutral, and sometimes 
acid : when the stomach is empty, the fluids of the moutb, ac- 
cording to this writer, are acid ; during mastication, alkaline ; 
the acidity disappearing sometimes at the presence of the first 
mouthful. The latter part of this opinion, is of course, mere 
nonsense. 

According to M. Donn^, who seems to have investigated tbis 
matter with great carefulness, with the hope to find in it some 
semeiological fact, which might lead to great practical results, 
tbe saliva is constantly alkaline when tbe stomach b In a 
healthy condition. This, then, he considers tbe normal or na- 
tural quality of tbe fluids of tbe moutb, and all deviations from 
it lie considers uuhealtby, and indicative of gastric diseasti. 




I 



M. DonD^ declares that he has never fouLd the Baliva acid, 
when the stomach haa performed its fuDctioas well. 

The only testing means used by this gentleman in his many 
experimeots upon the saliva, vere slips of litmus paper. The 
saliva, if acid, will redden the paper. For test of alkalescence 
the paper should first be reddened by an acid and then sub- 
jected to the action of the saliva. 

M. Donnt- narrates a number of cases of varions 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 Chariti5, 
lahouring under severe bronchitis, attended with great tender- 
ness of the abdomen, excessive irritability of the stomach, 
diarrhoea, ardent thirst, &c. The saliva was strongly acid. 
The disease assumed in its progress a marked typhoid charac- 
ter, the tongue was parched and coated with a brown crust, 
the abdomen was always very tender; delirium and coma su- 
pervened, and the patient died on the tenth day after admis- 
eioD. The saliva was acid daring the whole course of the 
illDesB. Dissection showed extensive disease of the mucous 
membrane of the stomach and intestines. 

A young man was received into La Charit^, as a fever pa- 
tient. All the symptonis of ataxic* fever soon developed them- 
selves. The saliva during the 6rst days was only slightly acid, 
but later it became more strongly so ; he died comatose. The 
saliva remained acid to the end. Dissection showed a fifth 
part of the mucous membrane of the stomach diseased. 

A young man was admitted into the hospital as a fever pa- 
tient. The symptoms were not serious ; there was a yellow hue 
of the skin ; the epigastrium was rather tender on pressure, 
there were, however, neither vomiting nor diarrhoea present; 
the tongue was white, and the saliva was alkaline. During the 
progress of the case the saliva became acid, continued to be so 
for three days, then became neutral, and as the patient reco- 
vered, gradually resumed its alkalinity. 

In the case of a young man who exhibited the symptoms of 
gastritis, namely, great tendernoaa of the epigastrium, thirst, 
* Ataxic. nerTouB or typhoid. 



k 



i 



152 MORBID 8B0RBTI0NS OV THE MOUTH. 

tongue red and parched, kc.j the saliva was found to be deci- 
dedly acid. By repeated leechings of the abdomen, and the 
use of demulcent and refrigerant drinks, the symptoms were 
speedily relieved, and in a few days the saliva was quite neu- 
tral, having no effect either on the simple litmus paper, or on 
that which had been previously reddened by an acid. It soon 
regained its alkalinity. 

This patient had two relapses of his complaint, and on both 
occasions the saliva was acid at first, and became neutral, and 
then alkaline, as the symptoms disappeared. 

From these and similar facts, M. Donn^ inferred that acidity 
of the saliva was always attendant upon gastric disorders of a 
febrile character. 

Professor Harris informs me that repeated experiments have 
satisfied him that the acidity is confined to the mucous secre- 
tions of the mouth ; the secretions from the salivary glands 
never reddening the litmus held to the mouth of their ducts. 

Schill observes that ^^ carious teeth indicate long-continued 
irregularities of digestion. The teeth become very sensible 
(sensitive) in many nervous diseases, and in consequence of the 
presence of acid in the stomach. They are sometimes covered 
with a whitish or gray mucus : this occurs chiefly in catarrhs, 
and inflammations of the digestive and respiratory organs."^ 

When we remember the extreme susceptibility of the teeth 
to be decomposed by the action of acids (see page 44), we may 
well understand why caries is general, and hard to arrest. 
Providence has made the saliva alkaline, in order to protect 
the important organs it bathes, from injury by acid matters 
taken into the mouth, and also to moderate the acidity of the 
gastric fluids. 

But under many morbid conditions, especially those most 
common to artificial life, the protecting fluid itself becomes the 
assailant, and the teeth, exposed at once to the attacks of acid 
aliments and drinks, and to the more constant action of acidu- 
lent saliva, soon yield to those corrosive agents. 

* Sohill'8 Semeiology. 



DTSPBPSIA. 158 

This acid state of the saliva may accompany a vitiated con- 
dition of the fluids of the stomach, when no gastric suffering 
has attracted the attention of the patient, and the existence of 
any disorder in that organ has not been suspected. In such a 
condition of things, however, the dentist can afford only tem- 
porary relief, unless, perceiving the evil, he suggests such 
remedies as may relieve the patient of the disorder upon which 
the disease of the teeth depends. 

The practitioner of dentistry should, therefore, be always 
prepared to test the quality of a patient's saliva, as regards 
acidity or alkalescence; and he should also be ready to 
give such advice as may be necessary, in consequence of any 
discoveries he may make. 

When diseases of an acute character exist there will be no 
demand for the services of the Dental Surgeon, unless his me- 
chanical assistance be required. It is not necessary, there- 
fore, for me to treat of such affections. But it often will hap- 
pen, that a patient will apply for operations upon the mouth, 
who may be affected with some subacute or chronic disease of 
his stomach, for which he is not under medical treatment. If 
the disorder be not very trifling, the dentist ought, in such 
cases, always to advise application to a judicious physician. 
But it will often happen, that the patient cannot conveniently 
procure such attention, or that the dentist may not have such 
confidence in the skill of the medical practitioner who could be 
procured, as to authorize him, as a conscientious man, to de- 
volve the case upon another. He must therefore give the ne- 
cessary advice himself. 

In calling, therefore, the attention of the dental student 
to the consideration of dyspepsia,'*' as a common name for 
chronic diseases of the stomach particularly characterized by 
indigestion, I do not think I am in any degree leading my 
readers away from the studies proper to them. 

DT8PKP8IA. 

Dyspepsia or indigestion, representing any derangement of 
the function by which the aliment, after having been received 

* I)78p«pBiA — AvCf with difficulty, and nirrtf, I digest. 



154 DTSPBPSIA. 

into the stomach, is conyerted into chyle, must necessarily pre- 
sent a number of appearances, more or less characteristic of 
the particular trouble they represent, and the degree of its 
violence. It is therefore impossible to furnish a description 
sufficiently accurate and comprehensive to cover all the condi- 
tions of defective digestion which are included under the com- 
mon name, dyspepsia. Several complicated organs are con- 
cerned in the process of digestion. These are connected to- 
gether by the natural dependence of reciprocal necessity, and 
by powerful sympathies ; and any of them, when diseased, may 
interrupt the functions of the others. To understand this sub- 
ject well, it will therefore be necessary to have a complete 
knowledge of all the morbid conditions of all the organs of di- 
gestion, and of all the means likely, under any circumstances, 
to be useful in restoring them to healthy action. 

Of course, it is not my purpose to discuss thb subject in all 
its fulness of detail. It will be sufficient to impart such prac- 
tical information, as may be easily remembered, and readily 
made availing by the dental practitioner. 

The symptoms of dyspepsia vary much with the duration 
and nature of the affection, the constitution of the patient, his 
mode of life, &;c. 

Generally the appetite is capricious, sometimes very feeble. 
Heartburn, a sense of weight or distension in the stomach after 
eating, incapacity of digesting certain substances, such as oily 
matters, pastry, &c., costiveness, abdominal pains, weakness, 
depression of spirits, &c., are most prominent. 

From the extensive sympathies existing between the stomach 
and brain, headache is a very common attendant upon dys- 
pepsia. This is often very violent, and attended by nausea 
and vomiting. The patient soon learns by experience that he 
cannot take certain articles of food or drink with impunity, and 
every deviation from the diet suitable for him, is attended by 
renewal of symptoms and aggravated suffering. 

Dyspepsia may be variously classified for the purpose of 
description and treatment, but the simple, plain, and practical 
distinction laid down by Dr. Eberle seems preferable for our 



DTSPBPSIA. 1 55 

purpose to any of the more accnrate, yet more complicated ar- 
raDgements presented by other writers upon this subject. 
According to Dr. Eberle, dyspepsia may depend upon two 
distinct morbid conditions of the digestive organs, viz. : 1. On 
functional debility of the stomach from deficient or vitiated se- 
cretion of the gastric fluid, and muscular inactivity, indepen- 
dent of vascular irritation or inflammation. 2dly. On defi- 
cient or vitiated secretion of the gastric fluid with vascular ir- 
ritation or chronic inflammation of the mucous membrane of 
the stomach and duodenum, and morbidly increased peristaltic 
action of these organs. 

The characteristic symptoms of the former grade of indiges- 
tion, are weak appetite ; tongue covered with white fur ; absence 
of epigastric tenderness, except after a paroxysm of colic from 
flatulent distension; costiveness; acid and fetid eructations; 
absence of habitual tension and febrile irritations of the pulse ; 
and the ability of bearing lean and tender animal food better 
than vegetable and farinaceous articles of diet. 

The phenomena which characterize the second or inflamma- 
tory grade of the disease, are tenderness to pressure of the epi- 
gastrium, and particularly about the region of the pylorus and 
duodenum ; a red, chopped, granulated or glossy appearance of 
the tongue; a firm, tense, small, and somewhat accelerated 
pulse, with slight manifestations of febrile exacerbations to- 
wards evening ; emaciation ; irregular action of the bowels, with 
frequent attacks of mucous, bilious, or watery diarrhoea ; violent 
protracted pain in the lower part of the epigastrium during the 
process of digestion ; fulness about the edge of the false ribs 
on the right side ; an anxious and discontented expression of 
countenance ; and inability, without great suffering, to endure 
animal food and stimulants. It appears that the irritative or 
chronic inflammation of such cases is seated in the mucous 
membrane of the pyloric extremity of the stomach, and of the 
duodenum, connected usually with a congested state of the liver, 
and often with foecal accumulations in the colon."*" 

* Eberle's Prac. of Medicine. 



156 DYSPEPSIA. 

The canses of dyspepsia are : 

1st. Hereditary predisposition. Some families inherit from 
their parents some pecniiarities in the intimate organization of 
the stomach that inevitably result in dyspepsia of protracted 
and aggravated character, which makes its appearance about or 
soon after puberty, and continues with more or less intermission 
for years. This predisposition, however, is not of very frequent 
occurrence. 

2d. Mental and moral causes, such as exaggerated passions; 
gloomy habits of thought ; depression of spirits ; over-anxiety 
of mind. 

The influence of the feelings over the stomach is well known. 
Grief destroys the appetite, so do joy and ardent anticipation. 
Fasting is a natural exponent of sorrow. 

3d. Irregular living, especially the artificial life of the fash- 
ionable world, which turns night into day and day into night ; 
robbing the body of sleep when most disposed to and best pre- 
pared for it, and forcing the stomach, at unnatural hours, to eat 
heartily of the most indigestible and irritating kinds of food, if 
such ingesta can thus be called without impropriety. 

4th. Excessive eating, and drinking, both of water and in- 
toxicating drinks. 

5th. Sedentary living without sufficient exercise. 

6th. Unwholesome and insufficient diet. The use of pickles 
in excess, especially by delicate females. 

7th. Want of healthful and sufficiently laborious occupation. 
It is owing to this, together with the adjuvant action of other 
causes which we have mentioned, that so many of the young 
women of our country are feeble, diseased, useless, and short- 
lived. 

8th. The abuse of medicines, especially those of a purgative 
character. People have a wonderful disposition to be actively 
purged. Millions of pills, containing irritating and powerful 
cathartics, such as jalap, scammony, aloes, calomel, gamboge, 
and croton oil, are annually sold to persons whose only disease 
is too frequent purgation. The result often is chronic and in- 
curable dyspepsia. 




9tb. Eating too fast, so that the gastric juice does not mingle 
ith the food as rapidly aa it is taken. Imperfect mastication, 
generally because of carious teeth. 

10th. Extensive disease of the teeth, oecaaioning frequent 
and severe toothache, vitiating the secretions of the mouth, 
and thus furnishing to the stomach saliva of a bad quality. 
We have jnat seen that imperfect mastication may cause dys- 
pepsia. Extensive caries interferes much with mastication. 
Moreover, pain disturbs digestion, and frequent toothache 
not only produces the common effects of pain, but from the 
position of the suffering, interferes with insalivation and regu- 
lar eating. 

11th. To all these causes may be added everything 'which 
tends to exhaust the vital energies, as every kind of excess 

«ssarily does. 

The treatment of dyspepsia consists first, in removing, as far 

possible, all the causes of it. It will be useless to make an 
attempt to cure unless the patient will make persevering and 
self-denying efforts. 

The patient must be contented to subsist upon such food as 
he can readily digest. The diet should be as dry as possible, 
for all drinks dilute the gastric juice, and when this is vitiated 

deGcient, dilution renders it still less efficient. 

As to the character of food, it is exceedingly difficult to lay 
bill of fare which will suit all cases. The stomach, in 
dyspepsia, is very capricious. Some patients will eat with im- 
punity what others cannot digest at all. I once had a dys- 
peptic female patient whose stomach revolted at the most 
simple and digestible substances, yet retained and digested 
comfortably, apple-pie and milk. Generally, the patient has 
learned, by repeated experiments, what food agrees best with 
him, and to this he should be confined. 

In general, when the disease is simply one of debility with- 
out gastric inflammation, animal food answers better than vege- 
table. In selecting the particular kinds of animal food, we 
■hould avoid young meats. Veal, lamb, and young pork are 
Tery indigestible by weak stomachs. The mode of preparation 




158 DYSPEPSU. 

also J8 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 
iQadmissible. All acid fruits, and the whole family of nuts, 
come under similar condemnation. Sugar is very apt to sour 
upon the stomach, especially if it be dissolved in warm water, 
as in the form of sweetened tea and coffee. 

In these cases of debility of the stomach, a little brandy 
taken at dinner is often very serviceable. The remedy, how- 
ever, is a dangerous one, and no prospect of advantage from it 
should induce us to advise it to one who has at some previous 
time been intemperate in its use. It is better for a man to be 
a dyspeptic than to be a sot ; and reformed inebriates have 
seldom a choice between abstinence and excess. Indeed, every 
patient who may be advised by his physician to use ardent 
spirits, should be faithfully warned againat the danger of ac- 
quiring an intemperate love of alcoholic excitement. 

The medicinal treatment of such cases consists in the em- 
ployment of such occasional purgatives as may be necessary to 
procure regular alvine evacuations; in the proper use of mild 
mercurial means to an extent aufEcient to remove torpor of the 
liver; in the administration of alkalies, if the patient be trou- 
bled with an excess of acid ; and finally, in the use of suitable 
tonics. All purgative medicines are not by any means equally 
well suited for the purpose we have indicated. Those of them 
which are very harsh and irritating, and those which produce 
watery and exhausting discharges, would be very injurious to 
dyspeptics. ludeed, we have enumerated the abuse of these 
cathartics among the common causes of the disease. 

Rhubarb, from its aromatic and tonic quality, and its mild- 
ness, is one of the best medicines for habitual use, under these 
(urcumstances. 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 



I 



the liver ts indolent, and its secretions deficient either in quan- 
tity or quality. 

Of the vegetable tonics, the pure bitters, such aa quassia 
and gentian arc 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 th^t the teeth of dyspeptic persons be 
carefully examined, for often the cause, or at least a cause of 
the disease may be found in the diseased and defective condi- 
tion of these organs, and a speedy cure be obtained by their 
removal. 

As to the form of dyspepsia attended by sub-inflammatory 
condition of the lining membrane of the stomach, its cure must 
be devised upon the principles which govern in the treatment 
of similar conditions elsewhere. Moderate antiphlogistic means 
and mild farinaceous diet, will generally be attended with per- 
manent relief, nevertheless the gastric surfaces, as the mucous 
membranes elsewhere, after having been inflamed, remain sub- 
sequently very susceptible to renewal of the disease, and the 
patient when relieved most be very careful not to presume 
upon the comfortable feeling of his stomach, and introduce into 
it stimulating meats, condiments, or liquors. 

All dyspeptic persons should be advised to eat slowly and 
chew their food well. If the absence or bad condition of the 
teeth interfere with mastication, as they will often be found to 
do, the skill of the dentist must supply the deficiency, or repair 
the injury of those important organs. 

Dyspepsia or indigestion expresses only the mal-perform- 
ance of an act which is the result of the combined effecla of 
various organs. Therefore, as failure of function in any one 
will interrupt the healthy completion of the groat common 
purpose, dyspepsia must be a general term comprising several 
diHorders. Being immediately connected with the digesting 
apparatuB, and in fact forming an important part of that great 




SYPHILIS. — RICKETS. — MEASLES. 

and complicated sysiem by wlucli alimeDt is received and pre- 
pared for assimilatioD, the dental apparatus caa hardly escape 
iiyury when the other organs of this system are involved in 
suffering. Indeed, the mucous membrane, which in the sto- 
mach and intestine is the seat of the digesting process, and in 
the mouth is continually pouring out important Suids from its 
surface and glands, is so intimately connected nith 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 toeth, and the secre- 
tions of tho mouth nill not be healthy when the functions of 
the intestinal canal membrane are disturbed. It is a hopeless 
task to save the teeth &om caries while the patient euff'erB 
unmitigated dyspepsia. 

Syphilis, also, by vitiating the general glandular and secret- 
ing systems, may produce a state of the buccal fluids very 
inimical to the structure of the teeth. This will oidy be the 
case in those secondary or constitutional forms of lues of which 
I have already written sufficiently when treating of ulcers. 

Rickets very much delays dentition, and so impairs the struc- 
ture of the teeth that when protruded they are very liable to 
decay. 

The enamel of teeth formed under the inQuence of this con- 
stitutional vice, is often craggy and worm-eaten in appearance, 
though sufficiently hard. The fang during the progress of the 
disease has been found somewhat softer than natural. 

The exanthematous febrile afTections, which commonly occur 
in childhood, interrupt the regular deposit of bouy matter in 
the growing teeth, and cause permanent defecU, 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 

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 i.ju.e the teeth. 

All serious diseases of the antrum must involve the dental 



MERCURIAL SALIVATION. 161 

arch. Inflammation may be propagated, nutrition impeded, 
caries communicated, and the arch actually broken up in the 
course of those often fatal diseases which have their seat in 
this geographically important cavity. 

The surgeon dentist should be well acquainted with the va- 
rious disorders and morbid growths which maybe developed in 
the antrum. Early detection is often necessary to cure, and 
none is so likely to have the opportunity of early discovering 
the hidden mischief, as the dentist. The first symptoms of the 
disorder are often felt in the teeth, and unless the dentist who 
may be consulted shall be able to point out the true nature of 
the evil, delay may be occasioned, and delay may be fatal. 

Mercurial salivation (ptyalism) has often caused extensive 
devastation in the dental arch. Mercury, like all other of 
heaven's boons, has been shamefully abused, and serious and 
even fatal injuries have resulted from the reckless administra- 
tion of this most useful medicine. Unhappily, the occurrence 
of such calamitous accidents has induced such general and 
unreasonable prejudice against the use of mercurial medicines, 
that vastly more evil is now suffered by society from the im- 
properly withholding, than injudiciously using them. The 
feeling against mercury has been the common hobby-horse of 
charlatans and unprincipled doctors, and it needs no little 
firmness to enable a physician to deal honestly with his patient 
in the use of this drug. From the fact that salivation is inju- 
rious to the teeth, dentists have been led to comment severely 
on the use of calomel, and thus have done much to spread 
abroad terrible notions of the evils inseparable from the em- 
ployment of this and other mercurial preparations. Some of 
these censorious gentlemen have seen evidences of mercurial 
devastation in every form of disorder and variety of decay, and 
to them calomel is the one thing to be avoided by all who live 
to eat, or eat to live. 

Doubtless salivation, especially if profuse, must be destruc- 
tive to the teeth, and fortunately it is at length understood that 
ptyalism is not, by any means, necessary to the attainment of 

all the benefit of mercury. Salivation is an accident always 

14* 



162 SYPHILIS. — SCROFULA. 

to be dreaded, and as far as possible to be avoided. Yet even 
at the risk of it, mercurial remedies are indispensable, inas- 
much as life is more important than teeth. 

There is no reason to believe that the use of mercury is in- 
jurious to the teeth, when salivation is not induced ; yet caries 
of these organs is very often attributed to it. People are ex- 
ceedingly apt to confound the post hoc with the propter hoc,* 
and dentists are as liable as other men to fall into the error. 
A patient who has escaped a severe attack of fever, finds his 
teeth rapidly decaying ; in great alarm he applies to the den- 
tist. The latter glances at the mouth, and with a look of 
boding sagacity, inquires if the patient has not been taking 
calomel. The patient replies that he has been taking more or 
leds of it, and then the man of science, as he is presumed to 
be, launches forth for the hundredth time into a bitter diatribe 
against mercury as the origin of all the evil. 

And why might not the lamented caries be as justly charged 
upon the tartar emetic or magnesia, which the patient may 
have taken simultaneously with the calomel ? or why does not 
the dentist seek for the all-sufficient cause of devastation in the 
fact that the teeth in question had been bathed in the acid saliva 
of a fevered mouth for weeks consecutively ? Why transfer the 
blame to the remedy by which the fever was subdued, and cast 
implied and serious censure upon the physician, whose judicious 
employment of the vilified drug has, perhaps, saved the pa- 
tient's life? 

Until I have other information than I now possess, I cannot 
believe that the proper employment of mercury is injurious ; 
and while I reprobate its abuse, and would think the physician 
unpardonable who would be careless or reckless in the use of 
a medicine capable of doing so much harm, I cannot but regard 
that man as the author of greater evil, who by silly declamation 
against an important remedy, fetters the practitioner in his con- 
test with the most formidable diseases. 

Scrofula, to which I have already caUed attention, interferes 
with assimilation, and consequently with the completeness of 

* To oooaidttr wliAterer ocean ni&jgym«r(y, lo be cojuegnoi/ apon what IkMS 
been obserred to precede it. 



PREGNANCY. 163 

nutrition and growth. Being often inherited and developing 
its mischievous nature very early in life, it influences the teeth 
during the important process of formation, and by preventing 
their perfect organization renders them feeble to resist the in- 
fluence of morbific causes. 

This evil consequence is, however, generally counterbalanced 
by the thinness and deficiency of mucous and salivary fluid, 
and the difficulty with which the fluids of the mouth of stru- 
mous persons become acid. 

Pregnancy is supposed to be fraught with danger to the 
teeth. Indeed, this opinion has been sufficiently general to 
have become condensed into the adage — "for every child a 
tooth" — meaning that the mother may expect to lose a tooth 
as the result of each pregnancy. 

Pregnancy is not disease : it is a physiological condition, and 
we cannot believe that it is per se, and naturally, a cause of 
disease anywhere, especially in organs distant and not imme- 
diately dependent upon the uterus. But in pregnancy, the ner- 
vous system is irritable, and the sympathies of the body are in 
more lively play. The vascular action is also greater, and the 
blood is more highly charged with fibrine. It therefore hap- 
pens that there is more liability to pain then than at other 
times, and less patience to endure it. Consequently, if the 
woman has any diseased teeth, previously neglected, they will 
be apt to ache, and when aching, the pain to her irritable 
nerves is intolerable. Besides this, there is occasionally a 
sympathetic toothache, which, though it cannot be directly 
traced to the uterus, appears to depend upon its gravid condition, 
and not upon disease of the tooth itself. The dentist should 
be aware of this ; it is readily alleviated by an anodyne. 

It also happens very frequently that the artificial life and the 
absurd habits of our young females, induce a constitution but 
little capable of sustaining childbearing, although to the wo- 
man of good health and vigorous frame, parturition is fraught 
with no disadvantage to health or shortening of life. These 
pallid, soft, and delicate girls, when become pregnant, begin 
rapidly to break down, and the hurried caries which destroys 



PRBaNAKCT. 



their teeth is bnt the first manifestatiori of the premature (Jecay 
of the whole body. This is a subject npon which I could ami 
vouM willingly write much, but it would be useless. 

Fashion, custom, inclination, will bear sway over reason and 
moral obligation ; years of comfort will be Bacrificod for hours 
of mirth ; showy dress and ball-room vigils will continue to 
feed the insatiable tomb with the loveliest of our race. 




CHAPTER XIV. 



MORBID KIFKCTS OF CONDITIONS OF THE TEETH AND QDMS, 
UPON TEE GENERAL 8VSTEU. 



I 



Hating conaiJered the several forras of disease m other 
parts, or of the general Bjatem, wliich morbidlj affect the teeth, 
I proceed to inquire vhat effect these latter organs, in their 
varied states, whether physiological or pathological, may in- 
duce in other parts, and what changes they may cause in the 
more general phenomena of vital action. 

As the body is a unit, knit by the closest bonds, pervaded 
by one system of blood-vessels and nerves, directed by one in- 
telligence, and kept in a continual relation of function and 
expression by an all-pervading law of reciprocal reaction and 
otopathy ; as diseases of other parts, and those which in die- 
tinction to well-defined and limited affections we call general, 
arc capable of affecting the teeth, it might be apparent, if we 
had no particular facts in evidence, that the morbid condition 
of the teeth may produce corresponding evils in other parts, 
and may even involve the whole system in troubled and morbid 
action. 

It might also be evident that severe and long-continued pain, 
located in the immediate vicinity of the brain, and in parts 
little accessible to soothing appliances, cannot be less danger- 
ous to health than pain in other organs situated at greater 
distance from the nervous centres and more easy of access. 

It might also be perceived that sensitive organs, in imme- 
diate contact with the great lining membrane of the thoracic 
and abdominal cavities, and intimately connected with it hy 
fuacttOD, cannot be k-sfi capable of propagating disorder to it, 





tlian parts located far from it, and having no immediate rela- 
tion to it. 

Yet natural as these inferences seem to be, they have been, 
nntil lately, almost entirely overlooked, and even now the 
medical profession are by no means awake to the facta and the 
importance of the morbid relation actually existing between 
the teeth and other parts. 

It is exceedingly uncommon to hear that a physician, in 
searching for obscure causes of protracted ill-health, has paid 
any attention to the state of the teeth, though often their ter- 
ribly diseased condition cannot escape involuntary recognition 
by more of his senses than one. The matter is never alluded 
to in lectures delivered to medical classes, and, in fact, ia 
hardly recognised at all ae a subject for pathological or hy- 
gienic consideration. 

Within a few years, however, several writers upon dentistry 
have urged the medical profession to turn their attention to 
the diseased conditions of the teeth in connexion with other 
disorders, and they have supported their appeals with such an 
array of well-observed and clearly narrated cases as must im- 
press the mind of all reSecting readers with the fact of the 
morbid relations in question. 

Unfortunately, these writings are not read by the general 
practitioner, and it is to be feared that a long time must elapse 
before physicians become properly informed upon this subject. 
In the mean time it is the more important that every dentist 
be able to perceive these sympathetic conditions, and call the 
attention of the patient and physician to them. 

The teeth, while in a physiological condition, are capable of 
inducing great local distreaa, and constitutional disorder even 
of a fatal kind. During their evolution and passage through 
the gum, the pressure even of a sound tooth upon a sound 
gum may be attended by irregular phenomena of the most 
alarming description : it would be strange indeed if the action 
of a diseased tooth upon the diseased gum should be attended 
with no evil consequences. 

That tile process of dentition happens in infancy, causes 



MORBID SFFECTS 07 THB TBBTH, BTC. 167 

certainly a modification of effect in accordance with the pecu- 
liarities of the infantile constitution ; but, the action of morbid 
teeth upon the less mobile nerves of the adult may be as cer- 
tain, though less rapid uid ostentatious. 

The question, however, like other medical questions, is one 
of fact, not of inference. And I would leave the truth to be 
deduced from a fair examination of subjected cases. 



168 



CHAPTER XV. 

MORBID EFFECTS OF FIRST DENTITION. 

Dentition is not, in itself, a morbid process, b^t a healthy 
physiological act. It would be strange, therefore, if it neces- 
sarily involved disorder of function and serious consequences 
to the subject. 

The truth is, that when naturally performed, under the favour- 
able circumstances of sound constitution and good health on 
the part of the child, the cutting of the teeth is eifected with- 
out pain or any collateral evil, these organs appearing in their 
place without any previous unpleasant sensations to attract at- 
tention to their progress through the gum. It is thus that the 
domestic animals perform dentition ; and many children com- 
plete theirs with no more perceptible inconvenience. 

More generally, however, the child experiences, at least with 
some of its teeth, more or less suffering of a local kind, and in 
many cases the pain is attended by sympathetic irritation of a 
grave and not unfrequently of a fatal character. 

It is important to know that, however large may be the pro- 
portion of painful, in comparison with natural dentitions, the 
former are nevertheless to be regarded as accidental modifica- 
tions of the regular and healthy process. Starting with this 
knowledge, we will, of course, be led to inquire into the causes, 
so general and so potent, which effect the changes in question, 
and to devise means and management most proper for escaping 
or annulling them. 

Does painful dentition depend upon the pressure exercised 
by the tooth upon the gums ? 

If it did, all children would experience suffering and more 
or less collateral morbid effects. For, although the difference 



MOBBID XFFBCTS OF FIRST DENTITION. 169 

of natural sensibility in different children would occasion dif- 
ferences in the degree of trouble arising from this cause, yet 
this comparative sensitiveness, being merely natural and 
healthy, could not account for the extreme contrasts exhibited 
between easy and simple, and complicated and dangerous den- 
tition. 

Nor is it at all likely that extreme sensibility would escape 
morbid manifestation during the rapid evolution of infantile 
life, until awakened from its passivity by the evolution of or- 
gans themselves not sensitive (in their healthy state), passing 
through structures not by any means remarkable for this 
quality, and performing their eruption so gradually as to make 
no sudden demands upon the nervous and vascular system, so 
as to disturb the equilibrium of nervous and vascular distri- 
bution. 

Nor is it consistent with the facts observed in the history of 
dentition that the cause of the suffering is the pressure of the 
fangs of the teeth upon the periosteum of the alveoli. Those 
who adopt this explanation have not considered that the shoot- 
ing of the teeth, characterized by the enlargement of the alve- 
olar walls, and the distension of the gums occasioned by the 
formation of the body or of the crown of the teeth, is an epoch 
often more dangerous than that of the organization of the 
roots ; which besides would do much more harm in compress- 
ing and binding the soft and pulpy part of the tooth than 
the serous membrane, which performs the functions of a peri- 
osteum and lines the interior of the gum and proper cavity 
of the teeth.* 

The truth seems to be, that a great number of children are 
bom into the world so feebly or disproportionably constituted 
that they are not capable of maturing. Most of these neces- 
sarily perish during childhood, by some of the many forms of 
disease common to that period. Many others, though born 
with sufficient vigour, are reduced by bad diet and defective 
management to a condition which readily yields to irregular or 
morbid agents. 

* Baames on First Dentition. 
15 



170 MORBID EFFECTS OF FIRST DENTITION. 

A child may be very feebly organized, and yet may appear 
for a time plump and healthy, but when the vital powers come 
to be tested either by accidental or physiological demands upon 
its energies, the natural feebleness is ascertained by the de- 
velopment of various morbid phenomena, indicating the parti- 
cular location and kind of disability. 

Again, children born healthy are often subjected to privations 
or to injudicious diet and regimen which rapidly alter their 
fluids and tissues, and lay the foundation for serious accidents. 

Dentition demands a certain amount of constitutional energy 
to accomplish it. The rapid development of any organ does 
this. The changes which take place at puberty, and the evil 
consequences, to the feeble, of the developments then com- 
pleted, are illustrative of this fact. This demand is the se- 
verest test of functional and organic completeness in the child, 
and many will not bear it. 

The development of the teeth determines an unusual flow of 
blood to the head. This happens at a time when the brain is 
proportionately large, and undergoing rapid evolution. Inde- 
pendently of dentition, this period of life is attended by a 
strong tendency to cerebral affections, and to pulmonary and 
abdominal complications. The nervous and vascular systems 
are, in the child of this age, remarkably active. The several 
organs have to perform not only their functions and the pre- 
servation of their entireness, but also rapid growth. Animal 
life is therefore exalted with all its qualities. Among these 
are sensibility and sympathy ; the capacity to be impressed 
and to propagate impression. Hence a slight cause may pro- 
duce great local or constitutional effect, and disease of any 
kind may induce sympathetic or constitutional disorder appa- 
rently much out of proportion to its own intensity or import- 
ance. 

In the older child the relation of secondary to primary affec- 
tions is more equable, and the second dentition is performed 
without the occurrence of those serious constitutional affiections 
which so frequently attend the first. 

Any unnatural obstacle or impediment to the eruption of the 



MORBID EFFECTS OF FIRST DENTITION. 



171 



I "first teeth, will tend very materiallj to angment the probability 
I of morbid conscqaencea. A disproportion between the teeth 
I BB(1 the jaw, or the unusual hardness and impenetrability of 
I tiie gam, arc of this nature, and sometimes provoke local and 
I irjmpathetic disturbance. 

The appearance of several teeth at once may make a larger 

I demand upon the system than it can readily meet, and hence 

embarrassment, or if their dentition be painful, the 

I amount of suffering may be too great for the sensitive and 

lympathetic nature of the child, especially if it be constitu- 

} lionally feeble. 

The natural symptoms of healthy dentition, are not remarka- 
I Ue. An increased flow of saliva is usually noticed, though this 
I perhaps, is not as certainly the consequence of dentition as is 
\ generally supposed. The mouth of infants is generally well 
I Mpplied with fluids, which, there being no teeth to prevent it, 
r will escape more or less from the mouth. The child also car- 
) its fingers to the mouth more frequently, and seems pleased 
(to press a resisting substance between its gums. Gentle fric- 
tion of the gum also seems to be agreeable. The gums arc 
noticed to be hot, and the child takes the breast frequently. 
Tho bowels are generally looser than usual, and the child ordi- 
nftrily manifests some little restlessness and sleeps less pro- 
foundly than previously. 

These symptoms precede the eruption of the teeth by several 
weeks, and seem to depend upon the rapid ossiScation and 
growth of the teeth. After a few days, they often subside, to 
be renewed when the teeth are pressing forward and about to 
penetrate the gum. 

It is common to alleviate these little inconveniences, by giv- 
ing the child a coral, crust of bread, or other hard substance, 
to press npon with its gums. 

Nature is generally a very correct guide as to her own wants, 
and as it is natural thus to allay tho 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. 




I m raei vtmrmoa. 



m &■» w( indioated Aa pnaose degree of 
r fmrfost, it woiM be md «• bm snb- 
I this qoalitjiB : 



t it Sftrah roaltoiTB, or Bqnorice root 

i decootioD of barlej — the Ger- 

fc m^ snd apices. It is doubtfal, 

B «f tUs inTeDtion for qaieting the 

f «r mother to neglect it, and 

»viliiAi>k ivmUttke eagerly anc] frequently. 

c tft»- ihAn« ae lbs frequent lubric^tioo of 

. -nai. »nd where Dothing in the 

■ iKr condition of her breast for- 

and unD&taral 1* <i«cT it. It 

i[ use of 8we«« aad wgweBt»l 

-toRinch of tke eUU ; att aeddent 

11^ teething. 

. MTsIly loose during dentitioB, and even 

'tTV fr*qu*nt we must not consider it ex- 

! A nurses freely, and cspeciaHy while it 

nil more to be feared under such circum- 

■ ,;. It IB unnatural, and unless overcome 

M will result in irritations, local, and per- 

ilitL'h may not easily be remedied. 

itant to restrict a teething child to proper 

ntcls may very readily be irritated, and the 

a u> violent excitement at this time that all 

J bo dreaded, especially irritation of the abdo- 

i Uw uio»t important part of a child, being the 

%^ji uutivo processes of nutrition and augraenta- 

V ^i'WOif Wi. This IB no time to try experiments 

Nuirttious and easily digested food, and 

I ftw*i» aoidity, is to be given, and in BucL 

■^ ' 1 i» nUling to take. Unless, indeed, it 

med and taught to cat an unna- 



MORBID BFFBCTS OF PIR5T BElfTITION. 178 

When the mother has milk, this is, of course, the best food 
for the infant, but it will generally happen that the child will 
require more nourishment than it can obtain from this source. 

In selecting food for it, regard must be had to the condition 
of the child. If delicate and thin, animal food will often be 
indispensable. Beef, mutton, and occasionally a little salt 
meat may be given with advantage. Young meats are gelati- 
nous and less digestible, and should be avoided. 

If the child, on the contrary, be too fat, if it has been over- 
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. Farina- 
ceous articles well diluted with water will be more suitable. 

Milk, if fresh and sweet, generally agrees well with children ; 
but the milk of the cow is more nutritious than that of the mo- 
ther, and should be diluted. Cream freely diluted with water 
generally agrees better than milk. 

It is common among the rich to thicken the child's milk with 
arrow-root, toiis les moiSj or other concentrated farinaceous 
food. The consequence generally is that the parents are en- 
abled to rejoice over fat babies, and soon to sorrow over sick 
ones. Instead of making the milk of the cow more nutritious, 
it should be rendered less so than natural. It is rarely that 
articles of this kind, even when they are what they are repre- 
sented to be, are fit for children. But this is rarely the case. 
Most of the arrow-root, &c., of the shops is potato starch."*" 

Some parents are in the habit of refusing children flesh of 
all kinds, and indulging them freely in milk and potatoes. The 
result generally is to fatten the children excessively, without 
providing them with a proportionate amount of muscular fibre. 

The child should have as much exercise in the open air as 
the circumstances of the parent will admit. All kinds of ex- 
ercise seem to do it good. It is seldom fatigued even by very 
long rides, and rarely fails to acknowledge, in its altered ap- 

* If the mUk require the addition of anj farinaoeoiu substanee, I prefer 
rice floor. 

15* 



MORBID EFFECTS OP FIRST DENTITIOH. 

pearancc, tho good effect of even an hour's exercise In tlic 
fiehls. 

Frequent bathing is of great use to children of all ages, but 
even thia means requires to be administered with judgment. 
The cold bath is a powerful rcmedj, and cannot be used with 
equal safety and advantage upon all children. Those who are 
ruddy and robust will boar it vroll ; 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 reraains 
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 
wanned 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. Tho local symptoms are to 
be allayed, serious symptomatic affections arc to be relieved, 
and the strength of the child to be supported through a tedious 
process, in which the powers of the system arc 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 arc, first, inflammation of the 
gums. These are swollen, hot, redder than common and very 
sensitive. The child will not permit them to be touched, and 
incessantly craves the breast, or cold liquids. The condition 
of the gum is almost always attended with more or less fever 
and irritation of the intestinal canal. There is also an evident 
determination of blood to the head. The face is flushed, the 
head hot, the eyes red and watery, tho flow of saliva profuse, 
and sometimes tho salivary glands arc swollen and tender. 
Aphthous exudations are often noticed, and it is said, though 
this must be very uncommon, that abscesses sometimes occur 
at the root of the tongue. 

The fever is generally ardent, and increases and subsides 




with remarkable suddenness. Tlie tbirst attending it is verj 

great, and a strong tendency to irregular muscular contrac- 

liona or convulsion is generally observed. The sleep of 

\ the cliild is uneasy and frequently interrupted. It often 

j.Rtarts and screams, and when awake is usually fretful and 

l-Vtupid by turns. 

These symptoms are often very suddenly and effectually 
f allayed by freely incising the gum and capsule down to the 
Ltooth or teeth, and liberating them from tfaeir investments. 
K^niis expedient is generally resorted to whenever the gum is 
T" elevated and distended; sometimes, however, it is of no avail, 
I i«ther because it is not effectually done, or because the symp- 
I toms to be relieved do not in fact depend upon the more me- 
1 shanical pressure. 

The French writers make a formidable matter of this little 
i operation; and indeed, as practised by some of tbcm, it is no 
I .trifle, for they make a crucial incision upon the tooth and Aia- 
I ,iect up the flaps of the gum, or else, with a bistoury, completely 
I cat ofl" the top of it. 

There is no necessity for such painful and protracted opora- 
k lions; a free incision, until the lancet grates upon the tooth, 
I JB all that is necessary for the incisors ; and when the double 
1 teeth are in question, a cross incision may be added. 

The lancet should be carried down to the tooth, or else no 
I good will be done. 

The bleeding which results Is triSing and salutary ; tending 
I to relieve the inflamed and swollen gum. 

It has been objected to this operation, that unless the tooth 
ihonld be very near the surface, the incision would heal and 
tho cicatrix would offer more resistance than the original struc- 
ture of the gum. 

The fact is, however, that if such a cicatrix should occur, 
, and the symptoms return, it would be very easy to divide the 
[ gum again ; moreover, a cicatrix is always a feeble tissue, 
[- which is far leas resistant than the natural part whose loss it 
I represents. 

Conjointly with the use of the gmn-lancct, attention must be 
paid to the bovrcla of the child. If it be costive, the torpor of 



176 MOBBID UFECTS OF FIB8T DBRTITION. 

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 
eifect insured by the subsequent administration of castor oil or 
magnesia. 

Small doses of calomel are ineffectual, and, if frequently 
repeated, are dangerous. 

Should the bowels be too loose, and the passages thin and 
white, the same medicine, similarly administered, or joined to a 
little rhubarb or chalk, will generally check the diarrhoea. 

In these cases, as where constipation exists, the fault seems 
to be in the defective or altered secretion of the liver, which 
calomel restores. 

The fever will generally abate in proportion as the bowels 
are put right Should it continue ardent, however, and 
especially if the cerebral plethora should increase or remain 
unabated, a few leeches behind the ears will often prove ser- 
viceable. 

The cold bath, or sponging with cold water, will also allay 
the fever and restlessness. The warm bath may sometimes be 
preferable, and will be equally serviceable. Above all, country 
air, and exercise out of doors, are the best means of combating 
the disorders of dentition. 

"Very different," says Mr. Jay,* "was the practice of our 
forefathers, who, misled by the fanciful doctrine of signatures, 
were in the habit of applying to the gums specific ointments 
made of the brains of hares, or of the combs of cocks, which 
as old Hartman would have us believe, ^ cause the production 
of teeth without difficulty, and free from accidents.'" 

* Cjdop. of Prme. Med^ Art I>eiititioii. 



HOBBID EFFECTS OF FIRST DENTITION. 177 

It is questionable whether we have much right to laugh at 
the metaphysical medicine of our ancestors: certainly our 
posterity will find abundant occasion to ridicule our own. 

We have yet to learn that any ancient theory or practice of 
cure was more utterly absurd than Homoeopathy or the cold 
water treatment. The doctrine of signatures is quite as philo- 
sophical as Mesmerism, and the combs of cocks and brains of 
hares are certainly as efficacious as Hahnemann's dilutions. 

Among the local diseases of complicated dentition we must 
enumerate caries of the tooth and abscess of the 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 ten- 
der ; an eiTusion of fluid takes place between the fang and its 
mvesting 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 efiiises its contents through the aperture thus formed, and 
the matter insinuates itself along the surface of the lower jaw, 
and forms an internal tumour near its base. This tumour is 
at first hard and discoloured, but in the course of time it ulti- 
mately inflames, and bursting or being opened, leaves a pucker- 
ing in the integument, which, adhering to the bone, remains a 
permanent blemish. When the diseased tooth, which is the 
cause of the mischief, is removed before external redness 
takes place, the tumour ultimately retires, and leaves the skin 
unblemished."'*' 

A spongy condition of the gums, in which they bleed freely 
at the slightest touch, is sometimes observed in dentition. 
Ulceration sometimes attends this condition. Weakened 

* Goleys' Diseases of Children. 



178 



MORBID EFFECTS OP FJBST DENTITION. 



digestion, and consequent imperfect preparation of chyle and 
insufficient nutrition, maj bo considered the cause of this 
affection. 

Treatment. — Inflammation of the gum may be very mucb 
abated by tbo application of a leech to it. In order to do this 
with facility, a thread may be passed by a needle through the 
extremity of the animal, and it then may be enclosed in a glass 
tube. When the inSammation has subsided, the canons tooth 
should be extracted. 

Should an abscess occur from a similar cause, extraction 
must also he resorted to. 

Sponginess and ulceration of the gums, depending upon a 
depraved digestion, must be mot by such means as will restore 
the alimentary canal to tbo regular and complete performance 
of its functions. 

Mild astringent lotions, such as myrrhine and alnminous 
solutions, may be simultaneously employed. 




I 

I 



EYMPATHBTIO DISEASES OF DENTITIOH. 



A VAST number of diseases hare been described by different 
authors, as the resulta of dentition. The recapitulation of 
them would ahow a crowp-ded list of formidable complaints, from 
which it would seem that no child could escape. Dentition 
appears in this oshibition as the Pandora's box from which all 
manner of erils are successively let loose to worry and destroy 
the devoted infant. Without pretending to enumerate the 
forms of disorder attributed to teething, I offer the following 
as a specimen : Vomiting, anorexia, diarrhoea, cholera, costive- 
nefis, increased or diminished urine, urethral or vaginal dis- 
cbarge, with painful micturition ; dry cough, dyspnoea, catarrh, 
pneumonia, spasmodic affections of the face, limbs, glottis, kc, 
insomnia, agitation, and fright on awaking; epilepsy, somno- 
lence, Btertor, coma, transient palsy of the arms and legs, 
ophthalmia, hydrocephalus, marasmus, eruptions, especially 
about the head and face, swelling of tbe bands and feet, en- 
largement of tbe cervical, femoral, and mesenteric glands, and 
other scrofulous affections. 

Although any of these disorders may, and all of them do 
occasionally occur during dentition, it does not by any means 
follow that teething is the cause of them. The mucous mem- 
branes of children are very liable to inflammatory affections, 
and their brain is very liable to sympathize with these and 
Other disorders. Moreover, the process of dentition would 
certainly afford an awkward complication to any of these forms 
of disorder occurring simultaneously with it, or provoked by 
accident during the progress of teothing. No doubt, also, den- 
tition itself, especially if obstructed, or otherwise irregular or 



■Rating MUse of anj doordET to 
w ^Bt hippen to be most pr<]c«^ 
s of s 



It should be reignlBtad by dw am- 
fmm^ aMd the jadgment of Am f kj m aa n. 
enuBtne tite gmas ttsn- 
K ftovtjT if the; be at an swollen. This 
■Munea irill result rery hnppQ/. 
■ost frequentlj, the moeooa oiEeetaoos 
kot eoDsbt in a kind of nortlidlj m- 
I we call irritatioa. The irritability 
■< TUfditing and purging are freqaentl; of 
ji^ only be aggravated br antiphlogistic 

fc a»p«cislly calomel, proper food, and Buf- 

dl b* fband to accomplish all or nearly all 

t Aa relief of such conditions. 

. >t Kcoinpanies dentition is also doe to the 

i^Mtw membrane, and needs no special treat- 

-; r»r«i'titioner must be careful, however, not 

vith proper catarrh or pneumonia, 

' »>*viTo pulmonary disorders, which re- 

::il vigorous treatment, and which it 

'.'1 often fatal to neglect. 

li'', the cjuick, short respiration, the 

^■'A the indescribable, yet intelligible ap- 

iUt) jtationt, will render mistake entirely 

ii>lication of dentition is undoubtedly 
, which has acquired the name of 

11 hot weather, and is almost pecu- 
^ :i-08 of it, however, occurring in 
the country, are sufficient to show 
I'ctident simply upon the beat of 
^hl is very much greater than ia 



STMPATHKTIC DISEASES OF DESTITIOS, 



I 

L 



oy i wtced in rural sitnatioDS, onlesa very unfavourably cir- 

This disease seems closely connected with dentition, for 
altliough Tery young infants may be attacked by it, they are 1 
by no means so liable as those who have completed their first ' 
year. Hence the familiar danger of the child's "second 
summer. " 

The disorder uanally commences by purging; frequently as 
the immediate consequence of some indigestible substance taken 
into the stomach, but often without any known exciting cause. 
The matters passed at first are light green — presenting some- 
what the appearance of chopped grass, and gradually becoming 
paler until they are of an extremely pale yellow or absolutely 
white. Vomiting, especially after swallowing liquids, gene- 
rally attends the diarrhoea, and commonly fever of a fickle 
fluctuating character also occurs. 

The child emaciates very rapidly, and in a few weeks or 
days will be reduced to a mere skeleton, and he too feeble to 
stand alone. The brain and nervous system become torpid, 
the muscles relaxed, the child somnolent and stupid, and death, 
from cerebral congestion or convulsions, closes the scene. 

The disease is sometimes acute and rapid in its development 
and progress, at other times chronic. The only medicinal 
agent which is uniformly beneficial in this disease is calomel. 
The nature of the alvine discbarges evinces a deficiency or 
entire absence of btlious matter. A full purgative dose of 
calomel rarely fails to restore this secretion, and all the symp- 
toms are alleviated by it. 

From the fact that this medicine can be given in smalt bulk, 
that it is almost tasteless, and that it will remain in the sto- 
mach which rejects all other drugs, it is peculiarly adapted to 
the condition in question. As this adaptation makes it the 
most available, it is exceedingly fortunate that its medical < 
qualities make it by far the most eflicient 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 he gained 



SYMPATHETIC DISEASES OP DENTITION. 



by this procedure, tliere ia risk incurred of mercurializing the 
child ; which would generally be fatal to it. It is true that 
this rarely occurs ; but some children have a peculiar constitu- 
ttooal susceptibility to mercurial action, and it is better to risk 
nothing unueceasarily in this respect. 

The dose which experience leads me to employ, is from five 
to ten grains, according to the age of the child and the condi- 
tion of its sensibility. It may be repeated several times within 
a week or leas, if necessary. 

Alkaline medicines, soda, potaasa, magnesia, and chalk, &re 
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 
vhich no other treatment will afford. It quiets the stomacb, 
soothes irritation, checks the diarrhoea, and gives refreshing 
sleep. 

The great difficulty in the treatment of this disease arises 
from the fact that it ia the result of causes which continue to 
act ; ao that the disorder is constantly reproduced. 

These causes are heat and dentition ; and it is often impos- 
sible to cure the child while the causes continue to act. 

In large, well-ventilated rooms, it is often possible, even in 
cities, to procure for the child a temperature which is salutary; 
but even under these circumstances it is not always possible to 
do 80. When, therefore, the little patient is the child of 
poverty, imprisoned in the small room of a small house, flhut 
up in a court or alley, it is almost impossible to rescue it from 
death. 

The most certain of all remedies is to take the child to the 
country. There proper medical treatment will rarely, or never, 
fail to cure the disease. Children in apparently the last de- 
gree of prostration are sometimes revived as by miracle, by 
the cool air of the country. 

But when we say country, we do not mean a. hot room near 
the roof of an unshaded tavern fronting on a turnpike road, 
where numbers of sick children are shut up together, in a tem- 
perature perhaps higher than that of the spacious city man- 



ETMPATHETIC DISEASES OF DENTITIOH. 



183 



s from which they have been hastily removed. Shade and 
Lpeen grass are essential. There mast bo no bare surface to 
trdect the heat, and there must be shade where the child may 
W'he exercised, and where it may be conveyed in the middle of 
■ tii« day, when country houses are as warm, and often, from 
their sixe and construction, warmer than city dwellings. 

Convuhiong very frequently occur during dentition. They 
are of an epileptic character. The symptoma arc a fixed atarc 
and of^n distortion of the eyes, insensibility and frequent 
irregular contraction and expansion of the muscles, generally 
of the limbs and face. The jaws are firmly clenched, and the 
saliva is ejected in froth from the lips. 

This is a very frightful and generally very alarming affection, 
though not very often fatal. 

I, Convulsions during dentition may be excited by several 
«ftiises. The first and the most common is the eating of crude 
ted indigestible matters ; secondly, fever ; and thirdly, the 
friitation of the teeth themselves: often two, and sometimes 
tfl three of these causes act together. 
The convulsion generally passes off in a few minutes, but 
Wtother will occur unless the cause be removed. Sometimes it 
irill 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 
sot speedily accomplish the end, more active means must be 
used, and such as look to the removal of the cause. 

If spontaneously, or by use of the bath, the convulsion sub- 
sides, we should carefully inquire into tho cause of it. If the 
child has recently eaten anything, it should be immediately 
Tomited, and indeed this can rarely be amiss, for it is often 
impossible to elicit tho necessary information, until the pre- 
sence of the ejected matters exhibits the cause of irritation. 

If the child have fever, it should bo bled, in order to relieve 
the brain, which is suffering from the rapid circulation of blood 
through it. This may bo done either by the lancet or by 
leeches. 

If the gum be swollen and tense, and the child secma to b 



i: 



I 



SYMPATHETIC DISEASES OF DENTITION. 

suffering from ttia cause, a free incision will often relieve the 
tendency to Bpasm, by allaying the local, and with it the cere- 
bral irritation. 

Finally, if the child be costive, its bowela should be imme- 
diately opened by injection, and subsei^uently by a purgative 
dose of calomel. 

Dr. Underwood describes a peculiar swelling of the hands 
and feet as a casual attendant upon dentition. He considered 
it, however, as rather beneficial than otherwise, as it ceased 
spontaneously with the appearance of the teeth. 

Oatatieoiis eruptions frequently occur during dentition, but 
they are of little consequence, as they spontaneously disappear, 
and, in some instances, may bo considered as a salutary diver- 
sion made by nature for the relief of the brain. Sometimes, 
however, they arc so disagreeable, that some efforts are de- 
maniied for their relief. Most, or perhaps all of them, occur 
independently of dentition, and as a description of them would 
bo tedious, and without plates, unsatisfactory, and as they are 
all fully described in works specially upon this subject, it will 
only be necessary to do little more than name them here. 
The curious student may seek further information from writers 
upon cutaneous disease. 

The principal varieties are, an erythematous efflorescence 
behind the ears, called, in medical language, intertrigo ; crusta 
lactea ; the seyeral varieties of strophulus ; small phlyctence, 
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 difBcult 
to show that they are necessarily connected with the catting 
of the teeth. 



This 13 a kind of erjtbemic 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 eiich other, the result is fre- 
quently a very ugly superficial ulcer. The disease can be 
readily cured by the use of absorbent or "drying" powders. 




Ali moUt applications do harm. A most valuable prescription 
for (Iiis 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 npon 
the sore bj 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 np these eruptions, but, according to ray observation, there 
is no ground for this supposition. 

This eruption appears with white vesicles, speedily passing 
into dark-coloured scabs, itching and ichorous, and frequently 
covering a large part of the face, head, and sometimes other 
parts. 

The eruption is very ugly and unpleasant, but ia rarely in- 
jurious to the child. The little patient is generally plump and 
hearty. Indeed, the disease seems rather to depend upon a 
plethoric state, than upon any morbid condition of an impor- 
tant nature. The teething is not impeded by it. 

Crusta Lactea is often obstinate and of some months' dura- 
tion. The only serious attendant upon the disease is the itch- 
ing, which is sometimes bo .innoying to the child as to canse 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 euro this affection the better. 
Time will certainly restore to the child its natural skin ; medicine 
might, and if persevered in, would destroy its appetite, tease 
its stomach, enfeeble its health, and, after all, produce no 
[ect upon the eruption, except, perhaps, to make it worse. 




JSS SEMPIXHRIC DISEASES OF DESTITIOX. 

OHHti of red or white &nd itchj* papols evolveil upon the 
&•■ aad lower limbs, disappe&ring nnd retomiag, and endiog 
gHMimllj in the throwing off of a kind of powder; desquama- 

The papulae 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 InUrtinctut 
(Rayer.) 

When the papulie are white, large, and without surroanding 
redneBs of the base, the affection is called Strophulus Candidut 
(WUlan.) 

When the papuire are very thick, smaller, and confluent, 
Willan calls it Strophuiiii Gonfertas ; and finally, S. Volati- 
cu», when it occurs in circular patches, or clusters, here and 
there, on the surface. All those forms of strophulus may affect 
the child at the eanie time. 

It is not by any means a serious affection, though it some- 
timea torments the child by the itching it causes. To allay 
this, we may use the cold or warm bath, purgatives, and cool 
dressing ; for the sufferings of the child may be very unneces- 
sarily aggravated by warm clothing, especially at night. 

The disease spontaneously declines, in a few days or weeks, 
leaving behind it no traces of its previous existence. 

Pblifctena, are vesications or blisters of different sizes, re- 
sembling scalds or burns. They soon disappear, and require 
no special treatment. 

There are a number of rashes seen during dentition, which 
it is not necessary for us to describe particularly. Scrofulous 
children are subject, during dentition, to the lymphatic disor- 
ders peculiar to their constitution, such as is manifested by the 
swelling of the cervical, inguinal, and mesenteric glands. 

The treatment of these, and kindred affections, must turn 
upon the means of invigoration previously referred to when 
considering the constitutional vice upon which they depend. 
Proper nutriment, exorcise, clothing, kc, will do all that can 
be expected from external agents. 




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 heing 
often crowded, not unfrequently occasion a great deal of sufFer- 
ing, such as acute local pain, inflammation of the gums and 
adjacent tissues, fever, violent headache, ophthalmia, &c. This 
eaSering has often been mistaken for that accompanying other 
affections, such as neuralgia, intermittent fever, and rhenma- 
lism. Abscesses near the angle of the jaw may occur under 
these circumstances. 

Of course the treatment would be to liberate the impeded 
tooth by a free incision, or even, under certain conditions, 
to extract it. The inflammation of the soft parts must be 
combated, if necessary, by antiphlogistic means. 



A number of well- authenticated cases of partial and even 
complete dentition, occurring in very old persons, are recorded 
in the books. In one instance recorded in the Edinburgh 
Medical Com., vol. iii., the subject of this late teething suffered 
very severely. 

The patient, in this instance, was sixty years old, and en- 
tirely toothless. At this time he experienced very severe pain 
in his gums and jaws, which at length amounted to excruciat- 
ing torture ; but at the end of twenty-ono days from the be- 
ginning of his sufferings, he was compensated by the appear- 
ance of a complete new set of teeth. 

With regard to the constitutional effects of this abnormal 
dentition. Prof, Harris, who relates two cases of this kind as 
having occurred under bis own observation, remarks : " It 
would seem that the efforts made by nature for the production 
of a third complete set of teeth, are usually so great, that they 
exhaust the remaining energies of the system ; for occurrences 
'3 kind are generally soon followed by death." 





CHAPTER XVII. 



! OV OISBASED TEETH AND QUM8 UPON ADJACENT TaRTS 
ASD THE GENERAL ST8TBH. 

"ElUT diaeased conditions of the teeth and the stractnres 
t^ttaat to them, do exert a moat pernicious influence upon 
tte giaiieral health, is a, fact as well established as an; other 
m/dtcal ubaerration ; yet the medical profession are, apparently 
i«lh wry few exceptions, entirely unaware of it. 

I ■■■ not apprised that the subject is ever alluded to by lec- 
lancs on the practice of physic, when recapitulating to their 
«|mm» tba causes of functional disturbance and constitutional 
MAtin^ ; it is not noticed in the many text-books on practice ; 
•wit cartainly, however frequently the physician may look into 
ths Btouths of his patients, it is very rarely that his compre- 
VMsive glance perceives anything worthy of note in the de- 
Ql^iag organs of mastication. 

It 13 full time that practitioners of medicine should perceive 
the importance of the teeth and of their diseases ; but, until 
tbey do so, it ia the more important that the dentist should he 
able to point out the causes of obscure disease, which the phy- 
siinaii has in vain endeavoured to discover, simply because he 
llH sought for it everywhere but in the right place. 

tl iMi^lit be granted, a priori, that if physiological conditions 
^ %h* l««tb, owing to their peculiar position, association, aad 
tebtC't *i*y exercise powerful influence upon the health of 
^i^K 4()t«a». pathological conditions of these same teeth can- 
«^Vi MUnly harmless. 

l^Mfc VI «« would examine the structure of a tooth, and 

t Wv completely its sensitive part is enclosed in an 

I ^Miy owe, we might readily infer from the consc- 



EFFECTS OF DISEASED TEETH AND QUMS. 18d 

quences of compresaion in other parts, that the swollen and 
inflamed pulp, &c., would bo exceedingly painful. If, too, ve 
Hould regard the close connexion existing between the teeth, 
the rapidity with which the flash of sympathetic pain darts 
along ibo nervous corda that vitalize them, and the intolerable 
and protracted suffering which ensues, upon even trifling irrita- 
tion of these sensitive filaments, and remember that pain itself 
IB fully capable of deranging the whole economy, and inducing 
serious and fatal disorder, we might, without the aid of much 
reflection, adopt the very rational conclusion that the diaeasea 
of the teeth must bo of considerable consequence to the entire 
organization. We might, also, with similar propriety, conclude 
that the teeth were not made merely for ornament, and that 
mastication and insalivation are something more than mere 
forms of introduction to the stomach ; that they are important 
to digestion, which is important to the entireneas of organs and 
the performance of function, and that if mastication, and the 
insalivation accompanying it, bo imperfectly performed, some 
corresponding imperfection of digestion must result. We 
might also infer, from the known consequences of long-con- 
tinued morbid influences, however unimportant in their imme- 
diate action, that disturbance of djggptlon, constantly repeated, 
must, in time, develope evils of a serious character. 

The old pathological maxim, " ubi irritatio ibi fluxus,""' is 
fraught with a valuable lesson to the medical practitioner. It 
is true that the nervous, and to a, certain degree, even the vas- 
cular forces hurry to the part which throws out the signal of 
distress, and all the floating energies of the system are directed 
to the relief of the sufi'ering. If it can be readily accomplished, 
the equilibrium of the body Is soon restored, and no perceptible 
inconvenience results. But if from the impracticable nature 
of the tissue or organ affected, but little relief can be given, 
and if the efforts of nature to accomplish cure or removal of 
the part, end only in accumulating about it an uncommon 
amount of sensibility, increasing the irritation and demanding 

* " Vhere thera is irrilatisn, t« tlitt part will be the flow." ^^M 

I i 




EFFECTS OP DISEASED TEETH AND ODMS. 



yet more of constitutional effort to combat it, the consequence 
mast be such a diversion of nervous influences from other parts 
to weaken their force of action, and to embarrass their 
^.£uictions. 

In short, it is easy to nnderatand that when the first move- 
ment towards constitutional deraogement has been made, if the 
cause continue to act, each accession of morbid condition must 
aggravate and extend the evil, and hence it is that causes in 
themselves very slight may, if long continued, from the influ- 
ence of sympathy and the accident of relations, induce morbid 
conditions of the most serioua character. 

The remarks of Mr. Koecker upon this point are so sensible 
and BO well expressed, that no apology will be necessary for 
introducing them here at some length. 

Mr. Koecker observes that, " to form a more distinct con- 
ception of the very powerful morbific influence which the dis- 
eases of the teeth and their contiguous parts must unavoidably 
produce upon the general constitution, it is necessary to con- 
sider the peculiarity of the structure and functions of these 
parts. 

" The extremely hard and dense structure of the bony parts 
of the teeth, and the great arterial activity and nervous irrita- 
bility of their lining membranes, which can so powerfully, and 
for BO long a time, defend the teeth against general local and 
morbid influences, are also causes of their producing very ex- 
tensive morbid effects upon the whole system. The functions 
of the teeth as well as of the gums, when in a healthy state, 
act as powerful stimuli towards their preservation, but when 
these parts are diseased or affected with disorder of any kind, 
they become constant causes of irritation upon them as well as 
upon the general health. The bony structure of the teeth, 
however, having in itself but little self-restoring power, and 
their peculiar functions being much less favourable to this na- 
tural process than those of any other part of the body, and the 
teeth and their gums, periostea and sockets, being altogether 
^ dependent upon each other, this power is much more constantly 
■ and in a much higher degree required, and seems to be much 



KFFECTS OF DISEASED TBETU AND GUMS. 



more exerted by these than by any other Btructurea ; 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, 1^'htlst at the same time a conside- 
rable portion of general health and strength is consumed in 
the struggle. 

" Diseases in the bony structure, and indeed of the teeth and 
gums generally, when yet in their incipient stage and without 
being influenced by any other causes than the local disorder 
itself, produce no greater constitutional effects than other local 
maladies ; but with this difference, that their self-curative a(^ 
tion is exerted in a proportion corresponding to the peculiar 
structure, functions, and relations of these parts, and therefore 
comparatively much greater and longer continued than that 
produced by diseases of other parts or bones. In this state 
they proceed very slowly, and their morbid effects can only bo 
detected by the most minute attention. 

" The general system, however, in the mean time being often 
disturbed, the caries will be found to proceed much faster to- 
wards the cavity of the teeth, and the inflammation of the 
gums to increase. In that event, any constitutional disorder 
is competent to aggravate the local one, whilst the latter, also, 
in its turn, greatly excites and augments the farmer. 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 
destruction of their lining membranes, are not only rendered 
useless, but arc converted into lifeless incumbrances upon the 
system, which produce, by their mechanical and chemical irri- 
tation, an action similar to that effected by gangrene or morti- 
fication in other bones, by means of which, nature attempts to 
throw off the dead part. 

"The parts surrounding such dead teeth, viz. : gums, perios- 
tea, sockets and maxillary bones, are thus involved in serious 
disease, inflammation grsduatly extends over the whole of these 



192 



EFFECTS OF DISEASED TEETH IITO OUMS. 



parts, om.1 a strong effort appears to be made to effect llie ex- 
pulsion of the decayed teeth, now become dead and offending 
bodies. But although nature mtglit succeed in thus remoTing 
almost any other soft or hard part of the body of equal dimen- 
sions, in a few weeks or months, a space of from five to ten 
years, and somotiraea a mach longer period is required for the 
removal, by the same natural power, of a. dead tooth. 

" As long as tbo primary diseases arc principally confined to 
the teeth themselves, and in these instances where they are the 
proximate local causes of diseases of the mouth without sup- 
posing the existence of many dead stumps of teeth, so lottg 
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 origioally commenced in the gums, periostea, 
alveoli, and maxillary bones, shall have extended to s certain 
degree, a total transition into a permanent chronic state of the 
disease takes place. 

"In such a, state of disease nature seems exclusively and 
actively engaged by producing inflammation and suppuration 
in extricating the mouth from all the morbid causes affecting 
the diseased parts, such as dead roots and stumps, tartar, and 
teeth which are loose or irregularly situated. The sanative 
power of nature being, however, very rarely competent to 
effect such a cure, the various diseases of the gums, periostea, 
alveoli, and maxillary boner 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 m the progress of disease, the sensibility of the parta 
a much d.mmished ; the gums and periostea arc thickened and 
callous, and the continual discharge sufficiently depletes the 
vessels, to reheve them of the suffering inciden!, to inflamma- 
tory engorgement. All resistance to devastation of the dental 
areh seems to cease, and the parts are abandoned to rapid de- 
struction. In the mean t.mo the patient congratulates himself 



• Koeoker, PHno. Donui 9 




EFFECTS OF DISEASED TEETH AND GDJIS. 



193 



that his teeth have ceased to ache, and consequently gives 
htmseir no trouble about them. Inflammation, suppuration 
and caries now spread along the dental arch until every tooth 
is hroken down and every root has become a permanent irri- 
tant, provoking a constant purulent discharge from the soft 
parts about it. 

The food is no longer chewed, and everything which passes 
through the mouth is mixed with a vitiated compound of saliva, 
tnticns, pus, and blood, which descends to the stomach to mingle 
■with the gastric juice, and deteriorate the quality of that most 
important fluid. 

The absorbents, too, are constantly at work, and the dis- 
solved fragments of carious bone, &c., are continually thrown 
into the current of the blood. 

The alveoli cannot escape the general ruin. Involved in the 
alt-pervading inSammatton, they also suppurate and break 
down, and not unfrequently the maxillary bones and the an- 
trum are also involved in disease. 

Dyspeptic symptoms, marasmus, cough and other pectoral 
symptoms, violent neuralgic affections of the face, great 
nervous depression, hysterics and hypochondriasis, may be 
expected to attend such conditions of the teeth. 

The dyspepsia is easily accounted for. In the first place, 
the food is badly prepared for the stomach ; 2d, the fluids of 
the mouth, constantly trickling into the stomach, impair its 
tone and vitiate its solvent secretion; and 3d, the continual 
demand made upon the system by the vain efi'orts which nature 
makes to cure the diseases of the teeth, and also by the fre- 
quent and severe pain, diminishes the nervous influence which 
the stomach receives, and impairs its powers. 

Every one is aware that when the stomach is full, there 
takes place in that organ such a concentration of nervous 
energy as is sensibly felt by its loss in other parts of the 
body. Hence the drowsiness and the indisposition to mental 
and physical effort experienced after a hearty meal. 

It is also well known that anything which attracts from the 



k 




EFFECTS OF IHSEASED TEETH AND GDMS. 



etomacli this accumulated nervous power, impairs appetite and 
digestion. 

Estraordinary emotions, powerful intellectual efforts, vene- 
real excesses, &c., all act in this way upon the digestive appar 
ratug. Tain, also, wlioreVer located, produces a similar effect, 
and the impairment from this cause will be important in pro- 
portion to the frequency and continuance of the suffering. 

In these several facts wo 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. 

Covgh and olher pectoral symptoms, may result as the con- 
sequence of any prolonged irritation, especially if digestion be 
impaired. The mucous membrane of the larynx, trachea, and 
lungs sympathizing with similar structures, and participating in 
the common defect of nutrition. 

Neuralgic affections of the face, head, and ncek, are occa- 
sioned by the continual irritation of the extremities of the 
dental nerve, and the propagation of it to the trunk and 
branches of the great fifth pair, or trifacial nerve. 

Depression of spirits, hi/sterics, and hypochondriasis, result 
from continual nervous irritation, and the debility of nerve 
which results from long-continued over-action. Indigestion 
also is a powerful cause of the melancholy or hysterical condi- 
tion ED often observed in these cases. 

Epilepsy, and other affections not enumerated above, some- 
times occur as the result of dental irritation, as will be shown 
by the following cases narrated by Dr. Hush {Med. Repoa. 
vol. vi. 285.) 

Case 1. "Some time in the month of October, 1801," Bays 
Dr. Rush, "I attended Miss 0. C. with a rheumatism in her 
hip joint, which yielded for a while to the several remedies for 
that disease. In the month of November it returned with 
great violence, accompanied with a severe toothache. Sus- 
pecting the rheumatic affection was excited by the pain in her 
tooth, I directed it to be extracted. The rheumatism imme- 



diatelj left her hip, and she recovered in a few days. She Las 
coDtinaed ever since to be free from it. 

"Soon after this I was consulted by Mrs. T. R,, who had 
been affected for several weeks with dyspepsia and toothache. 
Her tooth, though no mark of decay appeared in it, was drawn, 
by my advice. The next day she was relieved from her dis- 
tressing stomach complaints, and has contiQued ever since to 
enjoy good health. From the soundness of the external part 
of the tooth, and the adjoining gums, there was no reason to 
suspect a discharge of matter from it had produced the disoaae 
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 waa 
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 inquiry which is even yet very unusual in such 
caaes, but which serves to show the superiority of Dr. R. in 
judgment and comprehensiveness of thought], and was informed 
that several of them in his upper jaw were very much decayed. 
I directed them to be extracted, and advised him afterwards 
to lose a, few ounces of blood at any time when ho felt the pre- 
monitory symptoms of a recurrence of his fits. He followed 
my advice ; in consequence of which I had lately the pleasure 
of hearing from his brother that lie was perfectly cured," 

In commenting upon these cases, Dr. Rush remarks: 

" I have been made happy by discovering that I have only 
added to the observations of other physicians in pointing out a 
connexion between the extraction of decayed and diseased 
teeth, and the cure of general disease. Several cases of the 
efliciency 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 de- 
pending upon constantly recurring circumstances, such as the 
stimulus of light, food, exercise, &c. They were not true in- 



I 



^H LlTll 



EFFECTS OF DISEASED TEETH AND OUMS. 

termittents.) He also quotes from the work of Petit, two 
cases; the one of consumption (apparently), the olher of ver- 
tigo, both of long continuance, which were suddenly cured by 
the extraction of two decayed teeth in the former, and of two 
supernumerary teeth in the latter case. 

"In the second number of a late work, entitled 'Biblioth&quc 
Germanique Mi?<lico-Chirurgica]o,' there la an account, by Dr. 
Seibold, of a young woman who bad been affected for several 
months with great inflammation, pain, and ulcers in her right 
upper and lower jaws, at the usual time of the appearance of the 
catamenia, which were always deficient io quantity. Upon in- 
specting the seats of these morbid affections, the doctor dis- 
covered several of the molars in both jaws to be decayed. He 
directed them to be drawn, in consequence of which the woman 
was relieved of the monthly disease in ber mouth, and after- 
wards had a regular discharge of her catamenia, 

"These facts," continues Dr. Rush, "though but little at- 
tended to, should not surprise us, when we recollect how often 
the most distressing general diseases are brought on by very 
inconsiderable inlets of morbid excitement into the system. A 
small tumour concealed in the fleshy part of the leg, has been 
known to bring on epilepsy. A trifling wound with a splinter, 
or a nail, even after it has healed, has often induced a fatal teta- 
nus. Worms in the bowels have produced internal dropsy of 
the brain, and a stone in the kidney has excited the most vio- 
lent commotions in every part of the system. Many hundred 
facts of a similar nature are to be met with in the records of 
medicine.* 

* I met Willi a rcmarknble caao of Lhie kind a year ago. A wagoner, b«- 
twcen 40 nu'l 60 ycnre of age, a rerj athletic mm, bad been engaged on 
t!ie dfty previous in lifting some loga of wood, and pereeitod a little blood 
upon kii flnger, thoogb no wound could bo seen. Early the ncil morning he 
droTO hii team to the city, cine miles dislant. On the road ho Buffered 
Bitb inUnie pain in the finger, and when bo reached the city, ho was chilly, 
pnle, and evidently labouring under great congtitutional irritation. Th« 
finger nhowed no wound. The pain increasing, he with coneiderable diffigultj 
■--■ ' EryaipdaB appeared, and he died in k few day*. 

of the yenr, being winter, precludes the possibility of hia 
LaTing been bitten by a serpcoL He was net inlemperate in bii habita. 



EFFECTS OF DISEASED TEETH AND QUMS. 197 

" When we consider how often the teeth, when decayed, are 
exposed to irritation from hot and cold drinks and aliments, 
from pressure, by mortification, and from the cold air, and how 
intimate the connexion of the mouth is with the whole system, 
I am disposed to believe they are often unsuspected causes of 
general, and particularly of nervous, diseases. When we add 
to the list of these diseases the morbid effects of the acrid and 
putrid matters which are sometimes discharged from carious 
teeth, or from ulcers in the gums, created by them ; also the 
influence which both have in preventing perfect mastication, 
and the connexion of that animal function with good health, I 
cannot help thinking that our success in the treatment of all 
chronic diseases would be very much promoted by directing our 
inquiries into the state of the teeth in sick people, and by ad- 
vising their extraction in every case in which they are decayed. 
It is not necessary that they should be attended with pain, in 
order to produce disease ; for splinters, tumours, and other irri- 
tants before mentioned, often bring on disease and death, when 
they give no pain, and are unsuspected as causes of them. 
This translation of sensation and motion to parts remote from 
the place where impressions are made, appears in many in- 
stances, and seems to depend upon an original law of the ani- 
mal economy." 

Tissot, who wrote nearly a century ago, had become aware, 
from observation, of the great importance of diseases of the 
teeth to the general health. He describes toothache as result- 
ing from gout and rheumatism, as connected with disordered 
stomach, and as the result of the presence of noxious matters 
in the blood, which, according to the pathology of his day, was 
the mode of expressing what we mean by constitutional vices 
or disorders. He also mentions intermittent toothache, which 
he cured with Peruvian bark ; and neuralgic toothache, which 
was arrested by generous diet and wine. 

Modern medicine, or rather, medical writers, have retrogra- 
ded in some respects, however much they may congratulate 
themselves upon their progress in others. Microscopic soma- 
tology but poorly compensates for that close observation of 

17* 



198 EFFECTS OF DISEASED TEETH AND QTIJIS. 

living disease, upon wliich 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. Emraeach 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 auffor- 
ing. There was considerable vascularity of the conjunctiva 
and sclerotica, especially aronnd the cornea, which slructure 
itself was somewhat opaque and spotted. There was a, con- 
tinual flow of tears, with pain, and intolerance of light. All 
these syraptoma were greatly aggravated by any indiscretion 
in diet and the use of the slightest stimulus, such as a single 
glass of wine. All kinds of remedies had been tried in vain, 
at different times, and the affection seemed incurable. On 
examination of the upper jaw, Dr. E. found a carious tooth 
in the side corresponding to that of the affected eye. The 
portion of the jaw around the tooth was painful, and very sen- 
sitive to the touch. The patient thought the affection of the 
tooth had begun simultaneously with that of the eye. The 
tooth was drawn, and almost immediately afterwards the symp- 
toms relating to the eye began to subside, and aoon 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 tbc Diseases of the 
Mind, p. 33,) observes that "Irritation, from certain foreign 
mattera retained in irritable parts of the body, is among the 
causes of insanity." Ho adds, " I once knew some small shot 
which were lodged in the foot of a schoolboy, induce madness, 
several years after he became a man. It (insanity) has been 
brought on, in one instance, by decayed teeth, which were not 
accompanied with pain." 

Mr, Koeckcr has published a number of oases, forcibly illus- 
trating the effect of diseases of the teeth upon the general 
health. From these I select the following: — 



EFFECTS OF DISEASED TEETH AND QDStS. 



199 



Cask 4. "Mrs. P., a lady of great reBpectability, under the 
medical csre of Dr. Jule Rucco, of Leicester Square, bad, some 
years since, continnallj' Buffered from dyspepsia, aa well as 
from various kinds of nervous attacks of a very annoying and 
alarming natorc. Tiiia judicious pliysician had for a long time 
suspected the cause, and frequently proposed to consult me. 
By the wish of the lady, however, tho dentist of the family 
vras at last sent for, and three or four teeth and roots were 
removed, which, according to the assertion of the dental at- 
tendant, were all that could bo extractocl. The disease, how- 
ever, was only aggravated by this interference, and the suf- 
ferings of the patient increased more and more. 

"About six months after, the doctor again urged a meeting 
with me on the subject, and at last I was sent for. I found 
the lady labouring under a complete salivation, from an extraor- 
dinary sympathy of all the glands in any way connected with 
the teeth. On tho previous night, and, indeed, for many nights 
preceding, she had been suffering such violent fits of convul- 
sion as to alarm the whole family. The face was affected with 
an acute erysipelatous inflammation, accompanied with head- 
ache, as also with considerable derangement of the digestive 
fuDCtions, such as sickness, vomiting, loss of appetite, &c. By 
examining the mouth, I found that the previous dental treatment 
bad been very partial, and I proposed the removal of every 
tooth and root which produced irritation. 

"The lady consented immediately to my proposal, and tho 
necessary operations were performed on the 8th of October, 
1824, when nine decayed teeth, some of them mere roots, 
were extracted. The patient was requested to rinse her mouth 
frequently with a diluted astringent lotion. By this simple 
local treatment, and by the further medical care of Dr. Rucco, 
she was perfectly cured in about a week after the operation. 

" Very soon after her recovery, tho lady was enabled to 
fulfil a promise of marriage which for some time bad been pre- 
vented by her protracted and distressing disease. Since that 
period, she has enjoyed peifectly goo<l health. 

" The farther treatment of the case has, however, been de- 




200 



EFFECTS OF DISEASED TEETH AND OUMe. 



layed, on the accomplishment of which, of course, the perma- 
nency of the cnre will depend." 

Case 5. A literary gentleman in the neighbourhood of Lon- 
don had been for some years under the medical care of Mr. J. 
Derbyshire, of Greek Street, Soho, on account of a constant 
state of derangement of his digestion. 

Much sedentary occupation, and some excessive grief, had of 
late greatly augmented the distressing symptoms generally 
accompanying this cruel disorder. Uis disease had assumed 
the character of hypochondriasis. His spirits were so dejected, 
and the state of bis bodily health was so low, that he was no 
longer capable of attending to his ordinary business. ' 

Having had some conversations with Mr. Derbyehire on the 
influence of disease of the teeth upon tbo general health, that 
gentleman was induced, at his next visit, to inquire into the 
state of his patient's teeth, and learning that they were in a 
very deplorable condition, he proposed a consultation with me 
on the subject. After a particular examination, I found every 
tooth in the patient's mouth more or less carious, or dead, and 
all the gums and sockets in a very diseased state. 

On the 27th of May, 1824, twenty-one teeth and roots were 
extracted, all of which were more or less in a state of putrefac- 
tion — throe large grinders only excepted, which were either 
suffering from complicated caries, or producing morbid irrita- 
tion upon the other parts, from some other causes. 

The mouth was restored to perfect health in the course ol 
about six weeks. Daring the progress of treatment of the dis- 
eases of the mouth, the general health improved very surpris- 
'fg'y; and after the restoration of perfect health to all the 
maining teeth, and their relative parts, the patient enjoyed 
uninterrupted good health, and returned to his ordinary pro- 
fessional avocations. 

t^ASB G. The following is a letter which was handed to me 
(Mr. Koecker) by Miss E., Manchester Street, London, in the 
beginning of the month of May, 1825. The history it gives is, 
P *ps, one of the moat distressing cases of its kind, concern- 
ing a lady of great reap eel ability and rank in Scotland, of 




SmCTS OF DI8BA6BD TEBTH AND GUMS. 201 

about thirty-eight years of age. Its contents, indeed, are not 
less remarkable for the manner in which they display the un- 
common fortitude of the unhappy sufferer, than for the strik- 
ing confirmation which they give of the facts which I have de- 
tailed, as well as the description I have given, respecting the 
present state of dental surgery. Considering this evidence as 
most useful and important, I beg to submit to the reader the 
whole of the fair sufferer's most interesting and affecting com- 
munication. 

"My Dear , I have been so ill since I wrote you lasty 

that I have not been able to answer your kind letter. As I 
can express myself to you easier than to a stranger, I shall 
endeavour to give you some idea of my present state, and you 
can give my letter to Mr. Koecker. Constant faint gnawing 
pains in my gums, membrane of my mouth and cheeks, ac- 
companied with considerable swelling of the latter, which are 
always blotched, inflamed, and irritated, just in the way some 
people's faces are affected when suffering toothache ; my very 
nose is swelled and inflamed, and the muscles of the under part 
of my face so contracted and drawn upwards, that I cannot 
swallow anything but liquids. My mouth is contracted and 
full of slimy saliva. In bed I have constant twitches in my 
gums, like what I could figure electricity. Sometimes my 
gams and face burn like fire, and sometimes feel as if every 
nerve and blood-vessel were filled with ice, and the sheets near 
my mouth are wet with saliva. All these sensations often run 
down behind my ears, to my neck and arms; and at these 
times I have a great hurry and agitation of spirits, and aching 
across the breast and heart. To me, one of my greatest tor- 
tures is the extraordinary inflation of gums, particularly to- 
wards the roof of my mouth. They feel as if they absolutely 
tore from the bone, hove up, as it were, with the wind, and my 
jaws feel twice too large for my mouth, the pressure against 
my face is such. The same sensation often proceeds to my 
cheek bones, which increases the swelling of the muscles and 
the dragging up of the under jaw. 



k 



EFFECTS OP DISEASED TEETU AND GUMS. 

" I must now go back in my history, that Mr. Koecter may 
know the progress of the last five years of my continued misery. 
Bui, unluckily, I fear it is impoBsible to make any one under- 
stand my sufferings, they are so various and complicated. Tou 
know I always blamed my teeth as the cause of all my suffer- 
ings ; but I am now convinced that the disease is in my gums 
and remains of the alveolar processes ; and as I was told that 
was a part of his profession Mr. Koecker was supposed to bo 
very skilful in, it makes me very anxious to have his opinion. 
You will remember how long (many months) the sockets of mj 
large molar teeth stood open, and even when they did heal up, 
the gums were full of morbid sensibility. When I last saw 
you, I had only about five front teeth remaining, and eight 
below. About 1818 they began to ache a little, and, as usual, 
to irritate and inflame my cheeks. The five upper ones began 
to spoil ; but I fought on with them until the winter of 1819, 
when the inflammation, and the various sensations I have men- 
tioned before as now suffering, increasing, and the teeth them- 
selves aching, I had them pulled. The gums swelled and 
inflamed most dreadfully, the horrid sensations in the roof of 
my mouth increased, and my face was as bad as ever. In about 
a month the wounds healed, but the gums remained swelled 
and became a hard white gristle. After suffering for many 
months, I had the gums opened. They were so hard and 
thick, the dentist said they were like bone. The sockets were 
not the least absorbed; of course, rough, and in some parts 
exfoliated. 

" The gums were kept open near a month, and caustic ap- 
plied to excite absorption. In the course of this process the 
point of a tooth was discovered in one of the sockets, and ex- 
tracted. It was a full-grown eye-tooth, which, for want of 
room, bad never made its way down. I was easier as long as 
the gums were open ; but Just where I nos, 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 Lear nothing in my mouth to touch ihem. My 



EFFECTS or DISEASED TEETH AND GDMS. 



lips became very tremulous, and my hands trembled so that I 
could neither feed nor dress myself. When warm in bed they 
ceased ; but from the moment I rose and began to speak, or 
let the air into my mouth, I never ceased trembling, and the dry 
retchings (which you remember how tortured I used to be 
with) increased so as to bring on vomiting. I suffered in this 
way for eleven weeks, when, in despair, I had all my remaining 
teeth pulled. The tremblings and retchings quickly abated, 
and ia 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 tliera to suppurate, I get no advantage, the wound- 
ing only increasing the hardness. 

"These gums seem to me to act as levers, pressing on the 
nervcB and blood-vessels, and keeping up a constant irritation 
and inflammation in my mouth and face. 

"Under an idea that my complaint proceeded from neural- 
gia, I was advised to have the mental nerves divided at the 
diin, which did no good, and has created such hard tumours 
on these places, that I think their pressure on the side of the 
jaw is the cause of the twitching pain of my under lip, and 
the contraction of the muscles. 

*'I would take it as a great favour if Mr. Koecker would 
Bay whether he thmka he could be of any use to mc 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 
t done here ; and if he will be ko very good as to mention what 
are the different kinds of diseases he has ever met with in the 
guios or alveolar processes, and his mode of treatment. There 
seems to be an idea here that if the sockets are not carious, 
there can be no disease there ; but I think Fox mentions other- 
wise. 

"My upper gums had not been touched for four years, until 
ek ago, when a part was opened that was very troublc- 
!, and much swelled. The bono was full 
ualities, and rough; sounding gritty, like 



I 




20-1 EFFECTS OF DISEiSED TEETH AND GUMS. 

was a great deal of thick slime, like the white of egg, mixed 
with blood. Some nitrous acid waa put upon the wound, to 
trj 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 
BUre if these old awelied gum3 could be got away, I should 
suffer less. 

" I should think there is about the eighth of an inch of the 
socket remaining. The ridge of the under jaw is as sharp as 
a knife, and so painful to the touch, when I press it, that it 
makes my face, ears, and neck burn. My lips are painful, and 
are drawn in. I was advised to try false teeth, but they in- 
creased my sufferings ten-fold, which is very hard, as the 
clinching of my jaws adds much to my sufferings. My eyea 
are beginning to bo 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 arc various opinions about my complaint. One saya 
it is a nervous complaint at the origin of the nerves, affecting 
the extremities of these nerves ; others say it is a nervous 
affection of the dental nerves and their ramifications on the 
face ; and others are of opinion it is an affection of the cover- 
ing of the hone. I am satis&ed it is some disease of the an- 
trum. Could it injure me to have the antrum opened to ease 
my mind? There is one place where I think there is part of 
a fang of a tooth, which I am certain was broken, as the den- 
tist burnt the tooth without letting me see it; perhaps that 
may torment me." 

Mr. Koecker gives no opinion upon this case; but the lady 
seems to me to have had more discernment than her profes- 
sional advisers. The disease was probably seated in the an- 
trum, and very likely the fragment of fang was the irritating 

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 

bis teeth, he mformod me that his general health bad been 



k. 



SFFSOTS OF DISEASED TEETH AND GUMS. 205 

very bad for four or five years past, and that he had applied 
to some of the most eminent physicians of New York, Troy, 
and Albany, bat had not obtained any permanent relief from 
his sufferings. 

^^ The character of the symptoms that prevailed at this time 
was very peculiar. His digestive organs were so much de- 
ranged, that he was obliged to observe the strictest regimen, 
and confine himself to the simplest kind of vegetable food. 
Besides the dyspeptic affection with which he was troubled, he 
had severe paroxysms of headache and vomiting, that recurred 
at regular intervals of from four to five weeks. These were 
always preceded by numbness, which commenced in his tongue 
and extended thence throughout the whole system. This sen- 
sation continued usually for about two hours, when it was suc- 
ceeded by a violent pain in the head and partial vertigo, 
from which, in about ten hours, he was relieved by vomiting. 
The effects of these paroxysms lasted about ten days, and the 
other symptoms had continued, without much mitigation, for 
three years. 

'' On examining his mouth, I gave it as my opinion that the 
diseased state of his teeth was the cause of his affliction. This 
idea, though entirely novel to him, he was disposed to believe 
correct, and therefore readily consented to the treatment I 
prescribed. Many of his teeth were much decayed, and nearly 
all of them covered with tartar. The roots of some were de- 
nuded of the gums, the alveolar processes more or less absorbed, 
the gums turgescent, fungoid, bleeding on the slightest touch, 
and of a dark red colour. The secretions of the mouth were 
viscid, and their exhalations exceedingly offensive. 

" Such of his teeth as could not be perfectly restored were 
extracted, and as much tartar was taken away as could be con- 
veniently removed at one time, and the rest at subsequent sit- 
tings. His gums were freely scarified, and a tonic astringent 
and detergent wash was directed to be used three or four times 
every day. Under this treatment the local affection of the 
mouth rapidly disappeared, and in about four or five weeks his 

teeth and gums became perfectly healthy. His general health 

is 



20C EFFECTS OF DISEASED TEETH AXD QVMS, 

also began to improve, and in about two montLs it was perfectly 
restored, and has bo continued," 

Case 8, communicated by Dr. JTarrts. " In February, 1851, 
\V. S., of Virginia, aged about 45, called on me for advice in 
relation to a tumour in the roof of hia mouth, which had been 
first perceived fifteen months previously, during which time 
there had been an occasional dripping of purulent matter be- 
hind the velum palatl. On inquiring into the history of the 
case, I learned, that ahout two or three weeks previous to the 
occurrence of the tumour, he had an attack of toothache. The 
pain -was felt in the first right superior molar, but had subsided 
before the formation of the tumour, leaving the tooth somewhat 
sensitive and sore to the touch and slightly elongated. As it 
caused him hut little inconvenience, having some years before 
lost the tooth in the lower jaw with which the diseased upper 
molar antagonized, it was not suspected to have any connexion 
with the disease of the palate, although the swelling had frc- 
fjuently extended down the side of the alveolar border opposite 
the palatine root. 

" Having ascertained these facts, I had but little difficulty in 
tracing the origin of the disease to the alveolus of the palatine 
root of the tooth in question : the tooth being necrosed. 

" The extraction of the tooth confirmed the correctness of my 
suspicions. In throe days the tumour of the palate disappeared, 
and the trickling of pus ceased." 

It might be curious to inquire, what would have been the opinion 
given of this case, and the treatment pursued, by some able sur- 
geons to whom the effects of diseased teeth upon the adjacent 
structures had never been a subject of inquiry or observation. 
As the tooth did not ache, and had not ached for some time 
before the appearance of the tumour, it probably would have 
never been suspected of any agency in the matter. Had its 
necrosed and elongated condition been observed, it would natu- 
rally have been attributed to the pressure of the tumour upon 
the alveolus. The probabilities arc very small, that any but 
a dentist or a surgeon more than commonly attentive to tho 
teeth, would have perceived the patient's condition, or relieved 



I 



EFFECTS OF DISEAJ^ED TKETH AND flDMS. 207 

il. Very probably be would have boon subjected to painful 
and worse than useless attempts at cure, until the disease, so 
rinplo anil so manageable, might have become far more serious 
and intractable. Aa a general rule, in all local in flam mat ions, 
tumours, &c., of the parts adjacent to tbe teeth, the latter are to 
he suspected as the cause ; and, until thorough obserTatJon 
and careful consideration have determined the contrary, we 
should not look elsewhere for the origin of the evil. Proba- 
bly, in nine cases out of ten, our first suspicions will prove to 
be correct. 

Dr. S , a distinguished surgeon and physician of Virginia, 

reports the two cases following : 

Case 9. " Mrs. S , a lady of thirty or thirty-five years 

of ago, with several children, in easy circumstances, rather 
delicate and of sedentary habits, complained of derangement 
in the functions of the digestive organs, with much nervous 
disorder, and a painful sensation about tbe head, as if there 
were a pound weight on the top of it, with an occasional tight- 
ening of the scalp. This last sensation, she compared to tliat 
which might be expected from having the scalp forcibly drawn 
together on the vertex by the clawing of some animal with 
talons, as a hawk. Her friends, at first, thought but little of 
her complaints, and from their eccentricity were inclined to 
believe them, for the most part, imaginary. The affection of 
the head, however, and tbe sensitiveness of the nervous system, 
evidently increased, until they became so harassing and acute, 
that they deprived her of rest, and made manifest inroads upon 
her healthful appearance. 

" Medical advice having been now obtained, a regular and 
carefully-directed course of purgatives was prescribed, but with 
little or no advantage. The cathartics having been discon- 
^nued, the Rub. Ferri, Bark, Valerian, Mineral Acids, Zinc, 
Assafcclida, Ac, were next tried, to which were added frictions 
and t«pid 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 
aweats, that much reduced her, and caused her coantenanoe to 



^m that li 

^H org&Di 



208 EFFECTS OF DISEASED TEETH AND OOMS. 

assume a sicklj aspect. She visited the watering-places in 
Virginia, but thougli her strength was somewhat recruiteil, llie 
distressing symptoms, with some slight modi6cation3, still con- 
tinued. She was occasionally confined to the house, but gene- 
rally was able to take some slight exercise in the open air, 

" This state of things had continued for eighteen months, 
when the attention of her physician was called to an abscess 
formed near the root of one of her incisor teeth. This brought 
about an inquiry into the general state of the teeth, of whicli 
the following is the result : 

" Mrs. S , at an early period had bad teeth, Trhich, since 

her marriage, had been gradually growing worse. A few years 
before the time of which I speak, two of the incisors of the 
upper jaw were clipped off close to the aockete, and artificial 
teeth were inserted on the fangs. Much pain, irritation, and 
swelling of the gums and lips followed the operation, and similar 
symptoms occasionally occurred for a year or two afterwards, 
and were frequently attended with alveolar abscesses. The 
remaining incisors of the upper jaw, and several of the inferior 
and superior molar teeth, were found to be in a dilapidated 
state. The alveolar processes of several of the inferior molars 
were partially destroyed, and one or two of their roots were 
turned on one aide, 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 prodnccd 
by the bad state of her teeth ; the more so, as her nervous 
system was exceedingly sensitive. She was persuaded to have 
the carious incisors and the worst of the molars removed; and, 
a short time after this was done, her health began to improve. 
The affection of the head and scalp soon ceased, the nervous 
symptoms vanished, and she is now in good health, and has a 
set of teeth decidedly more ornamental than those given her 
by nature ever were. The speedy restoration of her health 
after the removal of her diseased teeth, justifies the conclusion 
that her bad health depended on the bad state in which these 
organs were found." 



EFFECTS OF DISEASED TEETH AND GUMS. 209 

The following case, related by the same gentleman, is parti- 
cularly worthy of attention, as showing the terrible conse- 
quences which may result from ignorance of the effects which 
disease of the teeth, or even of a single tooth, is capable of 
producing in subjects of certain constitutions : 

Case 10. " Miss W , a maiden lady of about fifty years 

of age, in comfortable circumstances, and for the most part 
sedentary of habit, had suffered much from pain in the right 
cheek. For some time it was not considered of much moment, 
but, on its continuance, a physician was consulted. 

" He found but a single tooth, one of the second molars, in 
the superior maxillary of the affected side, and that was in a 
semi-decayed state. The gums above the teeth, and for half 
an inch on each side of it, were much swollen and of a livid 
redness. The tumour seemed spongoid and puffy to the touch, 
but there was neither fluctuation nor abscess. The patient's 
health had not sensibly deteriorated. She said the tumour on 
the gums had existed for many weeks, but had not been at- 
tended with any remarkable pain, until the occurrence of that 
of which she complained. She described it as being deep in 
the cheek, and generally dull, but now and then, for an instant, 
sharp and lancinating. She said the tooth, for several years 
past, had been accustomed to ache occasionally, but that, not- 
withstanding its decayed state, it was very useful, and she had 
therefore declined having it extracted. 

" The immediate extraction of the tooth was, however, 
thought advisable, and with her consent, it was effected. A 
week afterwards the spongy tumour of the gum continued, with- 
out any abatement of the pain in the cheek. The tumour was 
now laid open with a lancet. It contained no matter, but was 
filled with those shaggy or shreddy fungi, which are often seen 
to occupy tumours or diseased bones. An abscess, or some other 
affection of the antrum, was suspected. A perforation was 
therefore made in its cavity, and about a table-spoonful of very 
dark brown matter discharged, which gave the silver spoon 
into which it was received a thin coat of the blackest pigment, 

and, on account of its offensive smell, was almost insupportable. 

18* 



210 



EFFECTS OF DISEASED TEETH AND ODMS. 



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 waa accord- 
ingly applied to the alveolar portion of the Bupcrior maxillary, 
the soft parts having been first dissected up, and a correspond- 
ing portion of the bone was removed. The end of the little 
finger could now be introduced into the antrum, the inner sur- 
face of which, it was easy to perceive, had, at several points, 
been denuded of the pituitary membrane ami of the periosteum. 

" The disease was now fairly exposed, and nothing could ex- 
ceed the offcnsiveness of its fetor when not corrected by suitable 
dressings. The usual antiseptics and detergents were locally 
applied, while tonics and a generous diet were prescribed to 
sustain the patient's general health, and every effort was made 
to substitute a healthy purulent secretion for the ill-conditioned 
and offensive discharge from the antrum, but without any effect. 

"An irremediable necrosis seemed to have taken possession 
of the superior ma.xiltary of the affected side, which soon began 
to come away by piecemeal. In the mean time the soft parts 
about it were laid waste by the phagedenic character of the 
ulceration, and the eye of the same side became seriously af- 
fected. The disease now progressed rapidly. The perforation 
of the antrum was made on the 11th of March, 1821, and on 
the 26th of May following, the patient was found in a perfect 
state of apoplexy, the disease having penetrated the basb of 
the cranium and seized upon the brain itself. On the 30th of 
the same month she expired, and was thus released, by death, 
from the most horrible disease that can be conceived, but which 
had its origin in nothing more extraordinary than a neglected 
carious tootb." 



Dr. M , an eminent practitioner of this State, reports 

the following extraordinary case : 

Case 11. " In the summer of 1834, 1 was called to visit Mr. 
D. M , vho had come into this neighbourhood to obtain 



EFFECTS OF DISEASED TEETU AND QCMS. 



211 



the benefit of the country air, having reaiLled in Baltimore from 
his eurliest youth. When I saw him he was in the last stage 
of phthisis pulmonalis. He gave mo the foHowing history of 
his case : 

" About eight years previous be felt & soreneas and tumefac- 
tion in his gum at the posterior part of his mouth, and as ho 
had never cut the dentes sapientitB, he thought the disquietude 
was occasioned by the progress of one of these teeth, and in 
consequence gave it no attention until the soreness and inflam- 
mation bad extended themselves over the ^rhole surface of his 
mouth and fauces. The tooth not having protruded through 
the gum, he consulted bis family physician, who advised imme- 
diate extraction. 

" In conformity with this advice, he called on an eminent 
dentist of B'altimore, hut the tooth not having presented itself 
and the cause of his suffering being doubted, the operation 
was deferred. Uis sufferings, however, having become intole- 
rable, and the irritation having extended itself to the lungs, 
producing considerable uneasiness, he determined, if it were at 
all possible, to have the tooth removed. A few days after, he 
stated his determination to the dentist. The gum was freely 
split, and after considerable pain and dlQlculty, the tooth ex- 
tracted. The inflammation in his mouth and fauces immedi- 
ately subsided, his appetite returned, and his general health 
soon became as good as formerly. 

"About three years subsequent to this, his mouth and fau- 
ces, under similar circumstances, and from the same cause, 
became very sore and painful. The inflammation soon reached 
the lungs, and established a confirmed phthisis pulmonalis. lie 
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 arc indebted for the 



I 




212 



EFFECTS OP DISEASED TEETH AKD QUMS. 



preceding case, has recorileil another, in vliich the fatal result 
was more directly attributable to dental suffering. He says : 

Case 12. "My friend, Dr. L , of Frederick, Md., was 

called to visit a young gentleman who laboured under violent 
pain of the face and inferior maxillary, with very great tume- 
faction of the gums. His sufferings were traced to the roots of 
one of his molar teeth, which had hcen broken in an attempt 
to extract it. His gnma and the glands of his throat became 
BO much enlarged, that it was impossible to remove the offend- 
ing portion of the tooth. The inflammation, notwithstanding 
the skilful exertions of the physician, rapidly increased, high 
and intractable fevor supervened, deglutition became totally 
obstructed, and, in a few days, he died." 

Case 13. A case very similar to the last, though more for- 
tunate in its results, came within my knowledge lately. A 
dentist was applied to to extract a molar tooth, which he did. 
He told the patient that the tooth had come out entire; and 
dismissed him. Violent inflammation ensued, a large abscess 
formed, and the life of the man was brought into imminent 
jeopardy. His physician called in a surgeon, and both being 
baffled, an eminent dentist was consulted. He suspected that 
a fragment of the root had been left, and after great difficulty, 
owing to the swelling of the parts, he succeeded in extracting 
it, and saving the life of the patient. 

Dr. Fitch, in his "System of Dental Surgery," narrates n 
number of cases of constitutional disease, evidently caused by 
the protracted irritation incident to diseased conditions of the 
teeth and gums, from which I select the following: — 

Case 14. "In February, 1827, Dr. Samuel Jackson calle<l 

and requested me to see Mrs. R , living in Tenth above 

Walnut Street, who, he said, was labouring under every symp- 
tom of confirmed phthisis pulmonalis, and also appeared to 
suffer greatly from a diseased state of her mouth, I, accord- 
ingly, called on Mrs. R . The following were her symp- 
toms: great emaciation, hectic fever, almost constant cough, 
nearly a total loss of voice, articulation being extremely diffi- 
cult, the voico as if speaking through a trumpet. Dr. Jackson 




eaid that in tho practice of seven years in the hospital, alms- 
house, and private practice, he had never acen a person re- 
cover from the symptoms under which Mrs. R laboured. 

" The following was tho condition of Mrs. R 'a mouth. 

About two years before she had the upper wisdom-tooth of the 
left Bide pluggeil, and the plug was pounded in by a mallet and 
punch. Tho fangs of tho tooth converged together so as to 
form a fang of a conical shape. In bammeriiig 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 cesophagus, also over the glottis, epi- 
glottis, and larynx. It then travelled forwards on the right 
Bide of the under jaw, and caiised to inflame and slough away 
bU tho sockets and teeth of the lower jaw but one, which was 

the left dens sapientiae. When I first saw Mrs. R , the 

process of inflammation, sloughing, and gangrene was at tts 
height. Extensive exfoliations of the jaw were taking place. 
Dr. Jackson and mj'self concluded that tho patient could not 
lire more than four weeks. 

" Treatment. I at once removed all the teeth that were 
loose, and whoso sockets were in n state of gangrene and ex- 
foliation. I likewise, as fast as possible, removed all the dead 
bone, and directed the patient to wash her mouth constantly 
with a strong infusion of powdered galls. In about eighteen 
days her mouth was perfectly well. The amendment of her 
general health was surprisingly rapid. In five weeks she was 
able to take long walks in the street, and in six months she 
was restored to perfect health. Nearly six years have passed 
away, and she still continues perfectly well." 

As 3 corollary to this case, Dr. Fitch very properly ob- 
Mrves: "I think we may safely infer, although Jisensed teeth 
do not, in every instance, excite general diseases of the sys- 
tem and of the lungs, yet, like an insidious enemy, they aro 
ever ready to unite with or exasperate other causes, so as 
finally to undermine the powers of tho system. I would ear- 
nestly solicit the attention of the medical faculty in general to 
a critical inquiry into the slate of the teeth in all cases of pul- 




214 EFFECTS OF DISEASED TEETH AND CTJMB. 

inonary affection ; and there is hardly a doubt that their in- 
quiries would result in the general conclusion that a diseased 
state of the teeth and gums does very frequently excite pulmo- 
nary affections, especially in persons predisposed to them, and 
always aggravates these complaints, let them be excited by 
whatever cause they may." 

Professor Chapman, of the University of Pennsylvania, in 
his lectures related the following case: — 

Case 15, " Some years since a lady came from a distant 
part of the country to this city, in pursuit of medical aid, and 
placed herself under the care of Dr. Chapman. He found her 
labouring under every symptom of obstinate dyspepsia, by which 
her health and strength were greatly impaired. His correct 
and well-known acumen in the pathology of disease immedi- 
ately led him to inquire into the state of her gums and teeth. 
He found her gums in a high state of inflammation, and many 
of her teeth loose and diseased. By the direction of Dr. 
Chapman she applied to one of our most respectable dentists, 
and had her mouth and teeth placed in a healthy condition, 
and with the return of health in her teeth, gums, &c,, every 
dyspeptic symptom left her, and she became quite well. 

" After some time bad elapsed, and the lady's health seemed 
con6rmci], 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." 



h 



EFFECTS OF DISEASED TEETH AKD GUMS, 



215 



I 



Qufeland enumerates sound teeth among the signs of long 
life. "For good digestion," lie says, "good teeth are ex- 
tremely necessary, and one, therefore, may consider them 
among the essential properties requisite for long life: and in 
two points of view — First, good and strong teeth are always a 
sign of a sound, strong constitution, and good juices. Those 
who lose their teeth early, have, in a certain measure, taken 
possession of the other world, with a part of their bodies. 
Secondly, the teeth are a great help to digestion, and, conse- 
quently, to restoration." 

Mr. Listen observes:* "From the presence of cnrioos 
teeth, or decayed portions of teeth, many evils, both local and 
general, ensue, besides inflammation and abscess. They are 
frequently the cause, and the sola cause, of violent and con- 
tinned headaches ; of glandular swellings In the neck, terminat- 
ing in, or combined with, abscess; of enlargement and inflam- 
msUon of the tonsils, cither chronic or acute; of ulcerations 
of the tongue and lips, often assuming a malignant action from 
continued irritation; of painful feelings in the face, tic-doulou- 
reux, pains in the tongue. Jaws, &c.; of disordered stomach 
from affeclion of the nerves, or from imperfect mastication ; of 
continued constitutional irritation, which may give rise to sen- 
is diseases." 

Case 16. (Dr. Filch.) "Mrs. S , aged about 38 years, 

ins sent to me, by one of our most eminent physicians, nith ft 
truest that I would examine bcr teeth, and perform such ope- 
ntions upon them as I Judged proper, to render them and the 
gnms healthy. The state of this lady's health was miserable; 
she was harrassed by the most distressing symptoms of dys- 
pepsia. Her digestion was very imperfect, the stomach irri- 
tated, loss of appetite, and a most melancholy depression of 
spiritB. When she first called it was necessary for her to re- 
pose herself for some time, before she could have her mouth 
examined. 

" Upon examining her teeth and gums, I found nearly all the 
fonner in a state of disease, and the latter were in a state of 




216 EFFECTS OF DISEASED TBKTH ASD GUMS. 

suppuration, much inflamed and swollon. A considerable de- 
poait of tartar was formed aronnd the necks of the teeth ; in 
several instances their fangs were denuded of the gum by the 
deposit of tartar, and, in fine, her month 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 flrst operations 
were performed on her teeth, was also surprising, and would 
have been entirely ao to any person not acquainted with the 
immense sympathy between the mouth, gums, &o., 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 17. Neuralgia from diseased teeth. — (Prof. Harris.) 
" The following is one of the many cases of tic-doulourcnx or 
neuralgia faciei, produced by disordered teeth, that have come 
under my own observation. 

" The subject of it was a lady about forty years, of sedentary 
habits, and naturally of rather a nervous temperament. For 
several years she had been afflicted at times with a most dis- 
tressing and painful affection of her face, which was pronounced 
by her physician to be tic-douloureux. The pain was some- 
times so acute and lancinating that it almost deprived her of 
reason. It generally commenced near or a little anterior to 
the angle of the superior maxillary bone, thence it darted 
across the face to the alse of the nose, and then to the temple, 
forehead, and angle of the eye, accompanied with frequent and 
sudden transitions from one side to the other, twitching and 
tremors of the muscles of_the affected parts, and with a preter- 
natural flow of saliva. Ilcr face, and sometimes the whole of 
her head, were rendered so sore by these paroxysms, that the 
slightest touch would produce pain. 

"These paro.tysms, although they were generally of short 
daration, frequently recurred as often as ten or fifteen times in 
twenty-four hours, and sometimes lasted ten, sixteen, and eroa 




twenty days, after which they would gradually sabaide, having 
subjected her during their continuance to the greatest misery, 
uid leaving after thoir subsidence a. dull, heavy pain in one or 
both jaws. A sensation similar to this wus 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 
caaae. These spasms were more severe and occurred more 
frequently in cold, damp, and wet than in warm and dry wea- 
ther. 

"Bark, quinine, carb. fern, stramonium, belladonna, and 
various other tonics and antispasmodics were prescribed, but 
without any apparent beneficial effect. Leeching, sinapisms, 
and epispastica were also of no a\'ail. As a last resort, it was 
determined to divide the affected nerve ; but before the opera- 
tion the physician was induced by the pain in the jaws, always 
preceding these paroxysms, to examine the condition of the 
patient's teeth. The examination showed them to be in a very 
unhealthy slate. The molares generally, and especially those 
on the right side, were involved in complicated caries. The 
gums were much tumefied and inflamed, and very sensitive. 

"Her teeth and gums, from the diseased condition in which 
they were found, were immediately supposed to have some 
agency in producing the affection of the face. A consultation 
with me was therefore proposed, and I was requested to vbit 
her. 

"On examining her teeth, I found that eleven were so much 
decayed as to render their restoration impracticable. It waa 
therefore determined to remove them immediately, but it waa 
not thought proper, owing to her extreme debility and the state 
of her nervous system, that more than two or three should be 
extracted at one time. 

" So great was her agitation at the mere thought of the ope- 
ration, that notwithstanding the agony she suffered, she could 
not, on my first visit, be persuaded to have even a single tooth 
extracted, but requested me to call on the next day, when she 





EFTVTTi or DISBASKD TXKTH ASD QVMS. 

pnomind die v<rald Bolaut to tke ranorml of u manj &a she 
poMflilj eonU. 

" I aeeordlagl J called on tke f(dlowiitg d« j, mud to the as- 
toaiBhineDt of her friends, sh« iHowed all her jaw te«th that 
vere cariooB, elevea in Dumber, to be at once extract«d. The 
operation at once revealed the cause of her disease. The roots 
of three of these teeth were rer; mach enlarged by bony depo- 
sitions. One of the fangs, iras, at its extremity, about the die 
of a pea. Those of the other tvo were not quite so large, bat 
a disposition to exostosis was manifested by all. With the re- 
moval of these teeth, all symptoms of pain entirely vanished, 
nor have they, to my knowledge, returned since," 

Case 18. Death caiued by the extraction of a tooth. — (Jour- 
dain.) *'A citizen having submitted to the extraction of a 
tooth, the gams became gangrenoas; the gangrene reached the 
brain and caused death." The same author reports a case of 

Case 19. " ConvuUiont and death cauied hy the thortening 
of a tooth longer than the others. A nan of Padaa having had 
a tooth shortened in order to get rid of the deformity, died im- 
mediately in an epileptic convubion. A small fragment of 
nerve was discovered in the section of the tooth." 

This case and others, which fortunately have not terminated 
80 seriously, should be a warning to all operators upon the 
teeth, not to inflict sudden and violent pavgi. Experience 
shows U9 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 intenBity, Even in ex- 
tracting a tooth, it is better to operate gradually rather than 
wrench It out with a sudden and violent effort. If pain be 
gradually inflicted, the nervous system, conscious of the coming 
trial, summons up all its powers of endurance ; but when taken 
by surprise, the shock is severely felt and the consequenceB 
may even be futat, as in the case just quoted. 

Pain ii a great evil. It should never be inflicted unneces- 
sarily, and when necessity occurs, the inflictor should use all 
possible means to render the suffering as tolerable as possible. 
Moreover, there is great difference in individuals as to the 



k 



EFFECTS OF DISEASED TEBTH AND GCMS. 

tolerance of pain; even as to the perception of it. Many per- 
sona will suffer terribly from operations wliich would not cauae 
serious pain to others. The same persons will suffer much 
more at one time than another. All these considerations are 
TTcll worthy the attention of the dentist. 

Very severe headacho of the neuralgic kind, is frequently 
eansed by diseases of the teeth and the irritation produced by 
the pressure of dead roots in the jaw. In illustration of this, 
I will quote a few from many cases : 

Case 20. "Inveterate headache cured by the extraction of 
many roots of carious teeth. — (Fabriciua Hildanus.) A lady was 
afflicted with a very severe continued pain in the left side of her 
head. The violence of the pain was chieSy experienced in cold, 
damp weather. By the adrice of her physicians, she had tried 
a great many remedies, internal and external, but without suc- 
cess. Finally, I was called to bpo 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 
Bimilar one in the corresponding side of the head. I conjec- 
tured from that the headache was caused by the roots of dead 
teeth. Upon examining the upper jaw, I found four carious 
teeth whose roots were deeply planted. I advised her to have 
them extracted, to which she cheerfully consented. I then 
pnrged her freely and applied cups to her neck and shoulders, 
and directed an aposeme to be taken during four days in the 
morning. On the fifth, while fasting, I extirpated the roots." 
After other treatment of a kind then in vogue, but of no 
utility, the lady recovered. 

Case 21. Headache dependent upon the teeth. — (M. Petit.) 
"The late Princess of Cond^ recommended to her physicians 
one of hor protegees, to be cured of a headache of five years" 
duration. She iiad been bled twenty times, and finally M. 
Petit was requested to bleed her in the throat. This surgeon 
having examined the patient, was led from her complaint of a 
pain and weight in the lower jaw, to look into her mouth. He 
found some irregularity in tho teeth, aud upon close inspection 




220 EFFECTS OF DISEASED TEETH AND GUH8. 

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 ladj was cured of a headache of fiye 
years* continuance." 

Case 22. Ophthalmia and Io$s of an eye by abscess upon the 
teeth. — (Fab. Hil.) "A lady of Cologne was for a long time 
tormented with inflammation upon the last molar of the left 
side, which was carious. By the advice of physicians, she was 
frequently purged, and cupped between the shoulders, but as 
she refosed to hare the tooth extracted, the continued irrita- 
tion of the gums occasioned inflammation of the eye on the 
same side, which finally destroyed the sight." 

Case 23. Ear-aehe cured by extracting a tooth. — (Jour- 
dain.) '^ A lady had long suffered with severe pain in the 
right ear. All the ordinary remedies were used without effect 
At length she was asked if she had any carious teeth. She 
replied that she had not : that all her teeth were good and 
never gave her any inconvenience. Nevertheless, her mouth 
was carefully examined. At first sight all seemed tight, but a 
close inspection showed external caries of the dens sapientiss. 
As the pain of the ear extended to the angle of the jaw, and 
even a little along its base, I persuaded the lady to permit me 
to extract this tooth, which I suspected to be the real cause of 
the mischief. Three days afterwards, the lady was perfectly 
and permanently relieved." 

A similar case is reported by Mr. Koecker. 

Dr. Darwin relates several cases of serious disorder produced 
in adjacent parts and in the general system by diseased teeth. 
The following are very remarkable : 

Case 24. **Mrs. ^ about thirty years of age, was 

seized with great pain about the middle of the right parietal 
bone, which had continued a whole day before I saw her, and 
was so violent as to threaten convulsions. Not being able to 
detect a decaying tooth or tender one, by examination with my 
eye or by striking them with a teaspoon, and fearing bad con- 
sequences from her tendency to convulsions, I advised her to 



permit the estractioo of the last tooth of the under jaw on the 
affected aide, which was done without any good effect. She 
was then directed to lose blood and to take a hrisk cathartic, 
and after that had operated, about aisty drops of laudanum 
were given her, with large dosea 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. 

" Abont 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 molaria of the same jaw, opposite to 
the decayed one, to be extracted ; which was forthwith done, 
and the pain of her head immediately ceased." 

Cask 25. (Darffio.) Since the above was first published, 
I have seen two case which were very similar, and seemed 
much to confirm the above theory of sympathetic hemicrania, 
being, perhaps, always owing to the sympathy of the mem- 
branes about the cranium with those about diseased teeth. 

"Lord M. and Mr. B., of Edinburgh, both of them about 
the middle of life, were afllicted with violent hemicrania for 
about two years ; in the beginning of which time, they both 
assured me that their teeth were perfectly sound, but on in- 
specting their mouths I found all the molares wore now so de- 
cayed as to have lost their crowns. After having suffered pain 
for sixteen or eighteen months, almost incessantly, in different 
parts of their heads, tboy had each a hemiplegia, from which 
they gradually recovered as ranch as paralytic affections gene- 
rally do recover. All the stumps of their teeth, which were 
oselesB, were directed to bo extracted, as the swallowing so 




222 XFFBCT8 OF DISEASED TESTE AND GUM8. 

much putrid matter from decaying bones, seemed to injure 
their digestion." 

Sir Henry Halford, in a paper on tic-donlooreoz, read before 
the College of Physicians, related the following cases which 
came under his own observation : — 

Case 26. " A lady, forty years of age, suffered under the 
violent form of tic-douloureux, at Brighton, notwithstanding the 
careful attention and skill of a very judicious physician there. 
On returning to town, it was observed that the rending spasms, 
by which the disease is marked, were frequently preceded by 
an uneasiness in one particular tooth, which exhibited, how- 
ever, no signs of unsoundness ; but the constancy of this symp- 
tom was enough to justify the extraction of the tooth in this 
instance ; and on its being drawn, a large exostosis was ob- 
served at the root of the tooth, and the lady never suffered 
more than very slight attacks, and these very seldom, after- 
wards." 

Case 27. (Sir Henry Halford.) "The late Earl of C. un- 
derwent martyrdom by^this disease, and excited the warmest 
sympathy of his friends by the agonies he sustained for many 
years. He submitted to the operation for the division of seve- 
ral branches of the fifth pair of nerves repeatedly, by Sir 
Everard Home and Mr. Charles Bell, without obtaining more 
than temporary relief. At length he was seized with apoplexy, 
and lay insensible for some days, and in great peril, from the 
attack, but finally recovered. After the apoplexy the parox- 
ysms of tic-douloureux became less frequent and less severe, 
and were administered to satisfactorily by an ingenious physi- 
cian, who wrote his inaugural exercise on the disease. For 
the last year or two of his life, his lordship ceased to suffer from 
the tic-douloureux, and died at an advanced age, without any 
marked malady. While I attended him he underwent repeated 
exfoliatione of the alveolar process of the teeth^hich I thought 
occasioned his torment." 

Doubtless, the exfoliations being completed, and the disease 
of those parts removed, the irritation ceased, and the patient 
recovered. It is melancholy to think of the protracted suffer- 




I 

I 
I 



ing which rendered the life of this unfortunate nobleman 
wretched and comparatively uselcas, and which might probably 
have been cured with little difficulty, if such men as Sir Eve- 
rard Home and Mr. Charles Bell had been aware of tlio sym- 
pathetic disorder which may be, and often is, produced by 
diseased teeth. These eminent gentlemen not only did no 
good, but they inflicted great additional pain on their unhappy 
patient ; but, doubtless, ho would have fared little better in 
other bands, for the profession, while searching with powerful 
microscopes for causes of disease, entirely overlook the teeth, 
though reason and experience, the demonBtrations of the ana- 
tomist, and the voices of the most discerning of the masters 
in medicine, are continually pointing them to the important 
sympathies of these organs. 

From its relation to the teeth of the upper jaw, the fanga of 
which frequently perforate its floor, the antrum is often the 
seat of disease of a serious and sometimes fatal character, 
resulting from irritation produced by diseased conditions of 
these highly sensitive organs. Indeed, the teeth are directly 
or indirectly concerned in most of the diseases of the antrum. 
Boyer, Deschamps, Ilarris, and most others who have written 
npon this subject, give united testimony to this fact. 

Dr. Harris, in the second edition of his valuable work on 
Dental Surgery, records several cages 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 : — 

Cabe 28. (Dr. Harris.) "Mrs. L., at twenty-seven or 
twenty-eight years, of a scrofulous habit, had been at times 
affected, for more than two years, with a deep-seated pain in 
the right side of her face, midway between the orbit and the 
alveolar ridge, and on closing the left nostril, and making a 
violent expiration through the right, discharged a slightly, yet 
perceptibly fetid mucous matter, which occasionally excoriated 
the mucous membrane lining this cavity of the nose. The 
pain, from the fact that it was most severe in cold and damp 
weather, was thought to be rheumatic. General and local 




224 EFFECTS OF DISEASED TEETH AND GUMS. 

bleeding, fomentations, mustard plasters, purgatives, anodynes, 
tonics, and many other remedies, had been employed in vain. 

" A severe paroxysm of toothache, about this time, more 
than two years since she first felt the deep-seated pain in her 
cheek, induced her to apply to me. 

" On examining her mouth, the crowns of the second molar, 
dens sapientise, and first bicuspis of the affected side, were 
found to be destroyed by caries ; the gums, covering the sockets 
of their roots, were inflamed and very sensitive. It was the 
roots of the wisdom or third molar tooth that ached. Extrac- 
tion being the only remedy that held out the least prospect of 
relief, I at once proposed the operation, and, at the same time, 
urged upon her the importance of having the roots of the 
second molar and first bicuspid removed. A great deal of per- 
suasion was necessary to obtain her consent, she being of an 
exceedingly nervous and timid disposition ; but, having made 
up her mind to submit, she determined to have the operation 
performed immediately. She had no cause to regret it ; for 
not only was she freed from the annoyance which the roots 
had occasioned to her tongue, gums, &c., but the operation was 
also followed by a speedy subsidence of the pain in the cheek, 
and a cessation of the fetid discharge from the nose." 

Case 29. (Dr. Harris.) " In December, 1841, I was con- 
sulted by Mr. S. M. J , twenty-three years of age. He had 

been affected for several months with a dull heavy pain, which, 
as he said, seemed to be seated deep in his right cheek ; and 
as in the case last described, a fetid mucous matter was dis- 
charged from the nostril of the affected side, on making a 
violent expiration, though it, with the other nasal cavity, 
closed. His teeth, to all appearance, were perfectly sound ; 
but his gums, around the first and second bicuspides and first 
molar, were inflamed, spongy, and slightly ulcerated between 
their edges and the necks of the teeth, from which they had 
separated, to the edge of the alveoli. This condition he at- 
tributed to a blow which he had received by a fall, upon these 
teeth, about two years before. It was immediately followed 
by pain, inflammation, and, in about two months, the exfolia- 



I 



I 



EFFECTS OF DISEASED TEETH AND QVMS. i-lo 

tion of seTeral small portions of the alveolor proceBaea, which 
came out through the gum. These were the only unpleasant 
effects which he experienced at the time, l.'ut afterwards there 
ir»B always a slight soreness in the teeth that had received the 
injury. This gradually extended higher and higher into the 
substance of the jaw, until about four months previously to his 
calling upon me, when its place seemed i.o ^e taken by the 
kind of pain first described, and soon after, the fetid discharge 
from the nostril was discovered. 

" That the deep-seated pain in the right superior maiillary 
was occasioned by inflammation of the mucous membrane which 
lined the sinus, I could not doubt ; and that this had resulted 
from the alveolar irritation caused by the violence that had 
been infiicted upon the bicuspides and first molans, to me, was 
equally evident. I therefore proposed the extraction of the 
teeth, to which he consented. Three weeks afterwards the 
pain in bis Jaw had entirely disappeared." 

Case 30. (Dr. Shepherd.) Neuralgia vi. Toothache. — 
"Neuralgia has become a very fashionable disease now-a-djj^. 
end many persons sofier long and severely, and ransack the 
whole materia medica in search of remedies; and finally sd 
examination of the teeth is thought of, the very first thing that 
should have been done. In nine cases out of ten of supposed 
neuralgia, the extraction of some badly-decayed tooth, which 
the suffering individual knows ought to have been out more 
than a year ago, perhaps, would cause a subsidence of all 
symptoms of neuralgia. 

" As a prominent example of the above, I am induced to re- 
port the following case : — Miss C. W., a resident of this town, 
of delicate constitution, was attacked with severe pain in the 
right side of the head, neck and shoulder, about twelve months 
ago; and from the severity of the pain, and other ciroum- 
stances attending it, she came to the conclusion that it was neu- 
ralgia ; and by concurrence with her medical adviser, her opinion 
was confirmed. She used, therefore, all possible remedies for 
that disease, without success. In the mean time her attacks 
were growing more frequent and more severe ; &nd for the iMt 



226 EFFBCTS OF DISEASED TEETH AND aUMS. 

two or three months, they occurred daily at precisely five 
o'clock in the afternoon, and continued with the most intense 
severity until midnight ; when the pain would begin gradually 
to subside, growing less and less until she was perfectly easy. 
These daily attacks came on with such perfect regularity that, 
to use her own words, *five o'clock was a terror to her before 
it came.' At this stage of the disease she was in Baltimore, 
whether in search of medical advice or not, I do not know; 
but while there she consulted Dr. B., an eminent physician of 
that city ; and he advised her to have her teeth examined, in- 
timating that they might be involved; he gave her, at the same 
time, a prescription for neuralgia, to be used in case the teeth 
were not at fault. With this advice she returned home, and 
sent for me, and related to me substantially what I have stated 
above. I examined her teeth, and found the inferior wisdom- 
tooth of the right side decayed to the nerve, and I gave it as 
my opinion that all her * neuralgia' originated there ; I there- 
fore advised its immediate extraction, to which she assented. 
The first day after the tooth was extracted she had very little 
pain, the next still less, and the third none at all. 

" Thus a perfect cure was effected, of what perhaps nine- 
teen out of twenty of our very best physicians would have pro- 
nounced neuralgia, without once thinking of the teeth, by the 
simple extraction of a bad tooth. 

^^I do not offer the above as a case of rare occurrence; I 
have often met with such in the course of my dental practice, 
as doubtless dentists in general have ; and I cannot account 
for the fact, that physicians so generally prescribe for neural- 
gia, without once thinking of the teeth, when there is so strik- 
ing a similarity to true neuralgia in many cases of toothache. 
In the case above, there were some striking peculiarities, which 
would have been, perhaps, sufficient to screen the most vigilant 
from the charge of superficiality in the examination of his 
patients, though he might have forgotten the teeth. The dura- 
tion, the regular increase of pain, the extent to which the sys- 
tem was affected, and when the attacks became daily, the per- 
fect uniformity as to the time of commencement, together with 



EFFECTS OF DISEASED TEETH AND GUMS. 

ihe nervous temperament of the subject, were all circumstances 
well calculated to mislead the judgment; and yet this proved 
to be a case of toothache, a fact which might have been proved 
jnat as easily in its very commencement, if an examination 
of the teeth had been once thought of as a matter of any 
consequence." 

The cases above mentioned are but a few of a great number 
that might be collected, showing the importance of the teeth, 
in their healthy and iiaheaUhy conditions, to the well-being of 
the whole economy. Surely those here presented will be suf- 
ficient to arouse the physician to the necessity of regarding 
the agency of these organs in the production and continuance 
of diseases, and to impress the dentist with the importance of 
pursuing his vocation, not as a mere mechanical craft to be ex- 
ercised upon isolated escresconces of the body, but as a part 
of curative science, embracing in its relations, the knowledge of 
diseased life as manifested by many organs, or by them all. 
The general surgeon must bo more than a mere cutter of flesh 
or aetlor of bones; the obstetrician more than a man midwife; 
and the dentist ia unworthy of the confidence or respect of the 
community who ia not well-informed upon the nature and his- 
tory of disease, and the part which the organs upon which he 
operates perform in its causation, or modification. 

It is strange that physicians have paid so little attention to 
this subject. It would be less so, if so many of the ablest 
writers among them had not so earnestly and repeatedly pro- 
claimed the importance of giving to the teeth their due con- 
sideration in the diagnosis of disease. But when Hunter, Rush, 
Darwin, Ilalford, Chapman, and other such men, have taken 
special pains to direct the attention of the profession to the 
subject, it is unaccountable that their Toices have been alto> 
gether unheeded. 

Unfortunately, it has now become the fashion to study patho- 
logy in the corpse-house, rather than by the bed-side ; to make 
microscopical inquisitions of disease upon the dead, rather than 
to observe its phenomena in the living. From the very neces- 
uty of the case this necrological research falls into the hands 




228 



EFFECTS OF DISEASED TEETH A>ID GUMS. 



of the young and inexperienced, and these become writers and 
teachers before they have been to the only sure school of medi- 
cine, the chamber of the sick. As the teeth may be seen by 
the naked eye, they are not likely to be considered of mnch 
importance. Had they been discernible only by the micro- 
scope, they doubtless would have received due conside ratios. 
It is said that the celebrated Pennant, by use of the micro- 
scope, lost the use of his eyes. I fear that this is too com- 
monly the fate of his succesBors. 

I fully coincide with Dr. Fitch, who well remarks: "We 
are not to contemn the diseases of the teeth because tbey seem 
insignificant. Many persona are formed of a fibre so fragile, 
as to be broken by the slightest shock; of a stamina so deli- 
cate, as to he affected by the slightest impression. Disease in 
its steps at first is, as it were, soft and hesitating, weak in ita 
powers, and slow in its progress. But every instance of in- 
dulgence, and each succeeding advantage gained, confirms its 
step, increases its powers, and hastens its progress, and what 
but a moment ago seemed a thing too insignificant to mention, 
now rises a monster that derides human effort, and whose sting 
is the arrow of death. 

" Almost inappreciable are the beginnings of many fatal dis- 
eases ; and could the grave reveal its secrets, I have not a doubt, 
when I consider the number of diseases produced by diseased 
teeth, that it would be found that thousands are there, in whom 
the first fatal impulse was given by a diseased state of these 
organs; and could I raise my voice so as to he heard by every 
medical man in America, I would say to them, attend to your 
patients' teeth, and if tbey are diseased, direct such remedies as 
shall restore them to health ; and if in health, such means as 
will keep them so." 





CHAPTER XVIII. 



WOUNDS OF THE MOUTH AND FACE. 



The face, witK all the organs which enter into its structure, is 
exposed to the several forms of injury which are known hy the 
common name of wound. 

Surrounded as the human body is by a great number of suh- 
stances denser and more resistant than itself, it is liable to liave 
it3 tissues separated, penetrated, torn, violently compressed, 
or broken asunder. Consisting, also, of a number of ele- 
ments constituting organized parts, and hold in union by tho 
mysterious force of vitality, it is also liable to have this union 
dissolved by the action of forces more powerful than life, and 
to be chemically disintegrated. 

As the face from the necessity of the case must be uncovered, 
and as from its position it is most liable to bo injured by falls 
or reached by malicious blows, it is more frequently wounded 
than any other part of the hody ; and owing to the deformity 
vhich attends scarring of the countenance as well as tho Im- 
portance of the organs connected with it, facial wounds require 
more nicety in their management than any others. 

The mouth is very frequently involved in these injuries, and 
the teeth are often displaced or fractured by them. The mani- 
pulations required for the reparation of these wounds require 
a dexterity only to he acquired by daily observation of tho 
teeth in their natural positions, and the habit of handling and 
operating upon them. The dentist, if believed skilful, is there- 
fore often called upon, even by the general surgeon, to aid in 
the management of such cases. 

In medical language, a wound is a recent lesion or interrup- 




230 



WOUNDS OF THE MODTH AND FACH. 



tion of the coiitmuity of parts from an external cause ; but tte 
term is made to include all hurts received from agents acting 
mechanically or chemically upon the surface of the boJy. 

Wounds differ materially from one another, in kind, estent, 
pOBition, and character of the parts ivounded. 

When the parts are merely divided by a clean, sharp instru- 
ment, with as little injury to the separated tissues as possible, 
the wound is called a Simple Incision — {simple incisfd wound). 

If the parts be rudely torn asunder, the injury is called a 
Laceration — (lacerated wound). If the part be violently and 
suddenly compressed, so as to rupture some of the small ves- 
sels and break or otherwise injure the muscular fibre, skin, kc, 
the injury is called a Contusion, or Bruise — {contused wound). 
If a pointed instrument be forced into the body, penetrating 
tissues, it causes a Puncture — {punctured wound). If a bone 
be broken, the wound is called a Fracture. Injuries from 
bodies propelled by gunpowder are called Gun-shot icoundi, 
and from fire, Burns. To these may be added Poisoned wounds, 
or those in which a slight puncture or trivial laceration becomes 
the means of introducing venomous matter into the system; 
Buch wounds are inflicted by certain insects, serpents, and rabid 
anitnals. 

Simple Incised wounds are, per ao, the least serious of all 
injuries, though from the flow of blood which attends them, 
they are generally the most alarming. 

In these cases the parts are simply separated, of course not 
without injury at the immediate line of division, but without 
any which suspends the vital action of the separated surfaces, 
or breaks up their relation, so as to render readaptation diffi- 
cult. 

Of course these wounds may be of the most serious nature, 
or immediately fatal, if large vessels bo divided or vital func- 
tions interrupted by them. In these cases the danger is not 
from the nature of the wound, but from the accident of its 
seat. 

Commonly the most alarming and most dangerous complica- 
tion of incised wounds, is the bleeding or hemorrhage wltioh 




attends them. This will be greater or less, according to the 
size anJ character of blood-vessels divided, the form of the In- 
cision, and tho vascular activity, &c., of the patient. 

A wound of this character may be attended by veaoua or 
arterial hemorrhage. 

A alight incision will commonly be attended by a gush of dark- 
coloared blood from the superficial veins. This flows freely for 
some minutes, but if the wounded part be not officiously bathed, 
and especially if it be bound up, the hemorrhage soon ceases, 
and docs not again return. 

Sometimes the gush is so considerable as to cause the pa- 
tient to faint, or, in medical language, to induce syncope.* In 
this condition the patient has temporarily lost hia conscious- 
ness, his skin has become cold, and his pulse ceased to be per- 
ceptible. 

This state, though apparently very dangerous, is by no means 
so, unless the patient has previously been much exhansted. On 
the contrary, it is salutary ; for it checks tho hemorrhage, and 
affords time for the permanent closure of the wound in the way 
to be described presently. 

As the syncope depends upon the want of circulation through 
the brain, the patient should be placed in a recumbent position 
with his head low. If fiiinting he feared in any case, this is 
the best position and the best means to prevent it. 

The arrest of venous hemorrhage depends upon the singular 
and most important quality possessed by the blood to solidify 
or coagulate when exposed to the air. Without such a provi- 
sion, the slightest wounds would be very troublesome, and often 
fatal. 

As soon as a coagulum forms about the orifice of the wounded 
vessel, the bleeding ceases, and the current of blood, finding no 
longer an artificial egress, pursues its natural course. 

It IS evident that if the flow of blood bo very great, or if the 
wound be very large, tho coagulum will be longer in forming a 
sufficient barrier to the hemorrhage. For the blood must be 



k 



■ Sjneope, ZuyuTra — I fall down. 



J 



232 WOUTDS OF THE MOUTH A^fD FACT. 

at rest before it can coagolatey and the amount which, nnder 
these circumstances, will be arrested by the edges of the 
wound, etc., and detained nntil coagulation, will bear but a 
small proportion to the current, and will be constantly washed 
away by it. 

It is in such cases that fainting is sure to occur, and by this 
means the flow being stopped, the blood at the moment filling 
the wound is arrested and coagulates before the action of the 
heart is recovered. 

Sometimes, howeyer, it happens that small veins will bleed 
obstinately and profusely ; owing to the peculiar irritation of 
the wounded part or the indisposition of the blood to coagulate. 

It is evident that compression of the lips of a wounded vessel 
so as to obstruct its channel, is the readiest way to stop the 
hemorrhage, and that as the flow of blood in the veins is to- 
wards the heart, the pressure should, when these vessels are 
wounded, be especially upon the distal extremity of the 
wound. Inasmuch, however, as the veins anastomose^ freely, 
pressure must be exerted upon both sides of the wound. 

As soon as the flow of blood through the vessel is arrested, 
the blood begins to coagulate at the point where it is impeded, 
and in a little while a plug of coagulum effectually stops each 
end of the divided vein. 

It is never necessary to tie a vein, unless it be of the largest 
size, and the operation is always very dangerous. Arteries 
may be tied with impunity ; but the veins, when thus treated, 
are very apt to develope an inflammation of their lining mem- 
brane (phlebitisf) which is rapidly propagated to the heart, and 
is generally fatal. 

Styptics,! of many kinds, have been employed more or less 
for ages, for the stay of hemorrhage. 

These are astringent substances which corrugate the animal 
fibre, thus contracting the orifice of the wound, or articles of a 

* Anastomose— communicate by a number of mouths; from Ava, and 
ItcfAA, a mouth, 
t Phlebitis, from ^xi^y ^ "^tm. % Styptic, from Zrv^tiy, to constringe. 



I 



WOUXDS OF THE MOUTH AJTD FACE. 233 

poroua or loose texture, which arrest a considerable quantity 
of blood, and thus form a clot. 

Alotn, the mineral acids, cold water, &c., are of the first 
slsss; agaric, spoDge, spider's web, fur, &c., of the latter. 

These articles are only useful where small saperGcial vessels 
lure concerned. 

Arterial is far more serious than renoua hemorrhage. The 
Arteries circulate more blood and with more rapidity. The 
blood from an artery is red, that from a vein purple and nearly 
black; the blood from a vein flows steadily, from an artery it 
Sows by leaps or jerks (per salturo). These characteristics 
will serve to distinguish the nature of the vessel injured. 

The rule, however, is not without exceptions. If a vein lay 
directly over an artery, the impulse of the latter may be so 
sensibly communicated to the former as to cause the blood to 
flow per saltum. Again, in one instance the author found the 
Tenoua blood of a plethoric patient to be as red aa orterial, 
when issuing from the orifice. This, however, is very rare. 

The loss from arteries is therefore much greater than from 
veins. Moreover, the arteries contract and expand, and force 
their blood by this process, through their canals in jels or 
guahet. 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 » clear 
incision, will continue to bleed until the patient succumbs from 
ezhaufitton, unless artificial aid be afibrded. 

The means of arresting arterial hemorrhage ore, compressioD, 
Kgatnro, laceration, and the actual cautery. 

Compression may be exerted either upon the trunk of the 
vessel at a spot nearer the heart than the wound, and where 
ita 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 tempo- 
rary relief, as the current of blood will soon find its way 
through anastomosing branches Into the vessel beyond the im- 
peded point; upon the lips of the wound, unless very much 
fiivoured by posiUon, it can rarely bo perfect, as the arteriea 



k 



284 WOUKDS OF THE MOUTH AND FACE. 

for the most part lay deep, and the means of compression most 
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 modem over ancient surgery. 

The ancients supposed that the arteries contained a myste- 
rious something, which they called the animal spirits, and to 
prevent the egress of this, they resorted to the actual cautery ; 
thus adding 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 
coat, being firm and strong, remains unbroken ; the middle and 
the inner or serous coat, are always lacerated. 

The efiect 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 inflamma- 
tion by the exudation of coagulated lymph. 4th. To cause 
the formation of a coagulum in the obstructed vessel; and 
oth. To cause ulceration of the outer coat, by which the liga- 
ture 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 
circulation should receive it through other channels. But this 
means is provided in the facility with which, under these cir- 
cumstances, the anastomosing branches are enlarged. Through 
these rapidly-expanding canals the current of blood presses 
towards its destination, 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, 



WOUNDS OF THE MODTH AND FACE. 



235 



sround the artery, great care should be had not to enclose in it 
the nerve or vein which cominonly attend the former. Serious 
and even fatal coDseqaenceB would follow such a blunder as 
this. When the external coats of the vessel are so aoft as to 
give way before the ligature, a little of the surrounding cellular 
tissue or muscular fibre may be enclosed within tho 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 arrest- 
ing hemorrhage. 

When an artery is torn, the internal coat is, of course, brought 
into the condition produced by the ligature, except that tho op- 
posing surfaces are not pressed together. It generally happens, 
however, that the shock of this kind of injury interrupts the 
contraction and expansion of the vessel, and a coagulum is 
thus permitted to form. This mode of operation is only pro- 
per when we have to deal with small vessels. Their bleeding 
may generally be arrested by seizing them with the forceps 
and twbting them so as to rupture their internal coats. 

■ The actual cautery* is a terrible means, which should only 

I le used under peculiar circumstances. 

We have already said that until within a comparatively short 
period, scaring with a red-hot iron was the means commonly 
employed to arrest arterial hemorrhage. Stumps, after ampu- 
taUon, 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 tho animal fibre, is an eSToctual preventive of 
hemorrhage, and may be resorted to when there is no other 

< Tflsonrce. 

I It sometimes happens that an injury is done to a bone, which 

' (^ens an artery imbedded in it ; the same happens, occasionally, 

* Tlie Mtual Cftul«r7 in fire or a heated bodj, th^patmiial certain cliBml- 
cal subataaoe, wlueh cDmbloe vitli utd desiro; tlie tiaaatB, u nil. of tUftr, 
pnrtpotow. tx. 




WOCNDS OP THE MOUTH ASD PACH. 

in operating npon these organs. Under such circumstanccB, 
it is Bometimes impossible to use a ligature. 

It also iiappens oeciisionallj that in the extraction of a tooth, 
& vesael is ruptured which continues to bleed freely for hours, 
and eyen days, after the injury ; and the hemorrhage is uot 
only exeeedingly inconvenient, but sometimes is sufSciently 
great to be alarming. 

Under these circumBtances, after ineffectually stuffing the 
socket with lint, ic, 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 pa- 
tient, 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 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 organ- 
ized, 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 oc- 
casions the least deformity. It is, therefore, especially dea- 
rable 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, 
Tery desirable in all wounds of the mouth. 

It will be noticed, that we propose no means for curing 



WOnNDS OF THE MOCTH AND PACE. 



2S7 



I 



;V0iind3. The truth is, we havo none, and none are wanted. 
Mature is abundantly capable of repairing thoao 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 sur- 
faces. 

There is no virtue in salves or balsams to heal simple in- 
cisions ; 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, 
sntures, and bandages. 

Of these, adhesive plasters are the most important. They 
are generally sufGcient 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. 

Sutures or stitches, are threads passed through the lips of 
the wound and then tied, holding the divided surfaces together. 
When vpry 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 sufEcient sound surface upoa which to fasten the 
plasters ; in such cases, sutures arc useful. 

Lacerated wounda 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 oven when large arteries are torn 
afiunder. Cases have been observed where the arm has been 
torn from the shoulder by machinery, and the arteries 1 
hanging out from the wound, yet no serious bleeding ensued. 
Is the ezperimeat by Dr. N. R. Smith, the carotid artery of a 



I 



238 WOCYK OF THE MOUTH ASh FACS. 

W/ne^ wLe& mptured bj a Unnt hook passed under it, bled bat 
Hide. TLe ^bietiCe of Utedmg in extensiTe lacerations, though 
immtdlztelj conTeniexkt, ret indicates an amount of injury to 
the parts far greater and far more difficult to remedy than that 
irhieh attends incisions. 

The pans may be entirely destroyed ; or their vitality may 
be so far lessened as to make them incapable of resisting the 
inSammation which irill re^t, and caose them to mortify. 

Wounds of this kind do not heal by resolution ; they will 
suppurate, and consequently the cicatrix that results is more 
unseemly than is left by simple incised wounds. The pain 
is generally in inrene proportion to the extent of the injury : 
small lacerations canying 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 indication in lacerations are 
to cleanse the wound of any foreign substances, such as sand, 
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 ap- 
plications, 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 ag- 




grsTated cliaracter, which was treated in the way described by 
Dr. N. R. Smith. The patient was a boy, whoso hand had 
been caught in an agricultural machine. Hia 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 fingers were, for the moat part, disorganized, and the organ 
presented so hopeless a condition, that amputation seemed in- 
evitable, and I>r. Smith was invited to perform the operation. 
This esperienced and skilful surgeon, while he admitted the 
apparently 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 imperative character should supervene; that injuries of the 
hand were not apt to occasion tetanus ; and that he would advise 
to let the wounded member alone, to see what nature would do. 
A few spicnlac of bone were removed, and the hand was, 
without having been washed, bound up in its own hlood. 

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 n stump would have 
been. 

Contused wounds do not differ very materially from lacera- 
tions. They, too, require to be let alone, unless the infiamma- 
tion succeeding bo so great as to require the treatment hereto- 
fore described 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 extra- 
vasation, the colour becomes greenish and yellowish, and finally 
disappears. 

With regard to both these kinds of wounds we may say, that 
whatever treatment they require is demanded by theinfiamma- 
tion which follows them, and must be modified to suit the degree 
and character of it, without regard to the traumatic cause of it. 
Punctured Wounds. — These are injuries made by a pointed 
instrument, penetrating to some depth, and characterized by 



k 



240 WOUNDS OF THE MOUTH AKD FAOH. 

an opening yer j small in proportion to the extent of the wound. 
Very often, the instrument bj 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 
seyere injury than a simple incision. It is both a lacerated 
and contused wound, and of course is fraught with the pecu- 
liar dangers attending such injuries. But, moreover, it is in- 
flicted upon deeply-seated parts ; vital organs may be reached; 
large vessels and nerves punctured ; even bones penetrated or 
splintered. 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 adjacent parts, acting as an irritant, and spreading in- 
flammation in its course. 

The constitutional impression also is greater when deep- 
seated parts are wounded, than when superficial injuries, even 
of greater extent, are sufiered. 

The danger of punctured wounds depends upon the extent, 
situation, and character of the injury, and the age, constitution, 
&o., of the subject. 

The indications for the treatment of a punctured wound are, 
Ist. To remove any fragment of the instrument by which the 
ixyury has been inflicted ; 2d. To secure any artery which may 
have been wounded ; 8d. 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 abun- 
dantly competent to complete the work without active assistance. 
Some surgeons ii^ect 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 wound 
open, and lengthen it so as to convert it into a deep ineision. 



WOUNDS OF THE MODTH AND FACE. 



241 



This is often impracticable without doing vast injury, is always 
painful, and when accomplished will not prevent the natural 
consequences of the laceration already suffered. The object 
of ibis practice is to prevent the accumulation of the matter; 
but generally it will escape readily enough ; and Burely it will 
be time enough to provide for the evacuation of retained matter, 
when it shall bo 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 granulations from the bottom and the adhesion of the sides 
are completed. 

The tent should be removed every day, and a shorter one 
introduced, from time to time, until the cure be completed. 

Constitutional symptoms are to be treated upon general pria- 
dples. Before inflammation is established, and while the ays- 
tem is suffering from the pain and shock, opium will be our 
most iiuportant means. Should inflammatory symptoms run 
high, bloodletting and other antiphlogistic means will be re- 
quired. 

Oun-«hot Wounds are violent contusions made by dense 
bodies moving with great momentum. The injuries thus in- 
flicted 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 npon the principles which 
apply to all other mechanical injuries. If the ball or other pro- 
jectile 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 
nuiBol^ without causing 

31 




a 




242 WOUNDS OF THE MOUTH AND FACB. 

The notion which prevailed formerly, that lead, when pro- 
jected by gunpowder, is poisonous to the flesh, is a mist&ke. 
This metal does no injury, except by its weight. 

Burns. — Injuries caused by the action of fire or heated solid 
bodies are indiscriminately called burns ; 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 clamour for relief, and the dogmatic empiricism with 
which nostrums are insisted upon by professional men, who are 
unable to give any satisfactory reason for the extraordinary 
confidence in their own suggestions. 

Some years ago a steamboat started from the wharf in tbb 
city, upon a trial trip, and exploded before she had gone a 
hundred 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, labouring under great 
constitutional irritation. 

Under these circumstanceB, 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, 



WO0ND3 OF THE MOCTH AND FACE. 

with many other applicatiooa, have been strongly advocated as 
dresainge 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 s feeble patient, whose whole constitutional effort cannot 
accomplish reaction. 

The danger of burns ia in proportion to extent rather than 
degree. A small portion of the body might be burned to com- 
plete destruction, with far less danger than a large surface 
could be reddened and vesicated. 

Scalds, therefore, which are superficial burns, are very dan- 
gcrons, because, from the diffusible nature of their cause, they 
are generally extensive. 

The reason ia, Ist. Because the pain of burns ia the prime 
cause of the constitutional distress, and of the serioua or fatal 
consequencea that ensue, and superficial burns of the skin are 
generally most painful and moat extended ; 2il. The skin haa 
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 persons scalded in 
steamboat explosions are 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 ti> 
protect the irritated surfaces from the air, which is most dia- 
tresaing to them. To this end, nothing is better than the raw 
cotton, which, to prevent its adhesion to the sore, should bo 
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 ia 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 



1 



244 WOUNDS OF THB MOUTH AND FAOB. 

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. 

An admirable application, which I have found to be attended 
with the best effect upon a superficial bum of the face, to which 
it was applied, is raw cotton steeped in solution of gun cotton. 
The application at first causes some smarting, but as the ether 
eyaporates, the part becomes easy and remains remarkably 
comfortable. 

If there be no blistering or abrasion of the surface, the in- 
jury being severe erythema, cold wat^r will give immediate 
relief- 

Sometimes the part upon which the bum has been immedi- 
ately inflicted will be disorganized or nearly so ; the surround- 
ing parts, and those subjacent, partaking of the injury in 
proportion 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 bums, 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 
whose hands were rendered entirely useless through neglect of 
this precaution. The palms had been bumed, 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. 




WOUNDS OF THE MOUTU AND PACE. 



A fracture is a solution of continuity of a bone, produced 
by violence, acting either by some external agent, or, occa- 
sionally, by the sudden and extraordinary contraction of 
moscles. 

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. 

CiBteris paribus, a simple division of the bone transversely, 
or a longitudinal fissure of moderate length, will involve much 
lees suffering from injury to the soft parts, and will be much 
more likely to heal without deformity, than a fracture which ia 
oblique ; because, in the former cases, there will be hut 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 ri<le upon the 
fixed portion. The action of the same muscles is of course 
continually opposing the force used to keep the restored frag- 
ment in place. 

Fractures may be comminuted — that is to say, the bone may 
be 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 and skin, protrusion of fragments of 
bono 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 fractur«» | 
consists in meeting the following indications : Ist. To restore I 
the displaced pieces of bono to their natural position. 2d. Tv* 1 
keep them there ; and 3dly. To afford any additional aid whioh I 
the nature of the injury and the constitutional circumstanCMj 



UNE uwm. %\mmi ^m 



WOUNDS or THE MOUTH AND FACB. 

may require. It does not always happen that the fragmenta 
are displaced. In such cases the duty of the surgeon, bo far 
as the condition of the bone is concerned, requires no more 
than to support the parts, and place them in such a position as 
vill beat guard against displacement. It will be seen that the 
surgeon has nothing wiiatever to do with the production of 
bonj union. That is entirely the work of nature, and is ac- 
complished by the formation of a hard intermediate substance, 
which is called callue. 

Soon after the injury, a swelling ia observed around the 
broken ends of the bone, which gradually hardens until it Bur- 
rounds the fracture with a kind of bony splint, within which 
the process of reparation goes on. Thia is called the provi- 
atonal calliig. As the cure advanceB, this hard swelling suh- 
sides, though it rarely entirely disappears, and the bone is 
found to be permanently united by an organized osseoua sub- 
stance, which well subserves all the purposes of the lost bone. 

According to the experiments of Breschet and Villerni, the 
following are the principal circurastances 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 tho periosteum and the bone, and likewise 
exuding from the Burfaces 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 connexion 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 tho character of bone. 

4. At the fractured parts a reunion of tho periosteum and 
soft parts, which are equally indurated and confused together 
with the intermediate substance between the fragments. 

5. A diminution and then an obliteration of the medullary 




WOUNDS OP THE MOOTH AKD FACE. 



24T 



P 



cavitj, at first bj a cartilaginous, and then by & boD^ deposia j 
tioD. 

6. Successive ossification of the whole of the swelling 00014 1 
posing the callus, and of the substance between the fragmento^ | 
preceded by a fibrous and cartilaginous Btntc. 

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 me- | 
dullary cayity and texture are gradually re-established, and \ 
tlie 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 between the thirtieth and fiftieth days, that nature 
labours efi'ectually in consolidating the callus. Hence, at thia 
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 reduccd-f 

FractureB of the Jaws. — The lower jaw is liable to be frao* 
tared at any part of its extent, as between the symphysis and 
tbe masseter muscle, within the muscle, and between it and the 
■ogle. The bono may also be broken into two pieces simultane- 
ously. Sometimes, also, the condyles, and less frequently the { 
coronoid processes, are broken oflT. 

Fractures of this bone may be perpendicular, oblique, or lon- 
gitudinal. Sometimes a part of the alveolar process with its 
teeth has been split ofi'. 

When the fracture is near the symphysis, the submaxillary 
Buscles 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 




Cooper's Sorg. Die, Art. Fractures. 



t Bojer. 



248 wwnnm or the mouth avb facb. 

dose tbe moiitli* When frmctored in two places, the middle 
fragment will be drawn downwards and backwards, while the 
lateral portions will be s upp ort e d bj their mnscnlar attach- 
ments. When the fracture ooenrs within the masseter, little 
dtfplacement can take place, as tbe mnscle attached to both 
fragments keeps diem in their natural position. 

Fractures of the lower maxillary may generally be detected 
without much difficolty. 

Itj after a serere blow or fall, there shonld be severe pain in 
the jaw, attended with laceration and swelling of the soft part ; 
if the line of the bone be irregular ; if crepitus be felt ; if the 
gums be denuded, and if the lerel of the teeth be interrupted, 
there can be no doubt that fimcture has occurred. 

Nor is it necessary that aU these appearances shaU be pre- 
sent in order to satisfy the obserrer of the nature of the injury. 
As the bone can be traced with the finger along its whole 
length, and its level obserred both upon the upper and lower 
margin, the displacement or crepitation, and the pain or dis- 
ability 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 pro- 
perly 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 perfo- 
rated for the reception of the chin, and the two ends divided 
longitudinally, so as to make two tails on each side. The an- 
terior of theie 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, 



WOPHDS OF TAB MOCTH AND FACE. 



249 



refraining from talking, and subsisting npon floid or semi-fluid 
food. 

Sometimes a tooth will be split in the fracture, and must be 
extracted. It eometimes happens, also, that the teeth are so 
irregular as to prerent the complete closure of the jaws, in 
which case a piece of cork may be so placed aa to accomplish 
the purpose of supporting the lower by pressare against the 
upper jaw. 

Dr. Rhea Barton, of Philadelphia, devised a bandage for 
fi«etare% 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 bono across the juncture of the coro- 
nal and sagittal sntures, 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 ob- 
liquely around and parallel to the basis of tho lower jaw over 
the chin, and continues the same course on the other Bide, 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 aa well as wo 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 bo treated as similar 
injuries elsewhere. Every attention must be paid to insure 
cleanliness, contact, and rest of the parts, and constitutional 
symptoms are to be met by antiphlogistics, anodynes, and to- 
nics, as cases may require. 



The forcing of articular surfaces out of thoir relativo posi- 
tion is called a dislocation or luxation, or familiarly, putting 

* Reese, Note Cooper'i Surg. Kcl. 
f Dit /oca, to got oul of place. 




out of place. These injuries require surgical aid, it being 
rarely possible for the patient to replace the bone by his own 
efforts. 

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 alnays 
more or less concerned both in effecting dislocation and re- 
pairing it. 

Iiuxationa 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 Tiolent 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. 

Dinlocations of the Lower Jaw. — From the latitude of motion 
enjoyed by tbo 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 bo 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, elo- 
Tating and pulling forward the posterior part of the bone. 



WOUNDS OP THE MOOTH AND FACE. 



251 



Dislocations of tlie jaw are very painful, gwing to the prea- 
Bure of the condyles upon the deep-seated temporal nerves, and 
those which go to the masseter, which nerves pass before the 
root of the zygomatic processes. — (Boyer.) The mouth ia open 
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 
.ooronoid process forms under the cheek bone a prominence 
irhich may be felt through the cheek or from within the 
Bouth.'*' 

Upon the whole, it ia not easy to mistake the character of 
the injury. 

Dentists should he aware of the possibility of such an acci- 
dent as this when extracting a tooth, and should guard against 
■uch a position of the jaw as would be favourable to it. It may 
happen, however, even In the hands of the most skilful and 
prudent, and they should be prepared to reduce the dislocatioa 
immediately. 

Mr. Fox dislocated the jaw of a patient on both sides, while 
endeavouring 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 bis 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 
j»w. 

• Cooper's Surg. Diet. 




252 WOUNDS OF THB MOUTH AND FACB. 

Efforts at reduction may be confined to one side, if one only 
be dislocated. 

In order to prevent a redisplacement, the jaw shonld 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. 



253 



CHAPTER XIX. 

PARTICULAR AFFECTIONS OF THB MOUTH AND ADJACENT PARTS. 

DISBASBS or THE OUM0. 

Of inflammation of the gums I have already treated, in con- 
sidering the general subject of inflammatign. They are liable 
to other disorders which arc worthy of notice. Among these 
are tumours, termed epulis* and parulis.f These tumours dif- 
fer entirely in character. The parulis is an abscess, the resuU 
of suppurative inflammation ; the epulis a true tumour or mor- 
bid growth, seated upon and involving the structure of the 
gum. Parulis is therefore a distension of the parts by injected 
blood and effiised matter ; epulis is an addition of organized but 
unhealthy substance, increasing the solid bulk of the parts. 

The term epulis is applied to diiferent excrescences seated 
upon 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 neighbouring 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, 

* Epolis — trif upon, cva«v, the gam. 
f Parolia — irtif*, near, wxff the gam. 

22 



SM 



AFFECTIONS OF TEE MOUTH, 



as it is not very eenaitive. It Ib 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 inay be perfectly sound. Some swelling of 
the gums and a discharge of pus accompanies this condition. 

A. smooth, shining, clastic tumour sometimes shows itself 
upon the gum. It is compressible, but little sensitive, and 
bleeds freely if cut into. It is not malignant. 

A scirrhuB may be located in tho gum, where it will exhibit 
its distinctive qualities, hardness, acute lancinating pain, and 
unequal surface. It follows tbo history of similar tmuours 
elsewhere, 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 pre- 
viously hard they soften, the bonea become carious, a fetid and 
sanious discharge is poured out, the teeth are loosened, the de- 
vastation spreads, the lymphatics swell, hectic supervenes, and 
after much severe suffering the patient expires, from nervoos 
exhaustion, hemorrhage, or suffocation. 

1 tho tumour is of tho non-malignant kind, and has not 
f progressed as to involve a largo mass of bone in caries, 
wft parts in ulceration, it may readily be removed, and its 
1 be prevented, by the removal of the carious teeth which 
cause it, if, as is generally tho 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 de- 
cided means must be resorted to, to prevent fatal conse- 
qucncee. 

Mr. ListOQ and Prof. Mutter both regard gcnuino cancer of 
the gums as a very rare disease ; but they concur in thinking 



AFFECTIONS OF THB MOUTH. 255 

that such affections are degenerations from original character, 
owing to constitotional causes, neglect, or bad treatment. There 
i8| therefore, more encouragement to hope for success in the 
attempts made to remove these affections, than when they are 
bat 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 tumour, and destroy what 
may remain of it by compression or caustic. 

If the tumour 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 
tumours, and will generally demand the use of the actual cau- 
tery for its suppression. 

The scirrhous or malignant tumour 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 tumour, with a pair of strong scissors, or rather 
catting forceps, and without stopping to arrest the hemorrhage, 
at once detaches the mass, by dividing the alveolar process 
above or below the tumour, as the upper or lower jaw happens 
to be involved, with cutting forceps, one blade of which is ap- 
plied 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 disease removed with a knife or scissors. If the bone 

* Liston and Mtttter's Surgery, p. 2S6. 



appears affected, it must bo cut away, and often a very good 
preventive to the return of the disease is the nse of the actuitl 
cautery. The hleeding may be arrested, either by the cautery, 
or by placing a pledget of lint, dipped in creasotc, in the cbaBin, 
over which a slice of cork may be laid, and then closing the 
jaws, make the sound one act as a compresa. To secure the 
dressing, the bandage for fracture of the lower jaw may be ap- 
plied. 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 he 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 bo applied, until this disposition in the wound is de~ 
stroyed, 

" Instead of using the perpendicular cuts with the short for- 
ceps, some prefer a thin saw, but the method just described is 
less painful, and accomplishes the object in a much shorter 
period. When the tumour is very large, the saw may bo re- 
quired, and should be always at hand, in case tho edges of the 
forceps should turn in making the first cut. 

"When the tumour 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 
fonnd 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 tumour, 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 
oheek maybe closed, and union by the first intention attempted; 
and when the dressings arc carefully attended to, tho 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." 



AFFSCTIONS OF THB MOUTH. 257 

Of whatever kind these tumours may bo^ 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 be- 
come painful during the movements of the jaw or contact with 
air or food, they should be extirpated. If pendulous and ac- 
cessible, a ligature or the knife may be used ; but if broadly 
based and fully incorporated with the gum, and but small in 
sixe, caustic will be required. 

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 epulis. In 
truth, all forms of tumours may appear upon the gum, and the 
only difference to be observed in their treatment in this loca- 
tion, grows out of the impossibility of using applications and 
appliances which are found useful and convenient elsewhere. 
So far as tumours 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 re- 
moved ; if with carious alveoli or maxillary bones, the treatment 
must be directed to the deep-seated cause ; if they are malig- 
nant, 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 tumours in other soft parts, and generally, if 
not always, depends upon carious teeth. 

Sometimes the abscess makes its appearance without prece- 
ding pain, over the fang of a diseased tooth, and after remaining 
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 abscess succeeds 
a violent and protracted toothache, 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 sensation, due 

to the inflamed state of the gum tissue. Sometimes several 

22» 



days and nights of severe suffering will elapse before the ah- 
scess ia 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 tumour softens, the pain abates, and 
fluctuation is perceived in the tumour. 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 check, and the pus bo evacuated 
on the outside. This is an accident much to bo deplored, and 
therefore, as soon as fluctuation is perceived between the gum 
and cheek, the pus should be evacuated. 

During the inflammatory stage of the tumour, before pus is 
formed, little can be done except to apply leeches to it. These, 
if applied very early, will sometimes prevent suppuration, and 
more often limit its extent. After the tumour 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 tumour ia due to alow suppu- 
ration of the fang or alveolus, and in this case the matter con- 
tinues to trickle through the opening, the edges of which become 
thickened and hard, and a fistula ia formed. 

Of course, the only remedy is to remove the diseased tooth 
or bone. 

It not unfrequently happens that abaccssca are formed at the 
roots of teeth which appear sound, and after much paJn 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. 



r 

si 

d 



AFFECTIONS OF THB MOOTB. 



259 



k 



The late Mr. DeBJardins, surgeon, requested me to visit 
with him M. Rose, Place de Gr&vo, 

This patieDt 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 hy Jay. 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 disease. 
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 per- 
ceive, 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 tooth. From the reflection of the light, we satisfied 
ourselves that the incisor tooth nearest to the canine was the 
cause of all the suffering. The enamel substance seemed to 
have lost its usual transparency. Finally, to be more certain, 
I pierced the exanthema, and serous blood flowed out. The 
stilet pierced the hone and struck the root of the tooth, which 
I extracted. Wo hnmcdiately broke it. The canal of the root 
and the pulp-cavity were filled with a black and very fetid pus. 

" Upon the same day, the patient became entirely easy, and 
in a few days no appearance of disease remained." 



" M. A. Petit called me to see the wife of M. Desplnasse, 
whom he had been treating for a long time for a fistula of the 
gum, situated at the lower part of tho gums of the two central 
incisors of the lower jaw, and which had an external opening 
upon ihe fossa of the chin. The teeth were neither loose nor 
altered in colour. 

" The patient could give do reason for the oocurrence of the 




dketae. Slie looked rery well, and was yet jonog. Tbe nicer 
gftTe ns DO cItK to tbe c&use of it. Tbe conditioD of the teeth 
made as besitste to extract tbem from the month of so yonog 
s woman, and the same reaeon had hitherto prerentcd such an 
operation. 

"Vartons caoatica had been introduced into tbe external 
opening. In short, with the exceptioa of the actoal caateiy, 
no means had been left untried to heal tbe fistnla. The open- 
ing of tbe gam bad indeed cicatrized, bat that of the chin had 
proved intractable. 

" Upon exploring the outer opening, I fonnd that tbe probe 
penetrated the base of the alveolar and maxillarj sulratanoe, 
and that these bones were traversed by little canals correepond- 
ing to tbe roots of the two teeth. Hence, considering the 
length of time that the disease had resisted all remedies, I 
strongly suspected that the alveolar extremities of these roots 
were carious. I imparted my suspicion to M. Petit, who agreed 
with me that the teeth should be extracted. When the teeth 
were drawn, I examined them. Tbe extremities of their roots 
were black and corroded ; the canal was in the same condition< 
and tbe pulp-cavity contained thick and fetid pus. Saitable 
treatment was now addressed to the carious bones, and the 
fistulas soon were healed." 



This affection is commonly called scurvy, but improperly so, 
as we have already observed. 

Tbe gums, wLeu thus affected, are darker than usual, swollen 
and less firm than when in health. They bleed freely ondor 
the brush, or when touched by tbe lancet, and upon pressure, 
discharge a very fetid pus, which often gives its disgusting odour 
to tbe breath. 

The gums arc generally detached to some extent from the 
teeth, and their margins are thickened. They are often vcrv 
sensitive. 

The extent of the disease, and the inconveniences attending 
it, vary very much. Sometimes it is confined to a very small 



I 



1 



AFFBOTIONS OF THE MOUTH. 261 

portion of the gum, being a mere local attendant upon some 
diseased or irregular tooth, at other times it seems to depend 
upon constitutional causes, and communicates itself rapidly to 
the whole gum structures of the mouth. 

When thus extensive, it developes disease in the periosteum 
of the teeth, causes bone to be deposited in the sockets, spreads 
carious devastation along the whole circle of the jaws, and de- 
spoils the mouth, either by causing the teeth to be pushed 
from their sockets, or by destroying the crowns by devastating 
caries. 

In the meanwhile the general health suffers. The fluids of 
the mouth are no longer fit to perform their office ; the teeth 
cannot masticate the food; fetid pus and blood trickle into the 
stomach, and the patient's nervous system is worn out by fre- 
quent paroxysms of toothache. ^ 

Though certain aptitudes of constitution give virulence to 
this affection, it is mainly a local disorder, originating from the 
presence of decayed teeth and tartar. The latter, gradually 
detaching the gum from the teeth, produces inflammation and 
ulceration of the gum, and accumulating under the opening, 
constantly increases the irritation. 

Dr. Harris mentions a form of this disease met with in per- 
sons of scrofulous habits, which he thinks differs essentially 
from the more common affection. In this case, " the gums, 
instead of being purple and swollen, are paler and harder than 
ordinary, and on being pressed exude a muco-purulent matter 
of a dingy white colour. They often remain in this condition 
for years, without appearing to suffer any loss of substance, or 
to affect the alveolar processes. This variety of disease of the 
gums is principally confined to persons who have very white 
teeth, and is much less likely to affect males than females. It 
rarely occurs before the age of eighteen or twenty, and though 
unquestionably the result of inflammation, yet the gums ex- 
hibit no inflammatory symptoms, but on the contrary are paler, 
less sensible, and possessed of less warmth than usual. It is 
never attended with tumefaction of the gums, and by absorp- 
tion only in its advanced stages. Its effects are the most aim- 



262 AFFECTIONS OF THE MOUTH. 

pie and innocent of any form of disease to which the gums are 
liable, but its cure is generally more difficult." 

The treatment of the common form of the affection is sim- 
ple and generally successful, yet it is often comprehensive. 
Every irritant to the gum, whether tartar or teeth, must be 
thoroughly removed. This remark applies not only to diseased 
but even to irregular teeth, and to those which have no antago- 
nists. This work of purgation of the mouth being thoroughly 
done, simple astringent washes will do all that is further neces- 
sary. 

The scrofulous form of the disorder described by Dr. Harris, 
demands entirely different management. Being but a phe- 
nomenon of general constitutional vitiation, it can hardly be 
permanently relieved by local treatment. Constitutional reme- 
dies, such as proper diet, exercise, air and clothing, iodine and 
cod-liver oil, should be prescribed. At the same time the 
edges of the gum should be touched with lunar caustic (nitrate 
of silver), which not only acts as an escharotic by removing 
the diseased surface, but exerts a singularly modifying influ- 
ence upon certain forms of inflammation. 

BIMOBBHAOI FROM TBI 0UM8. 

The gums, like other mucous structures, are sometimes so 
engorged with blood, that it is exuded freely upon the surface, 
constituting passive hemorrhage. The pathological condition 
attending this sort of bleeding is very different from that which 
is manifested by active hemorrhage. In the former case, the 
exudation of blood is caused by the weakness of the containing 
tissues ; in the latter, by the violence of vascular action. To 
relieve the one, we endeavour to fortify the parts by astringents, 
&c.; to check the other, we lessen the arterial force by which the 
blood is injected into the distended vessels. Hemorrhage of 
either kind may be due to the rupture of a vessel. This, how- 
ever, is not necessary to hemorrhage, even when profuse. It 
is much more apt to be the case in active than in passive 
bleeding. 



AFFECTIONS OF THE MOUTH. 263 

The hemorrhage from the gams is always passive. Even 
when the tissues are the seat of violent inflammation, they do 
not bleed, but when they are softened and rendered less resist- 
ing by local or constitational causes, they sometimes permit 
the blood to exude through them to an alarming amount. 

When the mucous membrane of the gums is thus hemorrha- 
gic, the condition is shared by the membrane covering other 
parts of the mouth. 

I have seen this affection as one of the phenomena attending 
exhaustion from intemperance. 

Occasionally persons are met with, who manifest the hemor- 
rhagic diathesis as an organic idiosyncrasy. In such cases all 
wounds are exceedingly dangerous, as the blood has too little 
coagulability to form a plug to any divided vessel. Instances 
have occurred, in which persons thus conditioned have bled to 
death from the rupture of trifling vessels in the extraction of 
a tooth. 

When passive hemorrhage occurs from the gums, astringents 
generally fail to check it. Indeed it is almost impossible to 
apply them effectually to every part of the bleeding surface. 

We have, however, a very available remedy in compression, 
which can be speedily and easily applied, by filling a wax 
holder, such as is employed for taking impressions of the 
mouth, with wax, previously softened in warm water, and then 
applying it in such a manner as completely to imbed the teeth 
and gums in it. This method, recommended by Dr. 0. Holmes, 
I have seen tried successfully in a very obstinate and danger- 
ous case. 

When troublesome bleeding results from the extraction of a 
tooth, it may be checked by the actual cautery, or by plug^g 
the tooth with a cone of waxed cloth or cork. 

The nitrate of silver will commonly arrest the hemorrhage 
promptly ; but it cannot be safely applied over a very large 
extent of the mouth at once. 




This is a congenital deformity, which consists in a fissure 
which divides the lip perpendicularly. Sometimes there are 
two 6a9ures ; the former ia single, the latter double hare-lip. 

The cause of the dcforitmy is unknown. It is a failure of 
nature, through an inscrutable cause, to complete the union of 
the two sides of the body at this part of the line of junction. 

Sometimes the affection exhibits a single slit, at others two, 
with a lobe or flap between them ; and sometimes the fissure 
extends along the roof of the mouth, thi> soft and hard palate 
being separated. Generally the lip on both sides of the fissure 
is not adherent to the alveolus, but sometimes it is. 

Most commonly the upper lip only is affected, but sometimes 
the lower is the seat of the fissure. When this is the case, the 
child cannot suck, or learn to speak with any distinctness; 
adults suffer from the loss of the saliva, which runs freely from 
the mouth, and indigestion is the consequence. This form of 
hare-lip is seldom congenital, but is occasionally traumatic* or 
accidental. 

Ttll degrees of hare-lip are attended with deformity and in- 
convenience, though some, from the extent of the separation of 
parts, are much more annoying and unsightly than others. Mr. 
Cooper describes a form of it, which must, however, be rare, 
in which " the jaw is not only imperfectly ossified in front, bo 
that a cleft presents itself there, but one side of it projects for- 



* Triumstie — the effect ef » wouniJ, 



DISEASES OF THE LIPS. 265 

ward, and is at the same time inclined too much outward, draw- 
ing with it the corresponding part of the palate and the septum 
nasi, so that a very unsightly distortion of the nostril and nose 
is produced." 

When the fissure pervades the palate, the patient finds it 
very difficult to masticate or swallow, and articulation is neces- 
sarily very imperfect. 

It is obvious that surgical aid must be employed for the 
remedy of the deformity. 

A considerable difference of opinion exists among eminent 
surgeons as to the proper time for performing the operation — 
some advising to delay it until the child shall be four or five 
years old, and others preferring to operate upon the infant 
of months. 

Sir Astley Cooper used to narrate several cases in which a 
fatal termination resulted from too early an operation — con- 
vulsions having occurred from the pain and irritation of the 
wound. 

Undoubtedly, infants may often be operated upon with more 
facility than older children, and in some instances the deformity 
is attended with so much inconvenience as to authorize early 
operations. If, however, the child be able to nurse, and espe- 
cially if it exhibit considerable nervous mobility, it will be bet- 
ter to delay the operation for several years. 

Mr. Listen advises to defer the operation until the first den- 
tition shall have been completed. He says, '^ when the opera- 
tion is undertaken at an earlier period, there is often great 
difficulty. Sometimes union does not take place, the parts 
turn out again, and the patient is rendered more deformed than 
in the first instance. When the features are enlarged some- 
what, you have more ground to work upon ; you can put -the 
parts neatly together, and you can almost answer positively for 
the union taking place." 

The cure depends upon the capability of two incised sur- 
faces to unite when brought into contact, and the proper per- 
formance of the operation consists in cutting off the edges of 

2S 



DISEASES OF THE LIPS. 



the fissure, and keeping the new surfaces so closely together ns 
to procure union b; the Grst intention. 

The manner of performing the operation is sufficiently sim- 
ple, yet it requires considerable dexterity to do it well. 

Some surgeons cut off the edges with a pair of strong sharp 
scissors ; others place a piece of wood under the lip, and then 
pare off the edges with a knife; others, confident in the cor- 
rectness of their eye and the steadinees of their hand, place 
the child between their knees, with the head towards them, 
enter the knife into the lip above the angle of the fissure, and 
carry it downwards until it completes the removal of all the 
portion of the lip on that side which is required. A similar 
cut upon the other side prepares tlie wound for closure. 

The bleeding readily stops upon pressure of the lips, and is 
rarely excessive. 

The wound is closed by the twitted suture; that is, two silver 
pins, with steel points, are introduced through the edges of the 
wound, penetrating the lip through about two-thirds of it« 
thickness, the first near the inferior extremity of the wound, 
and the second a quarter of an inch above. The divided sur- 
faces being thus brought into contact, thread is wound repeat- 
edly around the pins, first transversely and then obliquely, 
from the right side of the upper to the left of the lower, and 
vice verta, until the contact is firmly secured. The points of 
the pins should then be unscrewed, and a dossil of lint placed 
under each end of them. The pins should be somewhat curved 
and flattened. Some surgeons prefer the ordinary interrupted 
suture. 

Different bandages have been devised for the purpose of 
supporting the pins and preventing the separation of the 
adapted surfaces. That recommended by Mr. S. Cooper is 
used as follows : A close strong night-cap is provided, with a 
piece of broad tape attached to the back part of it, and with 
two ends of sufficient and equal length. A compress is then 
to be laid over one cheek, and fitted by bringing one portion 
of the tape forward over it, which is to bo fastened to the cap 
on the opposite side of the head. The other compress is then 



DISEASES OF THE LIPS. 267 

to be applied and fixed in a similar manner. Lastly, a band- 
age is to be put under the chin, and brought over each com- 
press up to the top of the head, "where the ends of it are to be 
fastened to the cap. "During all these proceedings, until the 
compresses are well secured, the assistant must support them 
steadily with his hands. Lastly, the bandage, compresses, and 
cap should all be securely stitched together. 

The cut through the lip must be as straight and clear as 
possible, and the operator need not fear to take sufficient of 
the edge to insure such a surface as will be well coaptated. 

When the hare-lip is double, the older surgeons advised to 
perform the operation on one side and then upon the other; 
but this is unnecessary. The edges may be prepared at once, 
and the needles pushed entirely across through the interme- 
diate flap. Sometimes a piece of bone projects and pushes 
out the flap. If so, the bony projection must be either reduced 
by compression or cut off*. It is always important to save the 
alveolus, and it appears from the practice of Desault and Mr. 
Dunn, that it is seldom necessary to remove it. 

There is often a deficiency of bone, which will cause defor- 
mity after the hare-lip has been successfully treated. 

Very often, when the fissure extends along the palate, it will 
be approximated after the closure of the lip ; but this is not 
always the case, and articulation and mastication continue to 
be very much interfered with by this unfortunate cleft of the 
palate. 

The dentist can often remedy this serious deformity, by 
nicely adapting a gold plate, so as to form a solid artificial 
palate, which will tolerably well supply the want of the natural 
one ; and this may be considered the most available means of 
relief at our disposal. 

Operations have frequently been performed for the cure of 
this palatine fissure, and sometimes have succeeded. The ope- 
ration, however, is difficult, very painful, considerably danger- 
ous, and very uncertain, and should never be performed except 
by a dexterous and experienced surgeon, and under circum- 
stances in which no artificial means could be used to cover the 



cleft. The design of the operation ia precisely the same as 
in the case of that for hare-lip, viz., to cut off the erigcs of the 
fissure and unite them by sutures ao as to procure union. 

The lips being very vascular, abundantly supplied with mus- 
cles, mucous glands, and nerves, are liable to become the seat 
of ulcers and tumours of various kinds. In the male, carci- 
noma of the lip is perhaps more frequently met with tban it is 
in any other part of the body. 

It is not necessary to particularize these affections, nor to 
give a detailed account of their phenomeuu and treatment. 
They must of course be managed as similar conditions else- 
where, the treatment being modified to suit the exigencies of 
the particular case, and the peculiarities of the location. All 
operations upon these organs must be conducted with great 
carefulness and nicety, on account of their sensitiveness and 
vascularity, and of the deformity and aerioua incoRvenience 
attending uny permanent alteration of their relations or struc- 
ture. Of these, adhesion to the gums and contraction of the 
lips are the most common and most serious. 

Adhesion is the result of acute inflammation of the surface 
membrane of the lip and gum, in the course of which plastic 
lymph is thrown out, and becoming organized, forms a perma- 
nent bond of union between the parts. In all cases of abra- 
Bton of these surfaces, or of long-continued inflammation, care 
should be taken to prevent this accident. It can rarely hap- 
pen, unless the parts thus prepared to unite be pressed together 
by a bandage or some similar mechanical application. 

I have seen it, however, result from salivation of a very se- 
vere grade. The cheek, from its less mobility, is more liable 
to this accident than the lips. 

Contraction of the mouth may result from a burn, aa may 
also adhesion of the lips to the gums. 

When so serious a deformity baa occurred, it can only be 
remedied by an ingenious operation, which, though very pain- 
ful, is generally endured with cheerfulness, so terrible is the 
sense of deformity to most persons, especially to females. 

A few casoB will bo sufficient to show what has been, and 



DISEASES OF THE LIPS. 269 

irhat may be done, in unfortunate cases of this kind, and will 
furnish to the ready mind a number of valuable suggestions. 

Simple dilatation of the mouth will be unsuccessful, and in- 
cision at the commissures will be ineffectual in permanently 
enlarging the orifice, on account of the impracticability of pre- 
venting reunion between the severed portions of the skin. 

In order to obviate this difficulty, the celebrated Dieffenbach, 
who has deservedly obtained a world-wide reputation for his 
success in rhinoplasties*' surgery, suggested that a strip of mu- 
cous membrane should be folded over the edge of the incision. 
This fortunate thought has led to a number of brilliant and 
successful operations for the cure of this class of deformities. 
The following cases are specimens : 

M. H., aged twenty-two, admitted to the hospital under Mr. 
Listen. About a year before, she was knocked down in a 
brawl, and a man jumped upon her, lacerating and bruising her 
cheek and mouth very extensively, and fracturing her jaw. She 
went to St. Thomas's Hospital, where her jaw was put up and 
bandaged. These were not removed for some time, and when 
taken off, the wound on the right side of the mouth was found 
to be healed, and the cicatrix considerably contracted. Since 
then the contraction has continued somewhat, and now the 
mouth is so small that she can scarcely get any solid food to 
pass her lips. There is a large and dense white cicatrix on 
the right side of the mouth, rather sharp and puckered toward 
the angle. 

Mr. Listen removed a triangular portion of the cicatrix on 
the right side of the mouth, dissecting it off the mucous mem- 
brane, which was then divided to the extent of the external 
wound. Lint, dipped in cold water, was then laid over the 
surface, to suppress the oozing of blood, which was by no means 
considerable. About five hours after the operation, all oozing 
having ceased, the mucous membrane was turned over the cut 
edge of the cicatrix, and united by three or four points of su- 

* Rhinoplastic — literally, note-making : a term first applied to the ope- 
ration for making a substitate for a loet nose, but now appUed to all opera- 
tions for restoring lost parts. 

2S» 



STO 



DISEASES OF THE LIPS. 



tnre to the skin of the check ; by this means, a mncons surface 
was secured to the newly formed prolabium, and the gradaal 
cicatrization and consequent contraction avoided. Oa the day 
after the operation, there was a little swelling around the 
wonnd, not ranch pain, and in ten days afterwards the patient 
waa discharged much relieved. 

Case II. — The daughter of a highly respectable physician, 
when she was eleven years old, was accidentally thrust against 
a heated stove, and her handa, arms, neck, and the lower part 
of her face severely burned. 

In spite of all the judicious means employed by the father, 
the wounds about the mouth healed with so much contraction 
that the opening into that cavity was almost obliterated. Her 
father then endeavoured to distend the mouth by tents, but 
these accomplished nothing. He then endeavoured to enlarge 
the orifice, by making a horizontal incision from each angle of 
the mouth, and preventing the surfaces from uniting, by the 
interposition of tents: but this expedient failed also. 

The patient waa then broaght to Dr. MUtter, who says: 

" When I first saw her, nearly a year had elapsed since the 
occurrence of the accident. Her appearance at this time was 
very singular. Firm and dense cicatrices nearly surrounded 
the mouth, but were most marked on the lower lip and about 
the angles; while the orifice of this cavity was barely large 
enough to admit the point of the finger, and presented an oval 
form. The cicatrices of the incision made by bcr father were 
also very apparent at each angle. The general health was 
good." 

Dr. MUtter performed upon this young lady the operation as 
proposed by DJeffenbach, 

" The patient was seated in a low chair, with her head sup- 
ported by her father, and exposed to a good light, I then in- 
troduced the extremity of the fore-finger of niy left hand into 
the mouth, and placed it under the left labial angle, which by 
this means was rendered prominent and sufficiently firm to 
permit the second step of the operation to be readily executed. 

" This ia accomplished by the introduction of one blade of a 



DISEASES OF THE LIPS. 271 

pair of narrow straight scissors into the substance of the cheek, 
between the mucous membrane and the other tissues, and a 
little above the commissure. The blade is then slowly pushed 
from before backwards, separating, as it passes along, the mu- 
cous membrane from the muscles and integuments, until its 
point reaches the spot at which we wish to locate the new angle 
of the lips. The blades are then closed, and the parts included 
between them cut squarely and smoothly at a single stroke. 
The first incision being completed, the scissors were withdrawn, 
and a second one, parallel and similar to the first, made in the 
lower lip, the distance between the two being about three lines. 
These incisions were then united at their posterior termination 
by a small crescentic section. 

^' By these cuts it is evident that a small strip of muscle and 
integument was insulated from the surrounding parts, and it 
only remained to separate it from the buccal mucous membrane, 
which was easily done by a single stroke of the scissors. 

^' The second step of the operation being thus finished on the 
left side, similar incisions were performed on the right. 

'^ The next steps of the operation, and by far the most dif- 
ficult of the whole, were the division into equal portions of the 
mucous membrane, the eversion of the flaps, and their attach- 
ment to the edges of the incisions just made, as well as to the 
red pellicle of each margin of the lips. 

*' To divide the mucous membrane equally, I separated the 
jaws of the child as much' as possible, by which measure the 
membrane was put upon the stretch, and kept sufficiently firm 
to bear the operation of the scissors. The incisions in the 
membrane did not extend as far as those made in the muscles 
and skin, but stopped short about three lines from the union 
of the latter. This was done in order to make the outer portion 
of this tissue adapt itself accurately to the new commissure. 
The flaps were then brought out, reflected over the margins of 
the wounds, and firmly attached to them by means of the 
twisted suture, the needles used being very short and fine. The 
membrane must be first attached to the commissure, by which 



272 DISEASES OF THE LIPS. 

measure ^e secure the proper adaptation of the flaps to the 
other parts. 

^' Everything being thus properly adjusted, a common roller 
bandage was applied, as in cases of fracture of the lower jaw, 
in order to prevent any derangement of the wounds. The pa- 
tient was then placed in bed, with her head elevated, and as 
she had, just before the operation, eaten freely of some light 
food, ordered to take no nourishment of any kind until the 
next visit, and to be perfectly silent." 

Four days after the operation the bandage was removed, and 
the Doctor proceeds : '^ The sutures, which had been closely bound 
down to the parts by blood, were carefully softened with warm 
water and cut away. As soon as they were removed, the most 
gratifying exhibition of the success of the operation was af- 
forded. On both sides, union between the everted mucous 
membrane and the margins of the wounds had taken place 
nearly throughout, and the new lips presented an appearance 
almost natural. Some of the needles were then removed, but 
as there appeared to be a feebleness in the adhesions at some 
points, the needles passing through them were allowed to re- 
main, and a thread cast loosely around them. The bandage 
around the head was also reapplied. 

''Nothing remarkable occurred in the subsequent treatment. 
The dressings were taken off in eighteen days. The mouth 
presented a very good appearance, though the lips were some- 
what thinner than natural, and there was some difficulty in 
bringing them into close contact, especially at the central por- 
tions. I have no doubt, however, but that this defect will soon 
disappear." 

An operation of a similar kind, but much more difficult, per- 
formed by Dr. Hullihen, will be described in a subsequent 
chapter. 

The following cases of cancer in the lip, and operations for 
the removal of the diseased portion, as published in the Boston 
Med. and Surg. Journal, by Dr. Gilman Kimball, of Lowell, are 
worthy of preservation as examples for the young surgeon: 

'' Cancer of the lip being so common a disease, and one that 



DISEASES OF THE LIPS. 273 

80 frequently besets the surgeon with embarrassment in de- 
termining what is best to be done under certain circumstances, 
the following cases are given with a view of showing that there 
are those of, apparently, the most unpromising character, where 
surgical skill may be made available, not only for the absolute 
removal of the disease, but in such manner as to subject the 
patient to a very inconsiderable degree of deformity. 

^' John Cassidy, eighty years of age, with good constitution 
and temperate habits, discovered, some eight years since, a 
small, hard tumour, the size of a pea, on the middle of the 
border of the lower lip. Unattended with pain or other in- 
convenience, and remaining stationary, as to size, for several 
years, it gave no inconvenience, and received little or no at- 
tention. 

^^ Two years since, it began slowly to increase in size, and 
for the last six months previous to its removal, its growth was 
very rapid. Early in April, he came under my charge. At 
this time the disease involved the entire lip, embracing its 
whole free border from one angle of the mouth to the other, 
and descending down very nearly to the chin. It was now ex- 
cessively painful, discharging abundantly, and very offensive. 
An operation was suggested and cheerfully submitted to with- 
out delay. 

^^ The whole lip, with so much of the contiguous parts as was 
likely to be at all affected with the disease, was, in the first place, 
cut clean away. This was done by making two vertical inci- 
sions through the lip, one from each angle of the mouth down 
to nearly the base of the jaw, and another, horizontal one, run- 
ning below the disease, and uniting the first two by their lower 
extremities. This part of the operation left a quadrangular 
space, which it was the design to fill up with parts supplied from 
the cheeks. With this view, two horizontal incisions were next 
made through the cheeks, running back from each commissure 
to the extent of an inch and a half; and then again, two more, 
of the same extent, running parallel with the base of the jaw, 
and continuous with the horizontal incision first made for the 
removal of the lip. A slight dissection was sufficient to detach 




these p&rta from their connexion with the jaw, thus affording 
two ample and properly-shaped flaps. These were now drawn 
forward, with slight force, and, by means of three twisted 
sutures, secured to each other on the median line. Several . 
other sutures were used, here and there, for the sake of pre- 
serving a proper adjustment of the parts, and particularly at 
the commissure, with a view of leaving the mouth, as nearly as 
possible, with its natural width. The mucous membrane waa, 
likewise, drawn over from the inner edge of the newly-formed 
lip, and attached to the skin on its outer edge. The dressings 
Trere very simple, consisting, merely, of narrow strips of thin 
linen, six inches in length, passing across the lip and chin from 
one cheek to the other, and secured thereon by means of col- 
lodion. 

"With regard to the auhsequent treatment of this case, it ia 
sufficient to say that, on the third day, the outer dressings were 
removed for the first time, also one of the twisted sutures. On 
the fourth day they were again removed, together with the two 
remaining sutures. At this time it was evident that union by 
the first intention, had taken place in every part of the wound, 
and nothing further remained to be done, but to keep the parts 
covered with the collodion dressing for about a week longer, 
and then to be discontinued altogether. 

" The healing of the border of the new lip was somewhat pro- 
tracted, and was not complete till the end of the third week. 
The stitches which had been used in the first place, for bring- 
ing together its outer and inner edges, all gave way in less 
than forty-eight hours ; so that in the end, they seemed to have 
done quite as much harm as good. 

"It isnowfourteenweekssince the operation, and the patient 
is, in all respects, quite well. His general health is greatly 
improved, and there is, as yet, no evidence of a return of 
the local disease. 

" Another case, similar in character to the above, has since 
come under my charge, and, though much less in extent, has 
been operated on after the same method, and with an equally 
satisfactory result. 



DISBASBS OF THB LIPS. 275 

'* The patient, a maiden lady seventy-eight years of age, of 
excellent health and constitution, first discovered the disease, 
on her under lip, about two years since. At first, not larger 
than a small-sized pea, without pain or soreness, it remained 
stationary, as to size, till within a short time since, when it 
began rapidly to increase, and at times to be attended with 
pain. The disease had not yet descended below the free por- 
tion of the lip, but involved something more than half its border. 
It was a case where the V incision might have been adopted, 
and the wound brought together so as, possibly j to have effected 
an immediate union. In such a case, however, more or less 
deformity would, necessarily, have ensued, so that the plan 
pursued in the case already described, was thought preferable, 
not only as offering the best chance of securing a perfect and 
immediate union of the parts, but also of avoiding, more cer- 
tainly, the probabilities of any considerable disfiguration. 

^' The disease was, at first, removed by making three straight 
incisions through the lip, and encroaching, at the same time, 
somewhat freely upon the adjoining sound parts. The portion 
thus removed was trapezoidal in shape, and embraced con- 
siderably more than one-half the entire lip. Flaps were next 
made after the same manner as in the previously described 
case, viz., by prolonging the horizontal incision, on either side, 
to the extent of three-fourths of an inch ; also, by extending 
backward an incision of the same extent from each commissure 
of the mouth. The parts were now readily drawn together, 
without force, and secured on the median line by twisted su- 
tures. The same dressings as in the former case were adopted, 
viz., strips of fine linen nicely laid on, and coated over with 
collodion ; and, finally, the whole overlaid with a thin compress 
moistened with cold water. 

'^ The subsequent treatment was very simple. The first dress- 
ings were allowed to remain undisturbed till the third day, and 
then they were entirely removed, sutures and all. The most per- 
fect and exact union was found already to have taken place in 
every part, yet, as a matter of safety, the collodion application 




was resumed, from time to time, for several days longer, when 
all dressings were permanently discontinued. 

" Id this ciise, though the disease, as has been already shown, 
was comparatively limited, the propriety as well as success of 
the method adopted for its removal, has been as satisfactorily 
illustrated as in the preceding case. Not only has there been 
no deformity produced by the operation, but even the traces 
of it would scarcely be noticed, except by more than casual ob- 
servation ; and, in consideration of the libera) amount of appa- 
rently Bound tissue cut away in connexion with the disease, also 
the previously healthy condition of the patient, it is, perhaps, 
reasonable to believe the malady will never return, 

" Aside from the interest that attaches to the above cases, 
merely, as successful results in two consecutive operations for 
the same disease, the more important object in furnishing these 
details, has been to exhibit a method of procedure* which, 
though not singular, has, at least, the merit of simplicity in its 
favour, at the same time that it ful6ls, most satisfactorily, every 
purpose for which it was intended. It may serve, moreover, 
to relieve, in some measure, the difficulty which a surgeon 
sometimes feels, when be comes to determine, among the va- 
riety of operations recommended for a given object, which, upon 
the whole, it is most expedient to adopt." 




277 



CHAPTER XXL 

DISEASES OF THE GLANDS AND GLAND-DUOTS. 

SALIVABT TUMOURS. 

< Ranula.* — This is the name given to a tumour under the 
tongue, which is caused by obstruction of the ducts of the sub- 
lingual gland, and the detention of secretion which conse- 
quently results. 

This swelling is not usually very large, though suflSciently 
80 to cause great inconvenience ; but occasionally it has been 
observed of an enormous size. Le Clerc mentions a case in 
which the tumour filled the whole mouth, and pushed forward 
the teeth of both jaws. The patient was nearly suffocated, and 
must have died had he not been relieved by an operation. 

The case related by Boinet to the French Academy, was 
even worse. The swelling not only filled the whole mouth, but 
projected out of it for a considerable distance. The two upper 
incisor teeth on the left side, were lodged in a depression ob- 
servable there, and the canine teeth of the same side, forced 
outwards by the mass of the disease, had pierced the lip near 
the commissure. A fluid, resembling mucus, flowed from a 
narrow aperture at the lower part of the swelling. The tongue 
could not be seen, so much was it pushed backwards, and for 
some time the patient had subsisted only upon liquid food, 
which he was first obliged to convey to the back of his throat 
by some mechanical contrivance. The four incisor teeth, two 
canines, and first molars, of the lower jaw, had been pushed out 

* Rana, a frog ; so called from a fancied resemblance. 

24 



278 



DISEASES OF THE GLANDS AND GLAND-OnCTS. 



of their sockets by the pressure of the swelling. The patient's 
aspect waa alarming, and he was threatened with suffocation. 

Extirpation was thought necessary, and it waa performed 
with all due caution. The largo cavity thus occasioned was 
filled with lint. The lower jaw being diseased, Boinet scraped 
some of its surface off, ajid covered the places with lint, either 
dry or dipped in spirit of wine. Some exfoliations followed, 
and tho fungous granulations which grew were suppressed with 
proper applications. In three months the cure was completed.* 

Hanula may readily be detected. It presents itself in the 
form of a rounded or oval, soft, semi-transparent tumour, on one 
or both sides of the frsenum lingua. It is not painful, and oc- 
casions little inconvenience until its volume becomes sufficiently 
great to interfere with the movements of the tongue. 

Nevertheless, encysted tumours of various kinds do sometimes 
occur in this locality, and have frequently been mistaken for 
ran u la. 

Simply to open the tumour and let out the fluid contents, will 
not cure the disease, inasmuch as the obstruction of the ducts 
will continue. It becomes neceasary, therefore, to reopen 
these, or, if this cannot be done, to make on artiUcial opening, 
which may permit the secretion of the gland to escape. 

Lewis advised the introduction of small leaden slilcts to di- 
late the canal, and permitting them to remain for a day or 
two at a lime. Dr. Physick and others preferred the passage 
of a thread through the tumour, which waa permitted to re- 
main as a seton. Dr. Reeae considers this plan infallible, or 
nearly so. 

The method parsuod by Lewis, and followed by Dr. Mutter, 
la to make an oval or round incision, and then to touch tho 
margin with nitrate of silver, so as to create an artificial fis- 
tula. 

ometinries all other means fail, and it is necessary to dissect 
ivary glands are sometimes the seat of tumours of a. 



" CoQpn'i Snig- VAtt., Art. Kuralk. 



DISEASES OF THE GLANDS AND OLAND-DUCTS. 279 

more formidable character. Being enclosed, the sublingual 
gland especially, by the muscles of the throat and tongue, these 
tumours, even if suppuration takes place, cannot commonly be 
relieved by the discharge of the contained matter. The sac 
may be repeatedly punctured without relief, for the fluid con- 
tinues to form, and repeated wounds result in thickening and 
enlargement of the gland, and finally a solid tumour is formed, 
which may go on to enlarge until it may cause suffocation. 

The case of Margaret Murray, so graphically related by Mr. 
John Bell, should warn us against trifling with even apparently 
trivial tumours of these parts, and dentists, as they may be the 
first to observe, should be prepared to distinguish these swell- 
ings, and advise that prompt and decided treatment which is 
so important in these cases. In the case of Margaret Murray, 
the tumour was as large as the patient's head, and threatened 
imminent suffocation. In fact, the poor woman lived in a state 
of semi-strangulation. When upon the verge of gangrene, the 
tumour, which was hard upon the surface but fluctuating beneath, 
was transfixed with a trocar. About two pounds of thick ropy 
matter were discharged. It was hoped that this discharge 
would afford relief; but, as Mr. Bell very justly observes, 
those who indulged such an expectation did not recollect that 
to produce a secretion so profuse, a great mass of vascular sub- 
stance is required, and the consequence of permitting a gelati- 
nous collection of matter to attain to such a size is, that the 
vessels by which it is secreted, not being, as in a case of sup- 
puration, ulcerated or destroyed, the basis, consisting of these 
vessels, is consolidated into a tumour. The sac may be emptied, 
but the nucleus to the sac cannot be discussed, but hardens and 
iD&VLmes pari passu with the evacuations. 

In the case of this poor woman, though the salivary matter 
continued to run, thin and pellucid, through the opening, the 
tumour did not diminish. ''She lay reclined, always strug- 
gling for breath, and sometimes attacked with violent asthma- 
tic paroxysms ; the jaws almost entirely closed, the mouth con- 
tinually open ; the nostrils dilated, and the stupor, which such 
difficulty of breathing causes, increasing every moment ; and 



3* amaasts or the glakds and glakd-ducts. 

'nM mwfr— Vg beiog equally difficult with her breathing, she 
itjifilwt IB t^ foortb week." 

.Utbuitgli tniuoars of this kind may contain thin matter, a 
[iwr« puncture is not sufficient for their relief. A free iucisioQ 
uiBsb b« lOBde, laying open the dlGeased gland, and the treat- 
meoc dirvcted to the permanent adhesion of the walls of the 
sac The sooner this is done the better. 



This gland ia very subject to inflammatory awellings, which 
frequently become indolent, and remain for a long time withont 
causing inconvenience. Occasionally, however, it is the seat 
of very dangerous and even fatal tumours. 

Mr. John Bell records the case of "Jenny Brown, a poor 
solitary thing, who worked laboriously to maintain her aged 
mother, her father being for some years dead. She slaved at 
all kinds of work, as an out-servant in a farm-yard. After 
churning milk, being exceedingly heated, she went out with 
her cap loose and her jaws exposed, and by carrying bundles 
of wet grass for the cows upon her head, had a severe tooth- 
ache, for which a tooth was pulled; and stilt continuing in the 
same labour, she got cold. Thence arose a kernel-like swelling 
of a gland under the lower jaw, near the gum of the corrupted 
tooth. Her face was swelled so that her eyes were cloeed; 
the lump grew as big as a hen's egg, with severe pain; the 
swelUng of the face subsided, the pain ceased, but the glandu- 
lar tomour remained. Such was the slight beginning of the 
disease." The tumour, however, continued to enlarge until it 
became necessary to extirpate it. This was attempted in an 
awkward and irresolute way, and abandoned in the midst of 
the operation. "One advantage this poor creature derived 
from this unsucccBsful operation, viz. the relief from pain, for 
she was relieved by the loss of blood, insomuch that she re- 
covered her health, and in some degree her strength, and re- 
turned to work for the support of her old mother : at least she 
could spin. For a long time she has been unequal even to 



DISEASES OF THE GLANDS AND OLAND-DUCTS. 281 

this. She has lingered and wasted in a very helpless condi- 
tion, and is now in a state of extreme weakness from want of 
food. She walks but a few paces without stopping for want 
of breath; her swallowing is difficult; she has great pain, 
night and day, from the mere distension and size of the tumour. 
The weight of it is intolerable, and it appears to me that in not 
many weeks she must be relieved from her sufferings." 

The suffering of the patient seemed to be occasioned by the 
great bulk of the tumour pressing upon the trachea, and even 
the breast, and embarrasing respiration. The tumour had every 
character of what is usually called a wen ; the whole mass 
incredibly heavy in proportion to its bulk, so that she supported 
it continually with a sling round the head and neck. It was 
extremely firm, not very vascular throughout its substance, but 
receiving its arteries at particular points. It had no great veins 
running over its surface, whence Mr. Bell presumed that it 
had nothing of a cancerous character or irritated circulation. 

Mr. Bell wished to operate, but was overruled. 

Some remarks of Mr. Bell, in lecturing upon these subjects, 
are so judicious, that I cannot refrain from quoting his language 
at some length. 

^' But it is not the discussing of interesting doubts and ques- 
tions of life and death, nor the performing operations within 
the limits of possible success or possible safety, that constitute 
the chief occupation of one engaged in practice. The more 
homely talent of distinguishing the various aspects and charac- 
ters of tumours, and treating them judiciously, is far more de- 
sirable to acquire ; and, indeed, there is a very perplexing va- 
riety of tumours within the mouth and around the jaws, which 
one learns to distinguish only by referring their various aspects 
to corresponding peculiarities in the structure of the parts. 
The tumours which I have just described are of a very malig- 
nant character, and I confess I know not whether to refer them 
to the salivary or the lymphatic glands ; to the latter, rather, 
I believe. This, for example, of Mr. M., though it looks like 
a tumour of the submaxillary gland, which holds embedded, I 
may say, in its substance, the facial artery, could not have 

24* 



r 



282 DISEASES OF THE GLANDS AND GLAND-Dt'CTS. 

been extirpated withoutdividingthatartery. The submaxillary 
glatid is divided into two masEeB, and the trunk of this orterj 
JB received into the rccesB or cleft. The artery soema to twist 
round the gland, and I have, hoth in extirpating the submaxil- 
lary gland and in aBsiBtlng at such operations, recognised it by 
this uurk. 

" The following case, if not full of interesting particulars, 
is at least accompanied with useful rules, and I transcribe it 
from my case-book, with those reflections which arose in my 
mind when forming my opinion and preparing for the operation, 
88 I have ever done, with a scrupulous and conscientious desire 
to foresee every eventual danger, and recollect every circum- 
stance, anatomical or pathological, which might contribute to 
my patient's good; the reflections, jou will perceive, bare a 
mutual relation to the instruction of my pupils and my own 
improvement. 

" It is the case of a young lady, who came from a very great 
distance, uiged by her own fears and the persuasion of her 
surgeon. 

" First, I observe that the gland affected seems to be the very 
gland which, after an unsuccessful operation, grew to bo im- 
mense a size in the case of Jenny Brown, and in her, though 
the tumour arose from the slightest and most accidental cause 
(extraction of a tooth), without any cancerous diathesis, or 
other malignant tendency, it proved fatal by suffocation. Whot 
might have become of tim lady, it is easy to foresee, had she 
not been warned by her surgeon, and alarmed by the recent 
accession of pain, for her own safety. 

" Secondly, when wc are consulted what is to be done in 
any particular case, wc arc, in other terms, called on to prog- 
nosticate what will be the patient's condition at the distance of 
one or two years. In the present case, the gland is very large, 
and of a stony hardness. It never can auppurato ; it is even 
threatened with a cancerous inflammation ; it is indeed incapa- 
ble of any other. The pain requires that something should be 
done, and our prognostica may be safely grounded on this un- 
questionable assumption, that such a tumoor will not fail to 



DISEASES OF THB GLANDS AND QLAND-DUCTS. 288 

grow, and that, in one or two years, the deformity and bulk 
will of itself be a motive, while the suffocating condition of the 
patient will be an absolute reason for operating, however dan- 
gerous the operation may be rendered by such unwise delay. 
It is moreover to be observed, that this gland is the submaxillary 
gland, which has the facial artery niched in between its two 
lobes, not so inextricably, indeed, as the parotid is connected 
with the carotid artery, but in a degree to give trouble to the 
surgeon, and accompanied with a degree of danger, in the 
case of operation, which is well worth calculating. 

'^ Thirdly, we are to regard the actual circumstances of every 
patient as a part of his case, and the danger to this lady, if 
remanded to her own country, so far distant and so difficult of 
access, is but too palpable. Should we speak to her the usual 
temporising language, and say, ' It will perhaps get well'; a 
slight course of mercury or cicuta may be useful, and time may 
do much ; perhaps it may be well to wait ;' it may happen that 
the gland may become stationary in its growth. A mercurial 
course may be of use, but I fear that this is, in the truest sense, 
tampering with a tumour, and that time can do nothing but in- 
crease the danger. 

^^ It seems to me but too possible that this lady, before she 
can take a second resolution and accomplish a second journey, 
will be suffocating and in immediate danger of death. Then 
we should not venture to do that operation which is now com- 
paratively easy ; for this gland being seated in the angle be- 
twixt the trunk of the carotid artery and its first great branch, 
the maxillary or facial, will distend that angle, and both the 
trunk and its branch will be too closely united with the tumour 
to admit of operation, or will make the operation most danger- 
ous and critical. 

^' Fourthly, though there is no imminent danger in the pro- 
posed operation, the circumstances are sufficiently forbidding 
to make it far from being a matter of choice. My assistant 
was unwilling that it should bo performed without the advice 
of Dr. Munroe, and his assent seemed rather reluctant. The 
tumour is of a very considerable size ; it is plainly the sub- 



284 



DISEASES OF THE GLANDS AND QLAWD-DUCTS. 



maxillary glanil, aa may be iDferrod from ita shape, size, and 
peculiar hardness ; not a lymphatic gland, for then, most likely, 
more than one would be enlarged. We must be resolved to 
deal with the artery in one of two ways : either to diasect 
it 80 from the tumour as to insulate the artery, and turn the 
tumour from under it ; or, should this attempt threaten to em- 
barrass our operation, to cut it across where it lies over the 
middle of the tumour, tying before dividing it, lest it should 
shrink back towards its trunk. No one circumstance is so fa- 
vourable to the operation as that extreme hardness of the 
tumour which makes the operation necessary, for that shows it 
to be circumscribed, and to be little connected by infiammation 
with the cellular substance. 



"We had agreed either to dissect so as to lay the artery on 
one side while employed in extirpating the gland, or to tie and 
cut across, and so proceed with greater freedom in the more 
dangerous part of the dissection; but after the first incision, 
which I made according to the length of the jaw-bone, the in- 
cision being long and more free, the several parts appeared in 
BO advantageous a state as to leave no doubt nor difficulty in 
the rest of our proceedings. 

" The artery presented itself arching over the diseased gland, 
much elongated and serpentine, so that in place of embarrassing 
the operation with any needless delicacy, or endangering the 
shrinking up of such an artery towards its trunk, we passed 
two ligatures of single thread under it, out betwixt the liga- 
tures, and then proceeded more confidently in extirpating the 
gland. There we fonnd no such adhesion of it to the trunk, 
or rather to the sheath of the carotid, as we had rcoson to ap- 
prehend. The tumour was of such a stony hardness, the cellular 
substance so loose, the arteries so disengaged from it, that 
without the help of the knife, with only the swallow-tailed end 
of its handle, which I used as a scalpel, I turned out the tumour 
in a few seconds, and the tumour carrying its cellular substance 




DISEASES OF THE GLANDS AND OLAND-DUCTS. 285 

along with it, the styloid muscles were left as clear, distinct and 
bare as after a neat dissection upon the dead subject." 

" Case IL* — A young woman of Berwick whose native pe- 
culiarity of accent had got a singular aggravation by such an 
nncouth obliquity and imperfect motion of the tongue, as con- 
veyed the notion of her attempting to chew and turn each vo- 
cable with her tongue before she proceeded to swallow it, in 
place of uttering it. 

^^ This was produced by a tumour of very great size, and of an 
appearance so peculiar as plainly to denote its character. It 
consisted in a vast collection of matter in the sublingual gland, 
and as that gland is covered by the whole thickness of the 
tongue within, and by the mylo-hyoidoei muscles without, and 
bounded by the line of the jaw-bone, it had the following sin- 
gularities of character. It could not be distinguished as a tu- 
mour, but had rather the appearance of a general swelling of the 
lower part of the face, jaw, and neck, such as often accompa- 
nies severe toothache or mumps. Upon laying the hand upon 
the outside of the neck, below the lower jaw-bone, the whole 
hand was filled with a swelling, apparently solid, but so little 
convex or circumscribed as to resemble in no degree the tumour 
of any particular gland, and yet so limited and so firm as not 
at all to resemble the general tumefaction proceeding from 
toothache. Upon introducing the finger into the mouth, you 
found the tongue raised, turned edge uppermost, and pressed 
entirely towards the left side of the mouth, the external tumour 
being upon the right side. Upon pressing the fingers very firmly 
down by the side of the tongue, and reaching from without, 
you could sensibly perceive not so properly a fluctuation as an 
elasticity, which implied the presence of a fluid ; the tumour 
seemed elastic like a foot-ball, but with a degree of tension 
which made it seem almost solid. It was by comparing a va- 
riety of circumstances, especially the original plac% and slow 
growth of the tumour, that I confidently referred it to the sublin- 
gual gland. In this I had the advantage of the surgeon under 
whose particular care she was, but I did him the justice to send 

* Principlet of Surgery, by John Bell, edited by Charles DeU. 



DIABASES OF THE GLANDS AND 0LAND-DUCT3. 



her back to him, again and again, expressing mj opinion and 
my wish at the same time, that he should do whatever he might 
suppose right. By good fortune, she called upon me the day 
she was to return home, nothing heing as yet done to the tu- 
mour, but supplied with abundance of blisters and plasters to 
apply at a fit opportunity to her throat. I felt now that pro- 
fessional ceremonies should give way to essential charities. I 
placed ber in b chair, and almost without her conaciousneas, at 
least before she was aware, I struck a fine bleeding-lancet deep 
into the tumour by the side of the frtenum of the tongue, when, 
from the firm compression of the surrounding parts, the matter, 
though too gross to pass freely through such nn opening, was 
spewed out from the orifice, in a manner expressly resembling 
that in which yellow paint is squeezed out from the bladder 
upon a painter's pallet. It was of a deep safi'ron -col our, thicker 
than mustard, mixed like gruel with seed-like particles, and 
exceedingly fetid. I knew that the tilmour was not emptied, 
though tlie outward swelling was almost gone, but I also knew 
that though I should not enlarge the opening, the second se- 
cretion from the surface of the sac, which is in all cases thin, 
■would dilute and wash out whatever viscid matter remained; 
and when she saw how suddenly my prognostic was fulfilled, 
she expressed a perfect confidence in whatever I predicted, and 
a perfect willingness to submit cheerfully to whatever I pro- 
posed to do. Next day I introduced the point of a probe-point- 
ed bistoury into the orifice made hy the lancet, and knowing 
that the lingual artery lies on a lower level, embedded among 
the muscles, and running along the lower surface of the tumour, 
while I had over the point and blade of my bistoury nothing 
but the inside membrane of the mouth, much thickened, I run 
it fearlessly and at one stroke, as the less painful way, along 
the whole length of the tumour, when the thickest of the yel- 
low mucul flowed freely or was raked out with the points of 
the fingers and the handle of the bistoury ; and tho tongue de- 
flcendod now to its natural level, was in a capacity once more 
of delivering the peculiar dialect of her native city in all its 
parity. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 287 

^^ So tense and apparently solid was this tumour, in conse* 
qnence of the compression by so many surrounding muscles, 
that her surgeon mistook it for a solid and strumous swelling. 
I reckoned that in this, as in all cases of sacculated tumour, 
the second secretion, which was thinner, would wash out the 
thicker mucus, and I was not deceived ; but she left me too 
early for me to witness the obliteration of the sac. 

^^ I find it, in all such cases, a matter of some importance, 
especially in a girl, to anticipate the outward suppuration of 
any sacculated tumour, by puncturing it, though to a great 
depth within the mouth and under the tongue, and equally ne* 
cessary to be at pains in preserving the opening and obliterat- 
ing the sac ; a slight misconduct in this respect occasions much 
distress to the patient, and much superfluous labour to the sur- 
geon. Among the examples of this which I have had occasion 
to remark, the following is the most instructive. 

" Case III. — The case of Peggy Hall represents a tumour, 
which in all its stages, and for a course of three years, was ill 
understood and worse treated. She was a stout and lusty girl, 
about twenty-two years of age. The tumour occupied all the 
left side of the neck, from the lobe of the ear and angle of the 
jaw, quite to the sternum, displacing the mastoid muscle. 
This, like the tumour of Jenny Brown, arose from that slight 
inflammation which follows the extraction of a tooth. More 
than two years ago, after being distracted with toothache, she 
had two carious teeth pulled from the lower jaw, and she dis- 
tinctly remembers that two days after the extraction of the 
sound tooth she was sensible, upon undoing the flannels in 
which her swollen and inflamed face had been for some time 
wrapped up, that there was a little lump about the size of a 
small plum. It lay under the angle of the jaw, and had never 
ceased to grow, and has now, without the slightest pain or 
change of colour, attained the present size. In the month of 
April, 1799, she was directed to apply some kind of plaster. 
In May, Dr. Monroe advised her to have it opened. In a few 
weeks after, this was attempted by the surgeon of the village 
in which she lived, who made a large incision, but being soon 



288 DISBASBS OF THE GLANDS AND QLAND-DUOTS. 

alarmed, he laid aside the knife and lancet, and prosecuted his 
work rather by boring than by cutting. He tried, with probes 
and directors, to make good his way into the sac, but having 
pushed them very deep, and toiled half an hour in vain, aban- 
doned his purpose. 

^' The tumour was distinctly a great sac of fluid secretion. 
There was nothing doubtful in the case. The sac lies under 
the platysma myoides, and under and before the mastoid mus- 
cle. The belly of the mastoid being raised .upon the bag or 
tumour, feels soft and flaccid, and might have seemed to an un- 
skilful surgeon to form a part of the tumour. By making his 
incisions over the belly of the muscle, he could not penetrate 
to the sac otherwise than through the body of the mastoid mus- 
cle. Having cut to a considerable depth among solid and 
quivering flesh, he became alarmed. Willing still to penetrate 
farther, and yet without danger, he bored with his finger, cut 
a little obliquely with his knife, and bored a little more with 
his director, till, having buried it apparently in the tumour, 
to the depth of three or four inches, he believed, and to the 
ignorant relatives and patient seemed to prove, that there was 
no fluid in the tumour, while there was nothing singular in all 
this but his own awkwardness. He had penetrated entirely 
under the belly of the mastoid muscle, pushing his probes ob- 
liquely between it and the sac. To avoid the great vessels of 
the neck, he wrought obliquely backwards, and by cutting ob- 
liquely backwards, he made good his way under the belly of the 
mastoid muscle. 

'^ The young woman endured the disappointment, and suffer- 
ed the tumour still to extend, not without great inconvenience 
and deformity, for seven or eight months; the operation being 
then performed more correctly and confidently, every cir- 
cumstance tended to confirm the notions I had formed of this 
awkward proceeding. The surgeon who now operated was 
timid and careless in conducting the cure. 

" The incision through the skin only was freely made. The 
incisions through the platysma myoides were made timidly, the 
flesh of its fibres retracting and quivering as they were cut 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 289 

The sac then burst from betwixt the divided fibres of the mus- 
cle, white and transparent. Upon this being divided, several 
pounds of thin serous fluid gushed out. Then the long iron 
probe was passed across the cavity of the tumour, and its point 
cut upon at the anterior edge of the mastoid muscle ; in short, 
near the place of the former incisions ; whereas, to lie across 
the tumour, the point should have been cut out behind the belly 
of the mastoid, and then the seton or cord would have more 
effectually inflamed the sac and obliterated the cavity. 

^'But this girl was doomed still to suffer from timid prac- 
tice. The seton, ill introduced at first, was worse managed. 
In whatever way introduced, it should have been made to ob- 
literate the sac. The sac was permitted to remain always half 
full ; its walls were never brought together so as to favour their 
adhesion ; the cord was even withdrawn and the orifice permit- 
ted to heal ; the fluid again collected to the amount of two 
pounds ; it was again evacuated by freeing the old opening, 
slitting up a part of the muscular sac with a probe bistoury, 
and obliterating it (a purpose which was very slowly accom- 
plished), by strong injections of port wine and stimulating me- 
dicines. 

" The case of this girl, which was protracted by unskilful 
treatment to six months, should have been accomplished in 
three weeks, and while the sac was pouring out matter from its 
thickened walls, and hardening into a solid tumour under the 
jaw, the girl was in danger of having established an incurable 
and growing disease ; for a tumour so situated, and proceeding 
from such a cause, could never, by the most dexterous opera- 
tor, have been dissected away from the neck and jaws.'* 

I have felt no hesitation in quoting at length the preceding 
narratives of cases, and the excellent remarks attending them. 
Facts like these impress the mind of the reader much more for- 
cibly and permanently than dogmas. In the instances above 
cited, we see what serious consequences to the glands of the 
mouth may be occasioned by the operation, to which every man 
thinks himself competent — the extraction of a tooth ; and we 

also see how very important it is to be able to detect the na- 

25 



290 



DISEASES OP THE QLAXDS AND GLAXD-DOCTB. 



ture of the disease in its earliest manifestation, and to ftpplj 
the bold prompt remedy wliich only can prevent tlie threaten- 
ed mbchief. 

Certainly, if the dentist, however careful, may be the nnfor- 
tanate agent to produce sucli tumours, he ought at least to be 
prepared to do all that skill can do to remove them. 



The parotid is the greatest of the salivary glands, and fur- 
nishes the largest part of the saliva. It is situated in the ir- 
regular cavity bounded by the ramus of the lower jaw and the 
mastoid process of the temporal bone, penetrating as deeply 
back as the styloid process, and even dipping behind it. It ex- 
tends from the zygoma to the angle of the jaw, and from the 
meatus extcrnus and mastoid process to the masseter muscle. 
This gland is subject to ordinary inflammatory G>\elling from 
cold, and especially to a peculiar specific inflammation, called 
cynanche parotidea, or vulgarly, mumps. 

The parotid is also sometimes the seal of carcinomatous dis- 
ease, and may be aiTected by all the modes of disorganization 
which aRoct glandular structures. 

The poi^ition of this gland, and its vascular and nervous con- 
nexions, render its extirpation one of the most difficult opera- 
tions in surgery. Until recently, the complete extirpation was 
considered impracticable, and oven now many doubt that it 
has ever been effected. Allen Burns, Boyer, Richerand, and 
other celebrated anatomists and surgeons, declared that the 
safe extirpation of the whole parotid was impossible; but there 
can be no reasonable ground for rejecting the testimony of the 
distinguished and honourable men who claim to have succeeded 
in the operation. 

The credit of having Erst demonstrated the practicability of 
this operation by actually performing it, seems to be due to 
Prof. Samuel White, of Hudson, N. Y., who extirpated the en- 
tire gland, for u carcinomatous tumour, in the year 1808; 
though there is some reason to suppose that it had been per- 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 291 

formed by some of the older surgeons. It certainly had been 
attempted. 

Notwithstanding that the patient was examined by experi- 
enced surgeons, who satisfied themselves «f the fact of the com- 
plete extirpation, the operation was not attempted in Europe 
until 1823. It has since been performed repeatedly on both 
sides of the Atlantic. 

That excellent surgeon, the late Dr. George McClellan, of 
Philadelphia, performed the operation in 1826, when the possi- 
bility was yet denied by eminent authority, and ten times sub- 
sequently. In all these cases the entire gland was removed, 
and in all but one the patients recovered. 

His son claims for him, with apparent justice ^' the credit of 
having done more than any other surgeon, by the numbers and 
success of his operations, to completely establish, as safe and 
feasible, the extirpation of the parotid gland." 

As the result of the testimony now submitted to the profes- 
sion, it is sufficiently determined : 

1st. That the exsection of the parotid, though an exceeding- 
ly difficult, is, in the hands of a good anatomist and skilful sur- 
geon, a feasible operation. 

2d. That the carotid artery and its larger branches are ne- 
cessarily implicated in the operation. 

3d. That it is impossible to spare the facial nerve, and con- 
sequently paralysis is an inevitable result of the operation.* 

I think it unnecessary to give any directions, gathered from 
the experience of the most successful operators, for the perfor- 
mance of so very delicate and dangerous an operation as the 
extirpation of the parotid. No sane man will attempt it un- 
less perfectly acquainted with the anatomy of the parts, and as 
familiar as reading can make him with the history of previous 
operations. To one thus prepared, there needs but the bold 
heart and expert hand to secure at least the utmost likelihood 
of success which the character of the operation will admit. 
There are no men whose habits of operating beget more facility 

* Cooper's Surg. Diet., bj Reeee. 



292 DISEASES OF THE OLANDS AND (iLASD-DBCTS, 

in manipalating, more Qi<:e mauuitl dexterity, than dentists, 
and if they will acquire the necessary information, they may 
become the most expert of operators. The example of Dr. S, 
P. Hullihen, of Wheeling, is worthy the imitation of all who 
would be scientific dental surgeons. 



The duct of the parotid gland, called the duct of Sleno, 
emergesattho upper extremity of the middle third of the ante- 
rior edge of the gland, and proceeds forward and inward, direct- 
ly under the skin, and on the mnssetcr muscle. It is distant 
from three to five lines from the lower edge of the zygoma. It 
passes on the anterior edge of the massetor muscle, penetrates 
between the fibres of the buccinator muscle, and opens in the 
lateral walls of the cavity of the mouth opposite the first pos- 
terior molar tooth of the upper jaw, according to Meckel, the 
second molar, according to Harris, and the second and third 
bicuspis, according to Cooper — the situation of the opening dif- 
fering somewhat in difi'erent subjects. 

This duct, being very superficially situated, is exposed to 
injury, and is often wounded by an incautious operator, or by 
a blow. Sometimes, also, the duct may be obstructed by the 
pressure of a. tumour or by inflammation. In such cases the 
Saliva will accumulate until it makes a passage through the 
cheek, and continuing to pass through the opening, will form 
a permanent opening, which is called lalivart/ Jtetula. 

The discharge of the saliva over the cheek is very annoying, 
and the artificial opening is a very serious deformity. 

A variety of methods have been employed to cure salivary 
fistula. Monro inserted a seton from the external fistulous 
opening into the mouth, and kept it there until a new fistula, 
open both on the cheek and in the mouth, had been fully form- 
ed. He then destroyed the edges of the external opening with 
lunar caustic, and caused adhesion between the new surfaces 
produced by the sloughing of the superficial eschar. The sa- 
liva of course continued to fiow through the fistulous channel 
into the mouth. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 293 

Dessault also employed a seton, but he introduced it through 
a canula, as follo^vs : Inserting two fingers of his left hand into 
the patient's mouth, and placing them between the teeth and 
cheek opposite the fistula, he introduced a small hydrocele tro- 
car in its canula, through the cheek, just before the opening of 
the posterior part of the duct, and in a direction inclined a lit- 
tle forward. An assistant now took hold of the canula, while 
Dessault withdrew the perforator, and passed a line of thread 
through the tube into the cavity of the mouth. The canula 
was then taken out, and a seton, which was then fastened to 
the end of the thread in the mouth, was drawn from within 
outwards, but not so far as to come between the edges of the 
external opening, where the thread alone lodged, and this was 
fastened with sticking-plaster to the outside of the cheek. 
The outer wound was dressed with lint and compresses. Des- 
sault used to change the seton daily, introducing regularly 
rather a larger one, and always taking particular pains not to 
permit it to pass between the edges of the external opening. 

The patient was enjoined to use the jaw as little as possible, 
and for some time confined to liquid food. In about six weeks 
he omitted the seton, leaving in the thread for a little while 
longer. This being taken away, he completed the cure by 
touching the little aperture remaining, with caustic. Beclard 
succeeded several times, by passing a leaden stilet from the 
inner surface of the cheek into the duct, at the point where it 
was obstructed. He then made a fresh incised wound of the 
external fistulous opening, and closed it with the twisted su- 
ture. 

Mr. Samuel Cooper prefers the operation of Beclard, when 
possible, as causing a more speedy cure. 



25* 




Tbb superior raoxillarj bone is frequently tbe seat of tu- 
mours, which, from their enlargement, interforo with the func- 
tions of speech, deglutition, and respiration, and often prove 
fatal. 

Some of these tumours are of the malignant fungous variety. 
These, coraroonly, are seated in the antrum. The first indica- 
tion of their presence is an aching of the face, which is usually 
attributed to toothache, but which continues and aggravates, 
notwithstanding all the efforts to alleviato it. The jaw rapid- 
ly sirella, and the nostril of the affected elde is soon obstructed 
to respiration, and discharges matter. The walls of the an- 
trum are soft, and yield readily to pressure. The nostril is 
filled with a bleeding tumour. The disease rapidly progresses 
— finds its way into the throat, detaches aud pushes forward tbe 
teetb, throws out an enormous fungus into the mouth or on tfae 
cbeek, hectic and emaciation rapidly reduce the patient, and 
he soon succumbs to aggravated suffering. 

With such a disease as this, we have no means of contend- 
ing. An operation would be worse than useless. Fortunately 
its progress ia rapid, and death speedily brings tbe ardently 
desired relief. 

There is another form of tumour, wbicb commences in tbe 
periosteum and bone, often from some accident, as a blow or 
fall. This tumour is of slow growth, and is solid and ri>sist- 
ing. It is littlo sensitive, docs not bleed, nor involve surround- 
ing tissues except mecbanically by its growth. In short, it is 



m 



TUMOURS REQUIRING AMPUTATION. 295 

a tumour of the benign kind, not connected with constitutional 
disease, and it may be removed with entire safety. 

In proceeding to remove a tumour of this kind, involving 
the superior maxillary, the surgeon must have in view, 1st. 
To take away every portion of the disease ; and 2dly. To 
cause as little deformity as possible. The tumour should be 
got out whole ; any incision into it would probably induce an 
embarrassing hemorrhage. 

The operation itself is by no means dangerous, as compared 
with other amputations, and it may be performed without much 
difficulty, by a dexterous and confident surgeon. 

Mr. Listen's directions for performing the operation are as 
follows : '^ Having to work among bones, you must use a good, 
strong, and broad knife — one with which you can make free 
and proper incisions. To uncover a very large tumour, you 
may make one incision from the point of the cheek-bone to the 
comer of the mouth, carrying it outwards also in the direction 
of the zygoma : another from the angle of the eye to the mid- 
dle of the upper lip. The mark of these incisions must always 
be more or less apparent. But if you have a tumouf of mode- 
rate size to deal with, you should make one incision from the 
angle of the eye, down the side of the nose, bring it under the 
alse, and cut away the alee from the edge of the superior maxil- 
lary bone ; then you bring the cut down well towards the co- 
lumna nasi, push the knife through the lip, and cut right down 
the median line. A scar from that incision will scarcely be 
perceived if the parts are cleverly and carefully put together. 

^^ You make another and much less extensive incision from the 
same point, in the course of the fibres of the orbicularis palpe- 
brarum, out towards the zygoma, carrying the knife under the 
eye ; you can then turn downwards and outwards a large flap, 
uncover the tumour, and get to the processes of the bones. 
These being divided, the tumour almost tumbles out. 

" Before commencing your incision, or after you have turned 
the flap back, you may require to take out one tooth, and you 
remove the lateral incisor. You must bo provided with strong 
edged cutting forceps for dividing the bones, and very strong 



LAMt U^^^H . ^\^^^^^^ "^^^ 



296 xnuouRS bequ:biso amputation. 

scissors for BCparating Ion gitn din ally the palatine arch. Be- 
fore applying them, you cut a notch out of the alveolar process 
of the tooth removed, with the point of the cutting forceps. 
Very often you are compelled to take away the os mala, or per- 
haps you may saw it through. Supposing that you are going 
to uke away the os mala by the forceps, you divide the zygo- 
matic arch and also the junction of this bone with the frontal 
bone, at the transverse facial euturc. You cut the nasal pro- 
cess of the maxillary bone ; then putting one blade of the scis- 
sors into the nostril, and the other into the mouth, cut down 
and you have destroyed all the attachments of tbo tumour. 
You must next carefully detach the parts within the orbit, cut- 
ting the superior maxillary nerve far back; that must not be 
drawn out from its origin ; then putting your finger on the tu- 
mour, you detach with your knife any remaining connexions, 
and out tumbles the mass. You tvill be astonished to find how 
little blood follows an operation of this kind ; it can be done in 
a very few minutes. There is seldom any necessity for stop- 
ping the bleeiling temporarily by pressure on the carotid; af- 
ter you have turned the tumour out, perhaps you will not find 
a single vessel to tie, or only one. You take hold of that with 
the fingers, put on a ligature, and then lay the flap down. 
The tumours should come out quite entire, and after stopping 
any vessel that may bleed, you put a dossil of lint into the 
cavity, bring over the flap, and put the parts neatly together. 
" Tou introduce some points of interrupted suture under the 
eye and by the side of the nose ; you attach the nine, and then 
put two points of twisted suture into the upper lip. In a short 
time the cavity fills up, and it is altogether an exceedingly sa- 
tisfactory operation. I have extirpated the upper jaw to re- 
move fibrous tumours, nine or ten times, without the loss of a 
single patient. It is an operation more successful than the 
amputation of the leg, or, at all events, of the thigh, and is at-' 
tended with as little risk." 



The lower jaw ia also sometimeB the seat of tumours which 



TUMOURS REQUIRINa AMPUTATION. 297 

may, like those of the upper maxillary, require the use of the 
knife. 

These tumours sometimes consist of a deposit of a glairy 
fluid between the plates of the bone, gradually distending it ; 
sometimes they are malignant, at others they consist of carti- 
lage and bone. 

Portions of the lower jaw have very frequently been taken 
away, and sometimes with but little difficulty. It occasional- 
ly happens, however, that a very large portion, even the whole, 
requires to be removed. 

In exsecting a portion of the lower jaw, it is very important 
to avoid unnecessary disfiguration, and our ingenious country- 
man. Dr. Rhea Barton, has made an excellent suggestion on 
this point. 

It is to preserve a rim or margin of the bone, so as to pre- 
serve the outline of the face, and afford a base for the inser- 
tion of false gums or teeth. In all cases where the extent of 
the disease will permit, this should be done, as the rim of bone 
thus preserved will be of immense use to the patient. 

The incision through the soft parts should be made beneath 
the base of the jaw, so as to hide the cicatrix as much as pos- 
sible. 

Prof. Mutter has succeeded in detaching a tumour with a 
portion of the jaw, without any external incision or deformity 
whatever. This tumour was seated upon the symphysis and 
two-thirds of the left ramus of the bone. The patient being 
seated, with her head supported by an assistant, the tu- 
mour was laid bare in its whole extent, by detaching the lip 
dnd integuments of the chin and cheek from the adjacent 
bones. No external incision was made^ yet Dr. M. had no 
difficulty in turning the soft parts down under the bone, so as 
to leave its base perfectly visible. Next, partly with a saw 
and partly with a strong scalpel, he cut through the base of 
the tumour, leaving a small rim of the bone, composed of the 
rounded portion of the lower jaw. Two perpendicular cuts 
were then made (one on each side of the mass),' with the cut- 
ting forceps — and the tumour, thus loosened, was readily re- 



TUMOURS REQDIRINO AMPCTATIOH. 



moved wtth a few strokes of the scalpel. As the hemorrhage 
was profuse, the actual cautery and pledgets of lint steeped in 
creaaote ivero applied, and with entire aucceBs. The tip was 
then brought back to its original position, and cold water 
dressing applied to the face. A perfect cure, without the 
slightest deformity, was accomplished in two weeks. 

To our countryman, Dr. Mott, is due the honour of having 
first attempted, und executed successfully, the amputation of 
the lower jaw at the articulation ; after him, Mr. C'usack, of 
Dublin, performed it. According to a note hy Dr. Reese, in 
Cooper's Surgical Dictionary, the operation had not been per- 
forraed by any others up to 1842. Mr. Listen, in his lectures 
delivered in 1844, speaks riither sneeringly about the "fuss" 
made about extirpating the jaw, and gives the credit of the ope- 
ration to Mr. Cusack, of Dublin. He then proceeds to de- 
scribe it as though it had been an every-day operation with 
him. This conduct of Mr. Liston is remarkable enough, but 
it is more strange that his editor, Prof. Mutter, has not cor- 
rected the error, and done justice to Dr. Mott. 

The operation is one of the utmost difficulty, and it is use- 
loss to give any directions for its performance, None hut a 
surgeon of well-tried skill would be justifiable in undertaking 
it, and such a one would pay but little attention to directions. 
These of Mr. Listen may he well enough, but we do not know 
that he ever performed the operation on a living body. 

Dr. S. P. Ilullihen, a practising surgeon dentist, of Wheel- 
ing, and one of the best surgical operators in this country, has 
performed an operation upon the jaw, which well deserves to 
be recorded here. As Dr. Harris justly remarks, "the inge- 
nuity, skill, and boldness displayed in the conception and per- 
formance of this complicated operation, place Dr. Hullihen at 
once among the ablest surgeons of the day." It is the more 
■worthy of notice here, as having been performed by a dcnttat, 
who thus furnishes a model of what we would have a dentist to 
be — not a mere mechanic, employed to repair iho teeth, or, if 
necessary, extract them — hut an accomplished physician and 
surgeon, who, while devoting his aiteution particularly to the 




TUMOURS REQUIRING AMPUTATION. 299 

teeth, is prepared to undertake the treatment of the adjacent 
partSy however formidable and complicated their diseases may 
be. 

" Miss Mary S , aged 20, daughter of the Hon. Wil- 
liam S , of Ohio, came to Wheeling, in the spring of 

1848, to obtain relief from the effects of a very severe burn, which 
she had received fifteen years before. The burn was princi- 
pally confined to the neck and lower part of the face, and its 
cicatrix produced a deformity of the most dreadful character. 
Her head was drawn downward and forwards, the chin was con- 
fined within an inch of the sternum, the under lip was so pulled 
down that the mucous membrane of the left side came far 
below the chin, the under jaw was bowed slightly downward, 
and elongated, particularly its upper portion, which made it 
project about one inch and three-eighths beyond the upper jaw. 
In front there was scarcely any appearance of either chin or 
neck. She was unable to turn her head to either side, the 
cheeks and upper lip were dragged considerably downward ; 
she could not close her eyelids ; she could not close her jaws 
but for an instant, and then only by bowing her head forward. 
She could not retain her saliva for a single instant ; and, as 
might be expected, her articulation was very indistinct. 

" She had been taken to the city of New York some years 
before, for the purpose of being relieved from this deformity, 
and was placed under the care of two of the most distinguish- 
ed surgeons in that city, who performed an operation by dis- 
secting up the cicatrix on the neck, then raising the head and 
sliding up the cicatrix from its original position, leaving a raw 
surface below to heal up by granulation. I need scarcely add 
that the operation was entirely unsuccessful. 

^^ After a careful observation of the case, it became evident 
that such a complicated deformity could be best remedied by 
performing three separate operations : one upon the jaw, ano- 
ther upon the neck, and a third upon the under lip. 

" To remove the projection of the under jaw, seemed to re- 
quire the first attention. Unless that could bo done the other 
operations, however successful, would add but little, if any, to 



the personal appearance of the patient. Thia lengthening of 
the jaw had taken place entirely between the cuspitlatua and 
first bicuspid tooth of the right side, and between the first and 
second bicuspids of the left. By the elongation, the teeth jast 
described wero separated on both sides about three-fourths of 
an inch. 

"To saw out the upper edge of these elongated portions of 
the jaw, and then to divide that part of the jaw in front of the 
spaces thus made, by sawing it through in a horizontal man- 
ner, 80 as to permit the upper and detached portion to be set 
hack in its original position — appeared to bo the only possible 
way of remedying the deformity. Thia plan I therefore adopt- 
ed, and performed the operation on the 12th day of June, in 
the manner now to be dcacribod. 

" The operation was commenced by sawing out, in a V ahape, 
the elongated portions, together with the 6rat bicuspid on the 
left side, each section extending about three-fourtha of tbe way 
through the jaw, I then introduced a bistoury at the lower 
point of the space from which the section was removed on the 
, right side, and pushed it through the soft parts close to and in 
front of the jaw, until it came out at the lower point of the 
space on the left aide. The bistourywaa then witbdrawn, and 
a slender saw introduced in the same place, and the upper 
three-fourths of the jaw, containing the six front teeth, was 
B&wed off on a horizontal lino ending at the bottom of the 
spaces before named, tbe detached portion being still connec- 
ted, on the outer and inner sides, to the jaw below, by thosoft 
parts. 

"After having with the bone nippers removed from the de- 
tached portion the corners which were created by the horiion- 
tal and perpendicular cuts of the saw, it was set back, so that 
the edges from which the V-shaped sections were removed 
came together. 

" Thus it will be perceived that this portion of jaw and teeth, 
which before projected and inclined outward, now stood back 
and inclined inward, and in its proper and original place. 

"In this position the jaw was secured, by passing ligatures 



TUMOURS REQUIRING AMPUTATION. 301 

around the cuspidati in the detached portion and the now ad- 
joining hicuspids in the sound portion, then taking an impres- 
sion of the jaw in very soft wax, a cast was procured, and a 
silver plate struck up and fitted over the teeth and gum, in 
such a manner as to maintain the parts in that same relation, 
beyond the possibility of movement. 

'^ The patient declared that the operation gave her little or 
no pain. There was a little swelling about the chin during the 
first three days after the operation, but not the slightest uneasi- 
ness. In this way the case progressed ; the gum healed in a 
few days, the jaw united strongly and in the time bones usually 
unite, and the wearing of the plate was discontinued within six 
weeks after the operation was performed. 
- " The deformity of the jaw being now removed, the next 
thing to be done was to relieve the confined condition of the 
head, and the distortion of the face and neck resulting there- 
from. This I determined to accomplish, if possible, after the 
manner of Prof. MUtter in similar cases, and I accordingly per- 
formed the operation on the 31st day of July, assisted by Dr. 
Wissell. 

^^ I began by dividing the skin immediately in front of the 
neck, about half an inch above the sternum, and then carried 
the incision back about three inches on eaich side. I then 
commenced a careful division of the strictures, which were so 
thickened in front as to extend to the trachea, and on the sides 
as not only to involve the platysma myoides, but a portion of 
the stemo-cleido-mastoid muscle also. After dividing every- 
thing that interfered with the raising of the head and the closing 
of the mouth, as far as the incision was now made, it became 
evident that to give free motion to the head, the incision on 
the neck must be extended back through the remaining cica- 
trix, which was at least two inches wide on one side, and about 
an inch and a half on the other. 

^^ This was accordingly done, the whole presenting a wound 

upwards of nine inches in length and nearly five in width. A 

thin piece of leather was now cut in shape of the wound, but 

somewhat larger, and placing it upon the shoulder and arm, 

20 




immediatelj over the deltoid muscle, a flap nearly ten inches 
in length and five in breadth, having an attachment or neck 
two inches wide, vaa marked out, and then dissected up as 
thick as the parta below would permit. This flap waa now 
brought around and secured in the wound on the neck by the 
twisted suture, the sutures being placed about an inch and a 
half apart. Between each of these sutures, one, two, and 
sometimes three Biiia.ll stitches were inserted, depending entire- 
ly upon the number necessary to bring the edges neatly to- 
gether. These stitches were of fine thread, had a, very super- 
ficial hold, produced little or no irritation, and served to keep 
the parts in better apposition than any other means I could 
have devised. The wound of the shoulder was next drawn to- 
gether about one-half of its entire extent; the remainder was 
covered with lint. One long, narrow strip of adhesive plaster 
applied around the neck to support the flap, and over this a 
cravat tied in the usual nay, constituted all the dressing deem- 
ed advisable at this time. 

"The patient bore this tedious and very painful operation 
with great fortitude, and uttered scarcely a murmur. She was 
somewhat cnhausted, but not from the loss of blood. There 
was no vessel divided of sufficient importance to require n liga- 
ture. 

" Aug. 1. During the fore part of last night, the patient was 
somewhat distressed, was very unmanageable, would talk in- 
cessantly, and occasionally sat up in bed. An anodyne was 
administered at 12 o'clock, after which she rested much better 
and slept some. Complains of sickness of the stomach this 
morning; has vomited three or four times; flap very pale; 
pulso rather weak. Directed to refrain from all kinds of 
drinks. 

, Complains only of pain in the shoulder ; was much dis- 
tressed the latter part of last night, on account of a retention 
of urine. The catheter was employed, and about three pints 

e drawn off, after which she rested well. Pulse s 
what excited; flap better colour. 

, The patient rested well last night ; the use of the 



I 
I 




TUMOURS REQUIRINa AMPUTATION. 803 

catheter still necessary. All efforts to keep the patient from 
talking and moving unavailing ; colour of the flap rather pale, 
save at the extreme point and about two inches along the lower 
edge, which is assuming rather a dark blue colour. Pulse about 
the same as yesterday ; removed a pin from near the point of 
the flap, and enveloped the neck in cotton batting. Patient 
complains of hunger ; chicken broth ordered. 

'^ 4th. Patient rested well ; the use of the catheter yet neces- 
sary ; complains of slight headache ; the colour of the flap nearly 
natural, and even the point is assuming a healthy hue, and ap- 
pears to be uniting ; pulse almost natural. 

"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 in- 
tention 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 anything but pain in the shoul- 
der, a slight headache of a few hours' duration, and the unea- 
siness occasioned by the retention of urine. The wound on 
the shoulder granulated rapidly and skinned over in about six 
weeks after the operation. It was curious to observe that 
upon touching the flap after it had healed in the neck, the pa- 
tient 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, go tbat it pouted out an inch or more 
further than the npper 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 in- 
verted 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 se- 
cured after the manner of a single hare-lip. The wound heal- 
ed in the most beautiful manner, and the appearance of the Up 
was greatly improved; but there yet remained a deep depres- 
sion or notch in the edge, sufficiently large to keep exposed the 
tops of two or three teeth, besides preventing the coming to- 
gether 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 Up, about two lines from the free edge, first on one side of 
the depression, and then on the other, and then carried the in- 
cisions 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 ^saected loose from the jaw, and then raised 
to a level with the remainder of the lip, and there retained 
by pins, after the manner of dressing a double hare-lip, the 
lint" of union forming a letter V. 

"This operation was as successful as the others, and the ori- 
ginal deformity being now removed, the young lady, though 
still bearing evidences of the burn, has the free use of her head, 
eyelids, jaws, and lips, and may mingle in society without par- 
ticular note or remark." 



805 



CHAPTER XXIII. 

DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

The cavity which bears these names is liable to be the seat 
of a yarietj of diseases. For the most part these are simple, 
and not at all malignant in their character ; occasionally, how- 
eyer, tumours 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 
reached 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 tu- 
mour, 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 afiected 

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 tumours, 

or may be involved in such morbid formations commencing in 

26* 



306 DISEASES OF THE AKTRCM OB MAXILLARY SINVS. 

the bony stractures or the thin fibroos tiBsne which attaches it 
to the bones. 

In treating further of diseases of this cavity, I wiJI ask the 
attention of the reader to, 1st. Dropsy or retention of mucus ; 
2d. iD^ainiiiation of the lining membrane; 3d. Suppuration; 
4th. Caries, necrosis, and other morbid conditions of the bony 
walls ; 5th. Polypi and other tumours ; 6th. The presence of 
insectB in the cavity. 



The term dropsy is entirely misapplied to this affection, and 
should he discarded. The disease has no similarity to dropsi- 
cal swellings : those are occasioned by effusion of water, while 
the affection ne 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. Be- 
ing retained, it will necessarily degenerate ; being degenerated, 
it vill irritate the membrane, and the membrane being irrita* 
ted, 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 ad- 
ditional drop of fluid thrown into it will cause the whole mass 
to act with great power upon the walls which confine it. How- 
ever thick the walls, and however strongly knit together, they 
cannot withstand the hydraulic pressure continually augment- 
ing within them. They are gradually forced outwards, and a 
rounded solid tumour gives external evidence of the outward 
pressure of the contained fluid. 

Until the pressure becomes sufficient to distend the bones, 
the patient docs not complain of pain ; hut 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 tumour in- 
creases. The integuments covering the distended antrum 
become swollen and red. A smooth, hard tumour presents it- 



DISEASES OF THE ANTRUM OR MAXILLART SIKUS. 807 

self, either in the roof of the mouth, or under the orbit, or un- 
der the cheek, and unless the contained fluid be speedily eva- 
cuated, the contents of the antrum will force their way through 
the bones. 

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 tu- 
mour presents a tolerably uniform hard surface, there can be 
no certainty of the nature of the distending cause ; but the 
uniformity of the tumour, the sense of weight, the slight dis- 
comfort or pain attending it, and, finally, the discovery of 
fluctuation, will determine 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 anywhere 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 injury 
to the parts, and which afibrds the most facility for the escape 
of the matter, during such length of time as an artificial open- 
ing 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 opera- 
tion was feasible, and being so, was, for many reasons, prefera- 
ble 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 an- 



g 0itmn fl 






1 



poaitioD of the molar 

' U It is, there- 

lugh the alveolus 

iftve been previously extract- 



'* j"!*^"**^ *" .-iiiig titrough ita vacant alveoloB ; 

"^j^ •'*'T*-(ib tho jaw, one must be extracted, 

'*^.jf(*«'''''**M|«Tifiefl a carious, in preference to & 

"jlf f*** "JuJI *• «»""^i '' would be best to extract 

^ IMtt- ^^4«»t;aM it will be necesaarj to extract 

\1^ ••*■ Jnfcttin sufficient room for such an open- 

^.((•tf *V -jtniotion of the tooth will be followed at 

B,pi«*''i^-— of the fluid; an opening having been 

Md^^ lolfi"'' ^y ^^^"'ig away the fang. More gcne- 

^fV i;will be neceaaarj to puncture the floor of 

jj##WV^^( preferred by Dr. C. A. Harris, for whose 

"* vrtch matters, I have great respect, ia a straight 

If**'* --J point of this instrument having been passed into 

Jff*y^(^ should be pressed against the bottom, in a direo- 

^.^•''Tj^the centre of the antrum. The intervening plate 

•• '^,T then be easily pierced by a few rotary movements 



■ ^ar. Care must be taken bo to moderate the pres- 
plied, that the instrument may not, upon the giving 
'**flftho floor, be suddenly pushed across the cavity and 
"*v ifl wound the opposite surface. 

*^n the removal of the instrument, a guah of fluid will fol- 
Should the opening not be sufficiently large to permit of 
u flto passage of the thick matter which may be contained 
. tb* o**''*/' 't ^'^1 ^^ ^^1 •■O enlarge it. 

ggino surgeons advise that a bougie should be kept in the 
^ping, others prefer a canula of lead or silver. Richter oh- 
■01). that if a canula be left in, it should be carefully stop- 
_^ lest particles of food and drink should find their way into 
1^ ptvity. DoschampB and Harris advise that the canula be 
pfpnred to the adjacent teeth, and left in the opening. If & 



DISBASBS OF THE ANTRUM OR MAXILLART SimJS. 809 

bougie 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. 

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. cupri, 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 subdued. 

As the morbid condition of the mucous lining of the cavity 
may result from the irritation of diseased teeth or fangs, all 
suspected irritants of this kind must be removed. 

In Mott's edition of Yelpeau, 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 un- 
der the cheek, is, in general, so soft that a bistoury or scalpel 
penetrates it without any difficulty. The operation is then ex- 
tremely simple. . Having freely incised the superior part of 
this border transversely between the cheek and malar bone, I 
excise its inferior portion with a second cut of the bistoury. 
The loss of substance thus made, remains fistulous, and pre- 
vents the sinus from filling up a second time. The 4hree pa- 
tients 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 dissect- 
ing ofi* 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 



310 DIBEABEa OF THE ANTRUM OH MAXILLiSY SINUS, 



directs, in sucli cases, that we should penetrate into the maxil- 
lary sinua immediately below the zygomatic proeees, between 
the cbeek booe 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 liook draws the 
labial angle outwards and upwards. The operator incises the 
fibro-mucoua membrane which covers the bone at the point 
designated, by means of a scalpel or good bistoury ; then per- 
forates the osseous wall with a solid pointed instrument, en- 
larges the opening as much as he judges necessary, and finishes 
by introducing 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 tliorein a leaden canula. 

A buccal fistula of the maxillary sinus suggested to Rufiel 
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 buc- 
cess crowned the enterprise of the surgeon. 

GuUison recommended that if the fluctuation should become 
perceptible at the vault of the palate, the artificial opening 
should be established there. Basch and Henkcl have suc- 
ceeded by means of a seton introduced through a fistula in the 
floor of the orbit, and brought into the mouth through an open- 
ing in the alveoli, Eertrandi 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- 
Blrument to the upper and outer part of the canine fossa, di- 
rects it obliquely downwards and outwards, carefully avoids the 
branches of the suborbitar nerve, perforates the sinus, and then 



DISEASES OF THE ANTRUM OR MAXILLART SINUS. 811 

leayes 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 external to the gum. An eye which both in- 
struments have enables us at the same time to pass through the 
sinus the conducting thread of a meche of lint, destined to per- 
form the duty of a seton, and which may be smeared with any 
proper ointment.* 
N 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. 

INFLAMMATIOX. 

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 
orbit 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 toothache will accom- 
pany the duller, deeper, more continuous ache of the antrum. 

* Mott's Velpeau's Sargery, toI. iii. 



312 DISBASES OF THE ANTRUM OR MASILLABY SISDi 

Ab the pain increaaea, fever is developed, whicti will be more 
or less considerable, according to tbe degree of the inflamma- 
tion and the sensibility of the patient. 

Inflammation of the sinus can hardly be confounded with en- 
gorgement. In the latter case there is Bwelliog of the bones, 
and in the former there is pain from the commencement of the 
attack. In fact, it cannot be mistaken except for inflamma- 
tory odontalgia, aflTccting the roots of the molar teeth; and 
from tilts, 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 vapour 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 
patient. When the inflammation has boon subdued, and the 
morbid irritability of the parts has subsided, the mouth should 
be carefully examined, and all diseased teeth removed. 



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 in- 
stead of acute pain there is a throbbing sensation in the 
part. If the outlet of the sinus be open, pus will escape into 



DISEASES OF THE ANTRUM OK MAXILLART SINUS. 318 

the nostril, and unless it finds a free vent, some pointing will, 
after a while, be perceived in the alveolar border, or a bony 
protrusion will be noticed upon the cheek. 

Suppuration of the antrum may occur without preceding 
active 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 mem- 
branes. This kind of suppuration is not uncommon in the an- 
trum, and the inflammation preceding it is not unfrequently 
unperceived until the greater mischief of suppuration or ulcer- 
ation has been accomplished. Even after suppuration, the 
true nature of the evil may be unsuspected ; the more so, that 
the preceding inflammation 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. Should 
pus escape into the nostril, of course the diagnosis will be com- 
plete. 

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 mis- 
chievous, 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. 

0ABIE8, NB0E08I8, AND OTHEB MORBID CONDITIONS OF 

TUE BONT WALLS. 

Caries is an aficction of the bone, somewhat analogous to ul- 
ceration of the soft parts. In this disease there is loss of sub- 
stance, causing, for the most part, irregular perforation of the 
osseous structure, giving, in many instances, a honeycombed 

27 



314 DISBASES OF TllE ANTHDM OR MAXILLARY SINCl 



or worm-eaten appearance ; at other times the dcstraotion may 
appear ia a continuous superficial excavation. There is a dis- 
charge of a dark, fetid, sanious pu3, and fre(|uently a growth 
of fungous granulations ehoottng up from the excavations. 

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 diseases — and to 
diseases only differing in appearance from those affecting 
softer structures, hy 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. Anything which lessens the 
vitality of the parts, diminishes its nutrition, or causes exces- 
sive interstitial absorption, may cause caries. 

External injuries may be the exciting cause, though far more 
commonly productive of necrosig. Long-continued inflamma- 
tion or irritation of neighbouring 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 moat 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 coloured, fetid, and often 
bloody pus which I have mentioned, and this will commonly 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 
sarf&ce of the bone perceived. Very often, however, the canal 



BI8BA8B8 OF THB ANTRUM OR MAZILLART SINUS. 815 

through which the pus escapes is too tortuous to permit of satis- 
factory exploration. 

If caries be not checked, it will end in necroaUj 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 
sometimes external ; more commonly, perhaps, they depend, 
at least for their predisposing cause, upon constitutional vitia- 
tions, 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, he says, are, in almost 
every instance, preceded by some other affection of the antrum. 

Caries and gangrene of the antrum are very distressing af- 
fections, 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 sensi- 
tiveness 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 pro- 
mises relief, will commonly be endured with patience by the un- 
happy 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 in- 
fer the existence of caries ; but in a few instances, the pus has 
been of a normal character and appearance, and though the 
presence of the pus, in appearance such as commonly attends 



316 DISEASES OF THE ANTRUM OR MAXILLAIiy SIKtlS. 

caries, may satisfy us that such a state of the bone exists, the 
absence of such pus is not equally satisfactory evidence ibat 
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 blant 
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 at- 
tract attention to tbe alveolar border : and soon separating 
from the sockets, ulcerating and sloughing, they will lay bare 
tbe diseased bone, and expose tbe true character of the dis- 
ease. 

-' When situated in the fioor of tbe antrum, the rough dentt- 
dedbono may be easily felt with a probe or stilct, 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 Decrosis 
of the antral bones, tbe 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 teetb, and that caused by the 
action of fluid detained in tbe cavity. 

The first step towards cure, must be to evacuate any macoB 
irbich may be distending tho antral chamber, and to remove 
any diseased teeth which may be suspected of causing irrita- 
tion. 

The following case reported by Deschamps * will serro to 
flhow that I have not laid unnecessary stress upon the agency 
of diseased teeth, in the production of caries of the maxillary 
bones. 

M. Martin the elder, who enjoyed at Lyons, a well-merited 
reputation, communicated to me tbe following case: 

■ rrait* ilea MkluUct iIm fosMS NM*t«*«t4eleiinainB*. 




DISEASES Of THE ANTRUM OR MAXILLARY SINUS. 317 

M. D. had a carious tooth in the upper jaw of the left side. 
A deutist having refused to extract it, a yiolent 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 tumour 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 extrac- 
tion 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 
membrane. 

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 mean time, 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 tumour 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 

27« 



316 DISEASES 






.• the junction 

■ji of this diseases 
.ier circumstancc£:s& 
/•lula, unwholesom 
- irequently begins a 
.V incisor teeth. Th 
*• lad pain. Sometimes 
. -e assumes an crytherax— 
. 5:::ns ; and this is subse- 
;.< purple or brown colour. 
—.'iily sphacelated, sloughing 
...?ns. The tongue is loaded 
...: becomes exceedingly offen- 
• I death suddenly ensues. In 
wome loose in the commence- 
. unfrequently drop out on the 
.:' the jaw. The necrosis in some 
. ^:oof the jaw, and the ulceration 
^ f: parts and affect the alae nasi, the 
. ^ -cirly to the orbit of the eye. Very 
^^! tails in, and the internal structure 
..•5o«l, while the lips will become tumid, 
.. .. These morbid changes, to a greater 
.^ ; : to involve, very speedily, the teeth, 
.^•^ and cheeks. The disease is very dan- 
^-. :iv fatal. 

..,' disease is evidently tlic effect of ct>nstitu- 
.; local treatment can arrest the devastation. 
M-^nable for sur«:eons tu make use of the 
tor the curt* of caries. The diseased bone 

^w-j«J *'^''*y' '^"^^ ^'^^ subjacent i)art carefully cau- 
^- ** * *.-^i-hot iron, in order to prevent the spread of 
♦^ *_ Such terrible means were rarely justifiable. 
•*^* —-is entirely local, and the constitution sound, 



caries, may sat* 
absence ofsn- 
the bone is v.- 
course dispr ' 

By prul'' 
cial openii. 
probe an! 

When 
of the « 
the sei' 

The 
tract 
from 
the 
ea.-t 

d( 

tl 



NiX" 



t«r*^ 



li>^ jgr^H>n can do is to remove the cause of the caries. 
•J '** 'Mfi^: to lay bare the diseased iwirt, in order to cjive 



DISEASES OF THE ANTRUM OB MAXILLARY SINUS. 819 

egress to the fluids^ and admit the atmospheric air, which is a 
stimnlant to the parts, or any other moderate stimnlant which 
may seem likely to hurry the process by which the great sur- 
geon, nature, is limiting and repairing the injury. The dis- 
eased parts should be cleansed with astringent and detergent 
'washes ; loose pieces of bone should be removed, and the pa- 
tient rendered as comfortable as possible, and properly sus- 
tained by such nutriment as may be best adapted to his state 
of strength. Meddlesome surgery is bad. 

When there is constitutional disorder, causing caries, or pre- 
venting the curative process, there will be no prospect of re- 
lief, unless the constitutional disease be removed. If the vene- 
real 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 medi- 
cation, which promise most in such case. 

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 na- 
tural 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 reproduc- 
tion, we must make the best substitute we can for the lost parts, 
as it is imperatively necessary to close the cavity. ^^ An ob- 
turator of gold should be accurately fitted to the parts, and se- 
cured 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 
opposite side. If it be necessary to replace the teeth lost with 
artificial ones, these may be so mounted that the plate upon 
which they are set shall cover the opening into the maxillary 




; wilctuQg and increased flexibility of the 

^ ^ . .^Huutioaofthenarmal quantity oftliephos* 

^^j^^^^«hioh earthy ingredient the hardness of the 

^P^^^ m* uittj occur either from absorption of the 

— - ■: fsilnro of the arteries to deposit it in saffi- 

-f It is ft rare disease, but it sometimes occurs in 

^..^^ I ains accompanied by a similar condition in 

.■^ .^ >uxicturca, it may be regarded as the consequence 

4«u(\' from within the cavity, either by a tumour or 

. . i'ui. !*u far as the softening itself is concerned, it 

. :wu»idored u subject for medical or surgical treat- 







ion is a hypertrophy or morbid growth of the bone, 
tin' phosphate of lime is deposited in unusual quan- 
««i a bard tumour occasioned. It is not painful of itself, 
a>4^jr iiMi^nsion of the periosteum and superincumbent soft 
ffg/Ob- it may gradually become a source of great distress. 
t^[(WKKlly> however, as the tumour augments slowly, the eoft 

t»;i4ju8t themselves to the increased bulk of the bone, and 
IMUiciQt escapes serious suffering. Much, however, will de- 
HH^upon the magnitude and position of the swelling, and 
,^fH Uio attendant condition of the periosteum. Should this 
l^ikitMuodttnd sensitive, it may occasion acute pain. 

t1u*<* already described this kind of morbid growth, in 
[P^fji"-^ of tumours, 

■^fcc Wues of the face have very often been the seat of exos- 
^^ uid uiauy formidable operations have been performed for 
1^ titwtvval of such tumours. A number of such cases and 
have been described, both by the older and modem 

• 8*e Mott-B Vqlpe»u. vol. Hi. p. 184. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 821 

These tumours sometimes attain to great size. M. Bean- 
preau presented to the French Academy, in the year 1767, an 
anatomical preparation, consisting of a tumour which occupied 
the whole right maxillary sinus, and several of the neighbour- 
ing 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 tumour, and is nearly effaced. The nasal 
bones of the left side are displaced, and the right nostril en- 
tirely closed up ; and the exostosis projects so much on the 
left side as to be nearly under the malar bone. " Exteriorly," 
says Bordenave, '' the tumour had a smooth and polished ap- 
pearance, 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 Hdtel-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 vigour of mind and body. When six years old, 
he had the small-pox, which ran a most favourable course. 
When twelve years old, his father lanced a tumour at the inner 
canthus of the right* eye, which suppurated for a long time 
after. Immediately after this, a prominence appeared about 
the middle of the nasal process of the right superior maxilla ; 
and in spite of every application, steadily increased until it 
had attained considerable size. When the boy was fifteen, 
both maxillse were equally enlarged ; the bones of the nose 
seemed buried between the tumours, 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 tumours, 
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 lining, and 
particularly of stimulating drinks. At the age of forty-four 
he was seized with a malignant fever — his Brat sickness since 
infancy — from which be was slowly recovering, when he was 
seized with pneumonia, of which he died. 

"Upon post-mortem examination," says Jourdan, " I could find 
on the face no trace of any muscles except those of mastication ; 
but the skin seemed tightly drawn over the periosteum covering 
the numerous tumours. The head and face were everywhere 
exostosed, nnd 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 the skull in an adult is one 
pound, nine ounces, showing an increased weight, in conse- 
quence of these exostoses, of six pounds, seven ounces. The 
patient had never complained of pain, either in hia head or 
face." 

The symptoms of maxillary exostosis 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 pre- 
sence 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 bo sufficiently acute. 

It is in cases such as these, that coustiCuttonal 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 bo done except to remove the tumour 
before its extent renders an operation difficult or impracticable. 
In many instances this has resulted in permanent relief. 



Bonea seem, notwithstanding their density, to bo capable of 
nflammation, and even of abscess. 1 have already mentioned 



DI8BASBS OF THE ANTRUM OR MAXILLARY SINUS. 323 

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 organ, rather than in the proper osseous tissues. 

Jourdain records ten cases of this character, of which I have 
selected the following : 

Oase I. — A lady suffered with inflammation of the root of an 
jipper first bicuspis, on the right side, followed by alveolar ab- 
scess. After the inflammation had subsided, the tooth was re- 
moved ; but a fistulous opening still remained, emitting an ioh* 
orous 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 in- 
flamed and the tumour 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 oase, 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 
opening into the interior of the bone. The introduction of an 
instrument to the depth of a line and a half caused a free dis- 
charge of sanguineo-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 completely healed up. 

M. Morand was in favour of an incision through the bone for 
the purpose of excising the distended portion, but with that un- 
prejudiced liberality which always mark^ the man of true wis- 
dom, he yielded to my arguments in favour of the cavity. I in- 
troduced the hot iron into the fistulous opening three times in 
eight days, following it up with suitable injections, which fre- 
quently brought away small fragments of bone from the inte- 



324 DISSASES OF THE ANTRUM OR MAXILLARY SIKUS. 



rior of the cavity. The alveolus was soon reduced to its natural 
size, and in forty-three days the patient was perfectly cured, 

Case II. — Madame Masaonet was referred to me by M, Mo- 
reau, of the Hotel Cleu, for a, fistula above and between the 
first and second superior incisors. At the posterior part of the 
palatine arch there was a considerable tumour, without pain, 
softening, or change of colour. From the summit of this tu- 
mour 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 tumour behind. 

No further cause could ho 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 
tumour. The other teeth were sound. Injections and other 
moans had been tried at the time of the appearance of the es- 
ternal fistula, but unsuccessfully. I regarded this case as one 
of true abscess of the hone. I ventured, M. Morand approv- 
ing, to enlarge the external opening and make an incision 
through the entire palatine tumour, which discharged only 
blood. Suitable 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 treat- 
ment was very simple. The fistula was readily closed ; and in 
six weeks the patient was sent home, perfectly restored. 

Case III. — Madam Boillard had a fistula on the anterior 
surface of the superior maxillary hone, the result of an alveo- 
lar abscess of one of the incisors. Those teeth were bo 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. 

I discovered by the introduction of the sound that the fisto- 



DI8BASES OF THE ANTRUM OR MAXILLARY SINUS. 825 

Ions 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 establish- 
ed a free and direct communication for the escape of the puru- 
lent secretion of the fistulous canal. By medicated pledgets 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 
extended 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 toothache, 
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 affec- 
tion which resulted from alveolar abscess over the fangs of a 
decayed first molar of the right side. After the first attack, 

28 



326 DISEASES OF THE ASTEOM OR MAXILLARY SINUS. 

although the abscess discharged itself freely, a Bensation re- 
mained in the cheek, as though there was a smalt stone there. 
The second attack, though attended by a free escape of pus, 
left the cheek hard and Bwollen, and the eyelid much dis— '. 
tended, with a peculiar clamiDyfeelirginthercgion of thczyg»- 
matic 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 aixth day, I made an incision there in the 
direction of the fibres of the orbicularis muscle. As the swell- 
ing 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 
Jourdaio, whose book 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. Linds&y k 
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 bis name.* The work should be in 
the hands of every surgeon, and surgeon dentist in the land. 



This is a term applied to all those cases of fetid breath occa- 
sioned by inveterate ulcers of the primary air passages. These 
nlcers arc sometimes seated in the antrum, sometimes in the 
nasal fossa, and are frequently connected with and owe their 



* Dr. riiilip AuslcD, d 
tOf., DBlencli. 



r Professor in ihu InstitoUon, 



DISBASES OF THE ANTRUM OR MAXILLARY SINUS. 327 

fetor to caries of the bones. They are, therefore, more com- 
mon in syphilitic and scrofulous subjects. 

The breath of persons afflicted with ozsena is often so offen- 
sive as to render them almost intolerable to others, and the 
consciousness of the disgust which their presence occasions, is 
naturally a source of continual mortification and distress. 

Where the ulcer can be perceived and reached, it should be 
touched with the nitrate of silver, and the application repeated 
until cure is effected. When no direct application can be made 
through the natural openings, as must be the case when the 
sore is seated in the antrum, an opening must be made as be- 
fore directed, and a solution of nitrate of silver injected, if 
the caustic cannot be immediately applied to the part. 

K the patient be tainted with syphilitic disease, no local re- 
medy can be effectual. He must be placed at once under proper 
constitutional treatment, and this must be persevered in until 
the vice is eradicated. In case of scrofula, the same remark 
applies. Local remedies, however, are not by any means to 
be neglected. They may very much hasten the cure, and per- 
haps may render effectual constitutional means which other- 
wise may be impotent. 

Every expedient should be tried before leaving the patient 
to suffer the distress and serious inconveniences attendant upon 
such a disgusting disease. 

POLYPI AND OTHER TUMOURS. 

Polypi are tumours of various consistencies and rapid 
growth, which appear in several cavities of the body which are 
lined by mucous membranes, but are most common in the nose, 
uterus, and maxillary sinus. They also occur, occasionally, in 
the rectum and vagina. They occur much more frequently in 
the nose than elsewhere, and next to the nose, in the uterus. 

The tumour growing into all the irregular cavities of the 
nasal fossa, &c., has sometimes an irregular form, which from 
a fancied resemblance to the animal of the same name, has ori- 
ginated its designation. 

Several varieties of polypoid tumours are described by wri- 



r namm ok haxillart snnrs. 

a class of theiu alwaje matignant, 

^■. Hw one like carcinoma being painful, 

jMi imtation through morbid processes de- 

_^ _^.iL :iii>l tending to convert adjacent tissues 

^ ^.^^ a^iMt Mnictnre, tlie other not painful, not cans- 
^ ^^M^ ktcal or constitntional, except indirectly hy 
• upon other parts or Biting up cavities which 
I kept open. In short, he considered that 
jdSHtfpit the benign, are inconvenient or even fatal, 
taical action; white the other, or malignant 
I wiBaUy troublesome by their pressure and ob- 
^i^iek they cause, are per sc pathologically dangerous 
h wd life. 
I describes four varieties, which ho calls vascular 
s lymphatic, acirrhous, and sarcomatous. 
nn classifies polypi as membranous, fibrons, and vas- 
Th« latter, he says, is rare. Jourdain recognised three 
a loose, pale, indolent, and benign, also called vesi- 
^^ ^ypus ; another, hard, unyielding, livid, and painf\il, 
^^tolJ *>lh veins, and often hideous; and a third, fieshy, 
^lg«t«d, and easily stretched. 

nuel Cooper observe?, " Some polyi are red, soft, and sen- 
■, but free from pain, and exactly like a piece of healthy 
When this kind of polypus is of a softer consistence, 
i-iransparcnt, and of a pale, yellowish colour, in conse- 
MBCe of being less vascular, it is called the gelatinous poly- 
Mm ond usually arises from the mucous membrane of the side 
^f^ antrum, or the middle of the cavity of the nostril be- 
pMH the upper and lower turbinated bone. No doubt car- 
^^ioiKtDus tumours in the antrum have occasionally been con- 
|M»dc<l with polypi, but there is no good reason for believing, 
^•Ame have asserted, that true polypi never originate in that 
-.viiv. Many eminent surgeons have testified to having met 
.■■ ;iritral polypi. 

I ■ po'ypus of the benign kind occurs in the antrum, it 
,^, ,.cj(ie detection until it has completely filled the cavity 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 329 

and begun to push its way into the nose and distend the walls 
of the sinus. 

A tumour of the malignant kind might be suspected from the 
pain seated in it, and when enlarged sufficiently to press upon 
the bones, the twofold suffering produced by pressing and be- 
ing pressed must cause greatly aggravated distress. The me- 
chanical consequences of the continued pressure soon show 
themselves. The cheek swells, or rather is pushed out, the 
palate and alveolar ridge are depressed ; the molar teeth are 
loosened, the gums become inflamed and spongy, the floor of 
the orbit is elevated ; fistulous openings are often formed through 
which sanious pus percolates, or the matter finds its way through 
the opening into the nose, and at length the tumour, pushing 
through the floor of the antrum, appears in the mouth, or forc- 
ing its way through one or both of the distended nasal open- 
ings is seen in one or both of the nostrils. 

Of course, the parts subjected to this pressure and disrup- 
tion, become diseased, and inflammation, suppuration, ulcera- 
tion, caries, and necrosis, may all be added to the list of secon- 
dary diseases incident to polypus. The causes of polypus are 
not satisfactorily ascertained. Probably they require some 
constitutional predisposition to render the parts where they ap- 
pear capable of producing them, and when the susceptibility 
exists, any irritation may be the exciting cause of the morbid 
growth. 

It is certain that diseased teeth and fangs must be regarded 
as the most common of the existing causes of polypus in the 
antrum. 

The following cases. from Jourdain are in point: 

"In 1772, I had occasion to visit a shoemaker, living in the 
Faubourg St. Marcel, who had for some years had a kind of ex- 
ostosis of the right superior maxillary. The tumour was as 
large as a medium sized apple, displaced the nose, deranged 
the palate, and threw the eye upward against the superciliary 
ridge, permitting the lids to open but slightly. The sinus had 
three fistulous openings : one below the malar process, a second 

near the bicuspids, and a third near the inner canthus of the 

28* 



DISEASES OP THE ANTRUM OR MAXILLARY SIJftlB. 



eye. In none was there any discoloration of the skin, and al- 
ternately, from the two first, there vas discharged an acrid 
reddish humour. Most of the teeth of the affected side were 
lost ; thoso which remained were sound, but much displaced by 
the tumour. The right nostril was obstructed by iv polypus of 
a scirrhous hardness. In sounding the sinus through the fistu- 
lous openings, the instrument came in contact with fleshy 
masses in that cavity, some bard, some soft, giving out, when 
wounded, a bloody discharge, resembling wine lees. The na- 
sal wall of the sinus was destroyed, but the maxillary bone was 
not softened. 

" The disease seems to have had its origin in repeated attacks 
of alveolar abscess, the consequence of bad teeth, which usu- 
ally terminated in fistula. Gradually the bone began to swell, 
and the nostril to become obstructed, till his appearance was 
much as I have described. Ilad I been suffered to operate, I 
would have removed all the teeth, good and bad, involved in 
the tumour, and then making a crucial incision through the 
cheek, would have exposed the bone, which, from its extreme 
thinness in this case, I might hope readily to remove. I would 
then have removed the exposed tumours from the antrum, by 
knife, cautery, or both combined, as occasion might suggest; 
looking carefully to the condition of the bone, and seeking, 
after the operation, to eatablish a healthy suppuration in the 
part. 

Case II. — Polypus in the Bight Sinvs. — In 1773, a lady, 
whose right check had been swollen and singularly h&rd for 
nearly two years, applied to me. 

" The tumour was the result of succesaive inflammatory at- 
tacks of the first bicuspis and three molars of that side, only 
the fangs of which remained, and these were covered by a poly- 
pous tumour that had distended and softened the outer plate 
of the maxillary bone. 

"I first made an incision down to the alveolar sockets, and 
after the arrest of the hemorrhage, removed the roots, twelve 
in number, each having at their extremity a morbid growth, 
showing that here was the chief cause of the disease. Their 



Their ll 



DISEASES OF THE ANTRUM OB MAXILLARY SINUS. 831 

removal cansed considerable hemorrhage. I examined the 
wound on the next day, and found that the bulk of the tumour 
lay between the plate of the maxillary bone, diminishing up- 
wards, and terminating at the orbit. 

'^Between the cheek and gums were two fistulous openings, 
which discharged a dark, fetid humour. The diseased state of 
the bones decided me to remove the tumour by two vertical in- 
cisions through them. This space permitted me to introduce 
my finger into the sinus. Its membrane was swollen, and there 
was yet a portion of the tumour attached to the orbital plate. 
This, from its propinquity to the eye, I feared to cauterize 
with the hot iron, and therefore used spirit of vitriol, with a small 
quantity of corrosive sublimate dissolved in it [nitrate of silver 
would be much better], being careful to employ dry dress- 
ings, that the escharotic might not, by spreading, cause injury 
to the surrounding parts. 

*^ After eighteen 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 
itself simply into making an opening into the sinus, and re- 
moving the tumour. 

Unfortunately, many of these morbid growths recur after re- 
moval, and grow with more rapidity than at first, and therefore 
it is necessary to destroy the mucous membrane upon which 
they are seated, so as perfectly to eradicate the disease. For 
this purpose, the old surgeons used the actual cautery freely. 
Probably the free application of lunar caustic would accomplish 
all that could be expected from the heated iron. It is often 
impossible to apply either so completely as to remove every 
particle of the diseased product ; and if the tumour be a result 
of constitutional pravity, we, for the most part, gain little by 
the operation. 

Dr. C. A. Harris thinks that in cases of malignant tumours 
seated in the antrum, the application of the white hot iron is 
indispensable to safety. 



832 DISEASES OF THE AKXllUM Oil MAXILLARY SINC8. 

In remftrkirig upon the bold practice of the French surgeons 
in the treatment of tiieae affections, Mv. Thomas Bell com- 
mends their mode of procedure as worthy of praise and imita- 
tion, and expresses himaelf very severely against the timidity 
of English surgeons who have shrunk from the use of the 
actual cautery, and have left the patient to die with a linger- 
ing and painful disease, without any attempt at relief. 

Certainly, as life is rendered intolerable, and death inevita- 
ble, by these tumours, we are justified in using any means 
which may promise relief. I have already (chap, sxii.), de- 
scribed a malignant fungous tumour which occasionally makes 
ite 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 aleo been given in chap. xxii. 



The human body has many parasites inhabiting its Tarions 
tissues. More than a score of these have been described. Some 
infest the intestinal canal, others are found in the heart and 
large arteries ; some dwell in the muscular, others in the cellu- 
lar tissue ; some prefer the liver, others the kidneys, and some 
the sinuses of the head. 

The mode by which these creatures are produced, has long 
been a subject of curious inquiry, but it is not necessary for 
me to discuss the subject. It is enough to know that they 
exist within the body, and often prove troublesome inmates. 
That the larvre of insects do find their way into the maxillary 
sinus, is proved by abundant evidence. 

In the Memoirs of the Academy of Surgery, vol. v. p. 233, 
as quoted by Deschamps, it is recorded, that in the course of a 
disease of the maxillary sinus, there issued, from day to day, 
a considerable number of whitish worms, two or three lines 
long, some of which were living. The same author relates two 
instances in which long round worms were found in the maxil- 
lary sinus. 

The most singular case of the kind is reported by Mr. Hey- 



DI8BASES OF THE ANTRUM OR MAXILLARY SINUS. 338 

sham, a medical practitioner of Carlisle, and may be found in 
Cooper's Surgical Dictionary. 

In this case, the patient was a strong woman of sixty, who 
was for many years subject to acute pain in the antrum, 
extending over one side of the head. 

These pains never entirely ceased, but were more severe in 
winter than in summer, and were always subject to frequent 
periodical exacerbations. 

The patient had tried anodynes without advantage, and had 
submitted to a mercurial course, by which her sufferings were 
aggravated. All her teeth on the affected side had been drawn. 
At length it was determined to open the antrum, though there 
was nothing to indicate abscess or any other disease in this 
cavity. 

In four days no benefit had resulted from the operation. 
Bark injections and the elixir of aloes were thrown into the 
sinus. On the fifth day a dead insect was extracted by means 
of forceps. It was more than an inch long, and thicker than a 
common quill. The patient now experienced relief for several 
hours; but the pains afterwards returned with the former 
severity. Oil was then injected, and two other insects similar 
to the former were extracted. No others appeared, and the 
wound closed. She was much relieved for several months, when 
the pains returned worse than ever, and were particularly com- 
plained of in the frontal sinus. 

We are not informed of further treatment. 

Should worms be found in the cavity, they must be destroyed 
by the injection of oil, or other liquids likely to effect the pur- 
pose. 




The palate is often incomplete through congenital defect. 
It ie fre4uently the Bcat of disease, which destroys its soft parts, 
and even its honea. 

As the palate forms the vault or roof of the mouth, separat- 
ing it from the nasal cavities, and furnishing a most important 
part of the organ of voice and mastication, its diseases and de- 
ficiencies are of great consequence, exceedingly impairing the 
comfort and usefulness of the subject of them. 

Congenital defects of the palate may differ very much in ox- 
tent. Generally the deficiency is found along the median line, 
Bometimes involving only the soft, sometimes also the bony 
structures. At times the fissure extends from the lips entirely 
along the median line of the roof of the mouth, presenting the 
appearance of the two lateral halves of the body not being 
united at this point. 

Congenital defects, however, are not always so regular. Er- 
rors of formation may occasion an increase of the concavity of 
the arch, forcing the alveolar ridgea too far apart, and produc- 
ing deformity in the dental range. Sometimes, from an oppo- 
site condition of things, the alveolar borders may be brought 
more than usually close together. The teeth may be imper- 
fectly developed, and their texture less dense than usual. 

Mr. Stearns makes three classes of congenital fissure of the 
palate. The first class embraces all the cases in which the fis- 
sure extends through the velum, palate, and maxillary bones, to 
the alveolar border, and sometimes through the whole extent 
of the median symphysis. This is usually complicated with 
hare-lip. 




DISEASES OF THE PALATE. 885 

In the second class, the bones of the palate are apparently 
entire, though the cavity of the arch may be somewhat greater 
than usual, and the fissure extend a short distance into their 
posterior margins. In this case, the lesion is almost wholly 
confined to the velum palati. 

The third class embraces those cases in which the fissure is 
confined to the soft parts, extending, perhaps, only a short way 
•up into the uvula. This form of fissure is, probably, less fre- 
quently met with than either of the preceding.* 

When the palate is defective, the voice is impaired, and the 
impairmenl is in proportion to the extent of the lesion. Some- 
times it is almost entirely destroyed by the inability of the pa- 
tient to utter distinct sounds. Nothing can be more distress- 
ing than this calamitous injury to the organs of speech, which 
combines the distress arising from the consciousness of ludi- 
crous appearance with the inconvenience of difficult and imper- 
fect articulation. 

Interference with the voice is not the only evil attending de- 
fects of the palate. Mastication and deglutition are also im- 
peded. Food, notwithstanding the patient's careful or instinc- 
tive efibrts, 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 nip- 
ple between the upper surface of the tongue and superior gum, 
&c., the infant places the tongue on the nipple, and presses it 
against the lower gum, closing the palatine fissure with the 
tongue, as with an obturator.f 

* nanifl's Dictionary of Dental Science. f Delabarre. 



336 DISEASES OF THE PALATE. 

The mechanism of nursing is perfected as the child advances 
in life ; dexterity of course increasing with the constant use of 
the parts, until such a proficiency is acquired that solids are 
masticated, and speech is as far as possible performed. The 
mechanism of mastication as performed in such cases is thus 
described by Delabarre. When the food is chewed, the aliment 
is conveyed between the tongue and movable floor, which serves 
for a point d'appui to it, and then it is brought back between 
the teeth. Thus it is that the complicated operation of masti- 
cation and deglutition is performed without the alimentary mor- 
sel getting into the nose, or if this does sometimes happen, it 
is the result of accident. 

When perforations of the palatine arch occur in mature life 
through the agency of disease, the patient is in a much more 
unfortunate case than the subject of congenital deformity. 
The latter, gradually habituated to the performance of mastica- 
tion and deglutition, with his imperfect organs, accomplishes 
these functions, if not well, yet with comparative comfort, while 
the former having been habituated to use the tongue differently, 
is not capable of adopting the mode of procedure applicable to 
his new condition, and consequently is continually passing his 
food and drink into the nose. If the teeth be not properly 
coapted, another source of difficulty and vexation is added, as 
the introduction of the food is thus rendered very troublesome. 

If the velum and uvula be defective or wanting, deglutition 
is exceedingly difficult, as the alimentary matters, instead of 
passing comfortably along the pharynx, are, to a greater or 
less degree, forced into the posterior nares. This is the case 
whether the lesion be congenital or accidental. Sometimes 
deglutition can only be effected by throwing back the head as 
far as possible and casting the food into the pharynx. 

The inconvetiience of imperfect speech is as serious as that 
of incomplete or difficult mastication and deglutition. 

Mr. Stearns says, that perforation or fissure of the palate 
may render the articulation of some of the letters impossible, 
and at the same time vitiate the character of all the others. 
The indistinctness of utterance is usually proportioned to the 



DISEASES OF THE PALATE. 387 

extent of the lesion. Thus, when the fissure extends as far as 
the alveolar processes, the patient loses several of the letters, 
which another, with only a portion of the soft palate involved, 
is able to produce with considerable distinctness. In cases of 
fissure, particularly those of the more extensive kind, the move- 
ments of the tongue are comparatively limited, as the patient is 
instinctively aware that the very effort he should make in order 
to give letters their appropriate articulation, often serves to 
render the impediment more painful. So far, indeed, is this 
inactivity of the organs sometimes persisted in, that speech be- 
comes little else than the emission of a succession of vowel 
sounds, which, in lieu of receiving proper consonant adjuncts, 
are only made intelligible by the accompanying inflection, key, 
gesticulation, and expression of countenance, all of which are, 
more or less, the vehicles of thought. "*" With the limited action 
of the tongue, nearly all the muscles concerned in the forma- 
tion of articulate sounds, in a greater or less degree, participate, 
while the muscles about the nose, as the compressor nasi and 
depressor nasi are violently contracted, for the purpose of clos- 
ing the nostrils and preventing the escape of the sound. This 
gives a particularly disagreeable aspect to the features. 

The most common cause of lesions of the palate is syphilis. 
This terrible disorder, when once it becomes constitutional, pro- 
duces a number of strange local affections, differing very much 
from one another, all of them distressing, and some of them 
dangerous, and not unfrequently fatal. 

Beginning as a local affection, usually a primary sore, 
syphilis may gradually poison the whole circulating fluids, and 
cause defects of nutrition and alterations of tissue in various 
parts of the body. 

The manner of effects produced by secondary syphilis, differs 
very much in different persons, as it is influenced by a variety 
of determining or modelling circumstances. Eruptions upon 

* Obserrations on Congenital Fissiire of the Pala^, with some remarks on 
Articulation and Impediments of Speech, by Charles W. Steams, Esq,. Sur- 
geon, London. 

29 



888 DISEASBS OF THE PALATE. 

the surface, local inflammations, ulcers, augmentation and losa 
of parts, mny 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 IB very necessary, however, to be aware that palatine ul- 
cerations, caries, and necrosis may occur from other than a 
venereal cause. It would be terrible indeed to add the cruel 
suspicion of such a malady to the sufferings of a patient 
whose disease, having no affinity to lues, should claim Bym- 
pathy instead of begetting contempt and disgust. We must, 
therefore, be very careful to make no mistakes in matters of 
such delicacy. Moreover, the treatment of these affections 
must depend upon the accuracy of the diagnosis, and that 
which would be judicious in the case of syphilitic affection 
might be very improper under other circumstances. 

When the true history of the case can be obtained, the facts 
will give much assistance in forming an opinion, but this can 
not always be procured ; we are, therefore, often obliged to 
form our opinion from the appearances before us, 

The only constitutional vice, other than the venereal, which 
may cause a similar palatine devastation, is scrofula, and when 
scrofula is the cause of the affection, the prevalent vice will 
display itself elsewhere, in derangements of the lymphatic sys- 
tem, and the other affections which usually attend upon this 
general pravity. 

Syphilis is more rapid than scrofula; and thelocal affections 
produced by it are more painful. According to Mr. Hunter, 
venereal disease generally makes its appearance, in these 
parts, at once, in the form of an ulcer, without much previous 
tumefaction. lie describes the ulcer as a fair loss of substance, 
part being dug out as it were from the body of the tonsil (if 
seated upon it). It has a determinate edge, and is commonly 
very foul, having a thick white matter, like a slough, adhering to 
it, and not admitting of being washed away. All authors, how- 



DISEASES OF THE PALATE. 889 

ever, admit the extreme difficulty of distinguishing venereal 
affections in these parts, with absolute certainty, by merely 
local observation, and no appearance of sores about the palate 
warrant us in declaring the disease syphilitic, without corre- 
sponding symptoms justify the suspicion. While this is the case, 
however, any suspicious sore will authorize us to try such 
remedies as arc known to be efficacious in syphilis, it being 
much more dangerous to neglect a syphilitic sore than tem- 
porarily to maltreat a scrofulous one. No purity on the part 
of a married female can always be satisfactory of her freedom 
from syphilitic taint, as, disgraceful as it is to human nature 
to make the confession, we are frequently compelled to recognise 
the ravages of the disease in these victims to the matrimonial 
tie, who are perfectly innocent of any impropriety. I need 
not say, that when the dentist discovers such a condition to 
exist, though humanity will demand that in some way or other 
the cure be provided, benevolence, no less imperious, requires, 
that the unfortunate subject of the odious inoculation shall 
be kept in blissful ignorance of the nature of the malady. 

Of course, where venereal or scrofulous disease is at work 
upon the parts, proper constitutional remedies must precede 
all mere mechanical attempts to repair existing damage. 

The devastation of the palatine tissues^ soft or bony, may 
sometimes result from the local irritation produced by dead 
teeth, &c. This, of course, can only occur in those enfeebled 
constitutions in which nature is not able to resist even a trivial 
morbid impression, but seems barely capable of maintaining a 
nutrition equal to the ordinary wear and tear of tissues. 

That such cases do occur, is stated by Jourdain, Harris, and 
many others. 

Harris says,'*' ^^ The local irritants occasioning the palatine 
diseases are dead and loose teeth, roots of teeth, salivary cal- 
culus, mechanical injuries, acrid humours, &c. The case of a 
lady of irreproachable character is related by Jourdain, in 
whom a scratch on the palate with a fish-bone, caused a tumour, 

* Dictionary of Dental Science, art Palate. 



S40 



DISEASES OF THE PALAIE. 



which suppurated and degenerated into an ulcenrith hard ele- 
vated edges and a fungus in the middle." Dr. Cone mentions 
a Bimilar case. 

The following are reported by Jourdain : 

Cask I. — " Mr. Noel had a tumour of the palate, which, on 
pressure, discharged pus through one fistulous opening, on the 
outer side of the right alveolus, between the canine and incisor, 
and another in the socket of the second molar, which had been 
removed some time since. The patient would not consent to 
proper measures in the first instance. The canine inctaors and 
first molar became loose and were extracted ; the alveolus 
around the aito of the second molar sloughed away. The tu- 
mour still continued to enlarge, and some embarrassment was 
feh in the nostril : the patient then put himself under my care. 
The tumour, when lanced, discharged a very fetid pus, and I 
found, on introducing my probe, that a portion of the palate 
and maxillary bones were necrosed and almost completely de- 
tached. I removed them with case: 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 snecKing excited by touching it on the lingual side. I 
dressed the wound for some days with dry lint, and then used 
gargles, &c. In twelve days the cicatrix was complete. 

"I hare 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 tho sound bone, gently withdrawn it. Simple 
causes may often be productive of extensive injury, as the fol- 
lowing case will show : 

Cage II. — "Ahailiff, named Broch, had a tumour of the palate 
as large as a pigeon's egg, with swelling of the nose and upper 
lip, consequent upon a decayed condition of the teeth. Pus 
escaped from the nose, and there was a fistulous canal from the 
second incisor to the first molar of the left side. 

" As the case seemed an urgent one, I removed the decayed 



DISEASES OF THE PALATE. 341 

teeth and stumps, thus destroying the fistula. I then excised 
the palatine tumour, and found the bone carious and the nasal 
membrane covering it perforated, which accounted for the dis- 
charge of pus from the nostril. I first employed dressings of 
dry lint, emollient and detergent gargles, and after the subsi- 
dence of local inflammation, touched the bone with mercurial 
water twice in eight days. In this time the sequestrum sepa- 
rated, leaving an opening into the nostril about the size of a 
quill, which was closed by a prolongation of the mucous mem- 
brane. I made use of dressings of dry lint, gently applied, and 
occasional styptics to suppress exuberant granulations. The 
entire cure occupied six weeks." 

f 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 

m 

disease, they should be promptly and completely removed. 
The after treatment will be conducted upon general surgical 
principles. 

When a fissure has been permanently formed and its limits 
ultimately defined, whether it has been congenital or accidental, 
the indication is to remove the deformity by producing a clo- 
sure of the fissure, or, if this cannot be done, to supply the defi- 
ciency of the parts by such mechanical appliances as may be 
deemed most suitable. 

When the soft palate or some portion of it has been lost, the 
lesion has been substituted by means of an operation, which 
has been termed staphyloplasty.* 

The operation can be successful only when the perforation 
is small. It consists in detaching a portion of mucous mem- 
brane from the surrounding parts, and so adjusting them with 
reference to the perforation, as to procure a permanent cover- 
ing of the cavity, when adhesive inflammation has been effected. 
The operation is difficult, and requires great dexterity in exe- 
cution as well as ingenuity in contrivance. Dr. Pancoast, in 
hb Operative Surgery, describes an operation of this kind, 

* Zta^vxjt, the UTula, and irKtiwwmf I form. 

29* 



successfully performed by himself, to close a hole near the cen- 
tre of the hard pakte, which formed a comnmni cation between 
the nose and month. 

The operation for closing a cleft palate is called staphylo- 
raphy.* It consists in paring away the edges of the fissure and 
closing them so perfectly as to produce union by adhesion. 

The operation has been Buccossfully performed by a great 
number of surgeons, European and American, and several 
methods of performing it have been adopted and suggested ; 
each having its advocates. 

Dr. S. P. Hullihen, surgeon dentist of Wheeling, Va., of 
whose surgical skill I have already made mention, had per- 
formed this operation successfully eleven times, up to the year 
1849. This ingenious surgeon has invented a bistoury for par- 
ing the edges of the fissure, which possesses decided advantages 
over the ordinary double-edged knife. It is composed of two 
parts, which open like sciasors, hut when closed, form a double- 
edged knife or bistoury. The manner of using it is as follows : 
After first seizing tho 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 hack towards and against the pa- 
late bone, should be pushed through the velum near its edge ; 
then, by opening it, the edges will he pared off in the roost 
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 shouldbe grasped by the assistant, with a pair of long- 
handled forceps, and as soon as the hold of the port-aiguille is 
relaxed, drawn through, replaced in the latter, and passed 
through from behind forwards, the right margin of the velum 
opposite to the left. After the patient has rested a few mi- 
nutes, a second, third, or fourth ligature should he introduced. f 



• Ira^ofji, and P«*», ■ suturc. 



I Die. Dental Science. 



DISBASE3 OF THE PALATE. 843 

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.'*' 

Dieffenbach recommends that a longitudinal incision be made 
at a short distance from the edges of the fissure, in order to 
permit the closure to be accomplished in the way before men-, 
tioned. 

A great variety of instruments have been invented by different 
surgeons, and recommended to be used in this operation. I 
have already mentioned the cutting scissors of Dr. Hullihen. 
A variety of needles and needle-holders have been proposed. 
Dr. J. C. Warren uses a needle with a movable point. Dr. N. 
B. Smith prefers a simple lance-shaped instrument, mounted 
on a handle, and having a slit near its point, which opens at its 
posterior end. The needle is broader in front of the eye than 
behind it, which renders the passage of the back part easier. 
Armed with a ligature, the curved portion of the needle is car- 
ried beyond the fissure, and its point introduced behind the 
middle of the uvula, and as soon as it has come out far enough 
to expose the ligature in the slit, the ligature is taken hold of 
with a tenaculum, disengaged from the slit or eye in the needle, 
and the needle is withdrawn. A second ligature is introduced, 
half an inch higher up, and, if necessary, a third, at an equal 
distance from the second. With the ends of the ligature passed 
through the uvula, this part is drawn forwards, until the fissure 
in the soft palate shall assume a nearly horizontal position. 

* Reese's Cooper's Surgical Diotionary. 



S44 DISEASES OF THE PALATE* 

Its edges are then cat off with scissors or bistoury. The liga- 
tures are then tied, and the ends cut off. 

Dr. Hollihen has invented an instrument for passing the 
needle, which he calls an acatenaculom, 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 foorth of an inch in breadth, and an eighth of an 
inch thick, with an arm at the upper end, rising at a carve from 
the staS^ and half an inch long. On the external or saperior 
side of this arm a duplicate arm is retained by a steel spring 
attachment, which brings the two arms in dose contact, forming 
the jaws of the instrument. Between these two arms, and on 
the duplicatore, is a small groove, formed to receive the ligature ; 
and when the ligature is pressed between the jaws of the instru- 
ment, they open, and it slides to the point designed for its 
reception, immediately below which, the jaws are perforated 
with a hole for the introduction of the needle. 

Two inches from the inferior end of the stafi^ 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 thestafi^ is made to fit the 
iq>per surface of the stafi^ and to move with ease up and down, 
upon guides on the same. From the superior end of the slide 
is a short, straight, spear-shaped needle, constructed with an eye 
just back of its point, with a small notch opening to it from the 
upper surface. 

When the ligature has been fined in its place in the jaws of 
the instrument, and the slide adjusted to the stafi^ 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 ligatur\^ drawn through the velum. This instrument is cer* 
tainly an ingenious one, and the preference given it by the 
inventor^ who has operated so often and so well, is sufficient 
commendation. 



DISEASES OF THE PALATE. 845 

For a more particular description of this instrument, made 
intelligible by an accompanying plate, the reader is referred to 
an excellent article on cleft palate, by Dr. Hullihen, published 
in vol. v., page 166, of the American Journal of Dental Science. 
Concise and admirable directions will also be found in that 
paper, for conducting every step of the operation. 

When the loss of parts is so great as to forbid an attempt to 
close the fissure by an operation, nothing remains to be done 
but to cover it by a gold plate or obturator, such as the circum- 
stances of the case will admit. The skilful dentist will often 
be able to remedy these serious lesions to a very great extent, 
by well-devised and artistically-executed substitutes. 

For a description of these mechanical means, and the mode 
of adjusting them, I refer the reader to the works on mechanical 
dentistry. 



CHAPTER XXV. 

ANESTHETICS — CHLOROFORM; SULPHURIC KTBEK. 

The term Anjesthetic haa been recently introduced into the 
Materia Medica to designate a class of substances which obtund 
and, if sufficiently administered, auspend the consciousness, and 
sensibility to pain. They are narcotics, rapid and fleeting in 
their action, and producing profound stupor, without the danger 
to life which attends tho production of such a condition by other 
medicines of the class. 

The introduction of these agents into medical practice is of 
T^ry recent date, and though their effeets upon the human bod;?, 
and their applictibility to the purposes for which they are ad- 
ministered, have been very carefully studied for several years, 
the important question of the extent of their availability has 
not yet been conclusively determined, 

The application of Aniesthettcs to Dentistry is a subject 
about which the utmost difference of opinion exists among those 
whose opinions are most entitled to consideration, and, as upon 
ft question involving such serious issues, all dentists should be 
hetter informed than they are likely to be without a much 
wider range of reading than the common scope of their studies 
requires, it may not be without advantage to devote a chapter 
to the examination of this subject. 

To devise some means of deadening the sensibilities to such 
an extent as to permit the performance of surgical operations, 
without the infliction of agonizing pain, and thus at once to 
prevent the actual suflbring and the preceding dread, which 
invest these frequently necessary processes of cure with so 
much of the horrible, has long been a desideratum with tho 




AN^STHBTICS. 847 

medical profession, but until an American dentist actually 
accomplished it by administering ether by inhalation, no pro- 
gress towards the desired result seemed to have been made. 

Sir Humphry Davy had reported a successful experiment 
upon himself with nitrous oxide, and Mr. Horace Wells made 
some trials, not altogether without success, with the same agent, 
as early as 1814. Berzelius had called the attention of che- 
mists to the fact that a mixture of hydrogen with oxygen when 
inhaled would produce sleep,'*' but none of these facts led to any 
practical application of an anaesthetic agent. 

In the year 1846, Mr. Morton, now Dr. Morton, a dentist of 
Boston, after experimenting upon himself and several of his 
patients, prevailed upon Dr. J. C. Warren to use the ether inhala- 
tion, in an operation at the Massachusetts General Hospital. The 
experiment was only partially successful, but being repeated 
with more favourable results, the use of Sulphuric Ether as an 
anaesthetic became frequent, both in this country and Europe. 
Public opinion was from the first very much divided as to the 
advantages of the administration. In many of the first expe- 
riments ether decidedly failed, and although accounts of success- 
ful inhalations were multiplied from various quarters. Burgeons 
found so much of uncertainty and inconvenience in the use of the 
agent, that it would probably have never come into general use. 

Dr. Simpson, of Edinburgh, having attempted the administra- 
tion of ether in parturition, was led to seek another agent, 
more certain and less objectionable, and after experimenting 
with various substances, announced the discovery of the extra- 
ordinary powers of Chloroform. 

Dr. Simpson's high standing in the profession, and the num- 
ber of successful experiments made by him, produced the most 
enthusiastic excitement with regard to the new agent, not only 
ampng surgeons and obstetricians, but the public generally. 
Chloroform was administered freely in an immense number of 
cases, and of course often very imprudently, yet there was a con- 
siderable time before a fatal accident occurred. At last, how- 
ever, several deaths under the use of this agent were announced, 

* Beck's Materia Medica, article Anesthetics, by Dr. Gilmao. 



346 



AK^STBBTICS. 



in frightful succeeeioti, and the profossion and the puhlic were 
taught that every good partakes of the imperfect condition to 
which human affairs are subject, and may by imprudence and 
ignorance be made an evil. 

Since the dangerous nature of chloroform And ether hare 
been discovered, we hare reason to wonder that a far greater 
number had not fallen victims to the recklessness with which 
the new medicines were administered and inhaled. 

These powerful agents were not only prescribed by surgeons 
who had yet to learn the extent of their control over the human 
system, but were inhaled by thousands for amusement, and to 
satisfy curiosity. 



With regard to the preference which should be given to one or 
the other of these agents, there baa been much controversy, 
and there yet is much difference of opinion. 

Those whose name and fame were identified with the succese 
of ether felt naturally reluctant to permit it to bo superseded 
by another anaesthetic, and their prominent position to be 
occupied by others; while the discoverer of chloroform, and 
thoae who were the first to proclaim its powers, may be sup- 
posed to have been excited by a similar feeling, to exaggerate 
the importance of their own agent, and deny the value of ether. 
The surgical profession, however, having no personal interest 
in the matter, set themselves carefully to investigate the 
several propositions submitted on the one side and the other, 
and the decided judgment is upon the whole favourable to 
chloroform. 

The comparison made by Dr. Simpson, who first introduced 
the anaesthetic use of chloroform, between this agent and ether, 
is thus set forth in his pamphlet : 

1. A greatly less quantity of chloroform than of ether ia 
requisite to produce the ana;sthetic effect, usually from a hun- 
dred to a hundred and twenty drops of chloroform being suiB- 
cient, and with some patienumuch less. I have seen a strong 



ANESTHETICS. 349 

person, rendered completely insensible by six or seven inspira- 
tions of thirty drops of the liquid. 

2. Its action is much more rapid and complete, and generally 
more persistent. I have almost always seen from ten to twenty 
full inspirations suffice. Hence the time of the surgeon is saved, 
and the preliminary stage of excitement which pertains to all 
narcotizing agents being curtailed, or indeed practically abo- 
lished, the patient has not the same degree of tendency to exhi- 
laration and talking. 

8. Most of those who know from previous experience the 
sensation produced by ether inhalation, and who have subse- 
quently breathed the chloroform, have strongly declared the 
inhalation and influence of chloroform to be far more agreeable 
and pleasant than those of ether. 

4. I believe that considering the small quantity requisite as 
compared with ether, the use of chloroform will be less expen- 
sive than that of ether. 

5. Its perfume is not unpleasant but the reverse, an4 the 
odour of it does not remain, for any length of time, obstinately 
attached to the clothes of the attendant or exhaling, in a dis- 
agreeable form from the lungs of the patient, as so generally 
happens with sulphuric ether. 

6. Being required in much less quantity it is much more por- 
table and transmissible than sulphuric ether. 

7. No inhaler or instrument is necessary for its exhibition. 
A little of the liquid diffused upon the interior of a hollow 
shaped sponge or a pocket handkerchief, or a piece of linen or 
paper, and held over the mouth and nostrils, so as to be fully 
inhaled, generally suffices in about a minute or two, to produce 
the desired effect. 

Dr. Henry J. Bigelow, in an admirable paper upon anaesthetic 
agents, appended to the report of the committee on surgery, 
published in the first volume of the transactions of the Ameri- 
can Medical Association, testifies that there is no difference of 
importance in the general character of the insensibility or other 

symptoms resulting from the inhalation of ether, and chloro- 

80 



850 



ANESTHETICS, 



form. The latter is much more potent than ether, more pala- 
table, and less irritating to the lungs. 

Dr. Gilman, in the report of the Committee on Obstetrics, 
Vol. II. of Transactions of American Medical Association Bays : 
There are to ether some very strong objections. It sometimes 
irritates the respiratory apparatus to sach a degree, that its 
continued use and the production of anaesthesia by it are im- 
possible. It is sometimes impossible to get the patient beyond 
the state of excitement, and this slate is always longer and 
more violent than when chloroform is used. Ether is more 
often followed by unpleasant effects, as headache, soreness of 
the chest, &c. Id some persons it produces a very free flow of 
saUva,which entering the posterior fauces may embarrass respi- 
ration. The advantages of chloroform are, asmallerquantityts 
required, fewer persons resist its influence, and it produces no 
cough, choking, salivation, or other evidences of irritation of 
the mucous membrane. The state of excitement is avoided, or 
is so short as to amount to nothing. In short, chloroform has 
every advantage except safety. The Doctor then proceeds to show- 
that the danger of administenog chloroform is rather due to 
the inexperience or carelessness of administrators than to any 
necessary quality of the agent itself. 

In the report on Surgery published in the same volume, Dr. 
N, R. Smith gives his voice decidedly in favour of chloroform 
over ether, as by far the most powerful anresthotic, and least 
annoying in the act of respiration. Dr. Smith is not satisRed, 
that in point of safety, there is much real advantage in the use 
of ether. In thefirsttwoinstancesof the employment of ether in 
his practice, though the administration wns cfTecteci by an expe- 
rienced gentleman from Eoston, the result was very unfortunate. 
In neither instance was the anEesthetio influence complete, and 
in both there resulted great perturbation of the vascular and 
nervous systems, characterized by delirium and a pulse of 140 
per minute. Both patients remained in a doubtful state in 
regard to recovery, for forty-eight hours. In another instance, 
in which the same surgeon employed ether in the amputation 
of the female breast, an unusual degree of irritative fever fol- 



ANESTHETICS. 85^ 



f 



lowed the operation, resulting, after some twenty days, in fatal 
consecutive abscess of the right pleura. 

The reporter proceeds : "We believe that the deleterious effects 
of ether are less clearly chargeable to this agent, because they 
are more remote, and therefore likely to be referred to other 
causes. The fatal effects of chloroform, being almost instan- 
taneous, are referable to nothing else. The post hoc, propter 
hoc here strikes the mind with irresistible force. It must also 
be borne in mind, in comparing the safety of chloroform with 
that of ether, that the former agent has been employed much 
more extensively than ether, though of more recent discovery 
and application. The use of ether had scarcely become general 
when it was superseded by the discovery of Mr. Simpson, and 
at this time the reported cases of its employment are twenty 
fold more numerous than those of the employment of ether. 

" He who fixes his attention exclusively on the fatal cases from 
chloroform, without adverting to the vast number in which it 
has been employed, is very naturally filled with alarm. But 
when we consider that this agent has probably been adminis^ 
tered to millions of subjects, and that only fifteen cases of death 
from its use can be adduced, the individual who subjects him- 
self to its influence ought to feel no more apprehension than 
he who takes his seat in a railroad car, and much less than one 
who essays a voyage across the Atlantic. The conclusions of 
the Committee upon this subject are thus summarily expressed : 

^^ Contemplating all the facts which, in relation to the use of 
anaesthetic agents, have been contributed during the past year, 
your Committee congratulate the Association on the great pro- 
gress which has been made in establishing professional and 
public confidence in these extraordinary agents, and on the 
vast benefit which is likely to result to mankind, from this 
achievement of science and humanity. To them the recorded 
experience of surgeons, at home and abroad, appears abun- 
dantly to justify the following conclusions. 

" 1. The means of generally rendering patients insensible to 
the pain of surgical operations, so long a desideratum, have at 






ANESTHETICS. 



length been furnished in the anaesthetic agents, Gnlphurie ether, 
chloroform, and chloric ether. 

"2. The employment of these agents for obviating pain in 
moat severe surgical operations is now not only justifiable, but 
the imperative duty of Surgeons, and indeed wo may olraost 
adopt the language of Profesaor Miller, before the Medico- 
chirnrgical Society of Edinburgh, that *no one among his surgi- 
cal friends would deem himself justified, morally or profession- 
ally, in now operating upon a patient in a waking and sensi- 
tive state.' 

"3. Of the ansESthetic agents, chloroform is decidedly the 
most efficient and facile of respiration ; but being most powerful, 
is at the same time most dangerous, when incautiously employed. 

" 4. In formidable and painful operations, chloroform not only 
obviates pain, but contributes to the safety of the patient, by 
preventing shock, and the irritation which is the antecedent, 
and, to a certain extent, the cause of inflammation. 

" 5. The use of chloroform is inadvisable in trivial cases, be- 
cause the danger from its use is greater than that from the ope- 
ration. Alt must admit that of the two objects to bo held in 
view in a surgical operation, safety and immunity from pMD, 
the former is the more important, 

*' 6. In regard to circumstances under which chloroform shouM 
be employed, we adopt the conclusions of the French Academy : 
' It should not be used when there exists any disease of the 
heart, any aneurism near the heart, any threatening dyspncca, 
any tendency to engorgement of the lungs or brain. Care must 
be taken, that during the inhalation, atmospheric atr bo suffi- 
ciently mixed with the vapour of chloroform, and that respira- 
tion be carried on freely. The inhalation should be suspended 
as BOOH as insensibility is obtained.' 

"7. The best vehicle for the administration of chloroform or 
ether is a handkerchief or sponge of loose tciture, through 
which the atmosphere maybe copiously inhaled." 

However similar may be the ultimate effects of ether and 
chloroform aa to tho production of insensibility, the result does 



ANESTHETICS. 853 

not seem to be attained by the same mode of action upon the 
nervous system. 

Ether is decidedly stimulating in the first instance, and the 
degree of excitement or intoxication it produces is sometimes 
80 great as seriously to embarrass or eyen prevent the operation 
it is intended to facilitate. Like all other excitements, this is 
followed by corresponding depression, and the secondary effects 
of the agent are therefore to be seriously considered, when the 
administration of ether is proposed. Chloroform seems to be 
directly depressing or sedative in its action, lessening the sen- 
sibility of the nervous system, without any preceding stage of 
excitement, or exhilaration. I have administered chloroform 
in a number of instances, but have never seen it produce a con- 
dition which might be termed intoxication. 

EFFECTS OF CHLOBOFORM. 

After one or two deep inspirations the patient feels a pleasant 
languor, attended with a sort of tingling sensation in his extremi- 
ties; some confusion of the understanding follows, throbbing 
sounds are heard in the head — numbness succeeds, conscious- 
ness is lost, the muscles are rigid, and sensibility is much ob- 
tunded. If the inhalation be continued, the sleep becomes pro- 
found ; the breathing deep and heavy, regular, sometimes ster- 
torous, the muscles relaxed, and insensibility complete. 

The pulse continues regular, though often somewhat feeble, 
until the inhalation has been carried to a dangerous extent. 
It then sometimes suddenly becomes decidedly weak, fails 
rapidly, the breathing becomes irregular and interrupted, and 
syncope ensuing, the patient expires. 

Dr. Gilman says that ho has frequently seen consciousness 
survive insensibility. Commonly the sensibility survives con- 
sciousness, and a patient, apparently asleep, will manifest ex- 
treme suffering under an operation, by his contortions and cries^ 

Extreme dread of an operation will keep awake both the con- 
sciousness and sensibility long after the understanding has been 

narcotized by the ansesthetic. 

80* 




I remember to have ailministerecl chloroform for a dentist to 
a young gentleman who had several molar teeth to be extracted, 
and who from the peculiar formation of his teeth had BulferGd 
exceedingly in previoiia operations of the kind. AUhongh he 
was resolutely bent upon having tho operation performed, such 
was his dread that after being brought apparently under the 
full influence of chloroform, the attempt to tonch his mouth 
aroused him so far as to cause him lo say, " Now I perceive 
that you arc adjusting the instrument" &c., describing sensations 
which really did not exist, as at the time no attempt was mak- 
ing to apply an instrument. It is remarkable that although a 
patient may manifest suffering by contortions and cries, yet 
when the anaesthetic passes off, there is never any recollection 
of the pain. Whether the patient, under these circumstances, 
has really derived any advantage from the chloroform, is j^ ques- 
tion which I will leave to philoaophers. 



That those agents act upon tho nervous system by passing 
into the circulation, and modifying the blood, is plain enough, 
but tho particular modification which they effect, and the man- 
ner in which the nervous system is acted upon by it, are as yet 
unknown to us. 

The order of affection, as given by Ilouvers, is this : 

First the cerebral lobes lose their power, and intellect is im- 
paired ; then the cerebellum is affected, and the power of regu- 
lating locomotion lost; afterwards the spinal marrow, and sen- 
sation and motion are gone ; lastly, the medulla oblongata, tho 
motive power of respiration, breathing ceases, and death is the 
result. 

The pithy remark of Dr. Gilman upon this dogmatical ex- 
position is a satisfactory comment. "This sounds very woll, 
but it seems to mo that any one who has studied this matter 
by the bedside will be quite unable to reconcile what he Ihen 
sees with the order of Mr. llouvers ; what, for example, was the 
state of the cerebrum and corobcllum of the Irishman operated 



ANiBSTHBTICS. 855 

on at the London Hospital, who made faces and jokes while 
insensible of the pain of an amputation 7 (London Med. Gaz. 
January 22, 1847.) Is the cerebrum and cerebellum affected 
when a patient in labour takes the handkerchief from her at- 
tendant, presses it to her face, and expresses in the warmest 
terms the relief from pain which is afforded her 7 All this 
must manifestly be restudied." 

CONDITIOHS FOBBIDDIirO THB U8B OF AN Jl 8 T H ■ TI C 8. 

Observation of the action of chloroform and ether leads us 
to consider the administration of them dangerous and improper, 

1. To persons labouring under organic diseases of the heart 
or great vessels. 

2. To persons who are subject to cerebral congestions, or 
whose brain is in any way unhealthy. Epileptic and hysterical 
patients are not proper subjects for anaesthesia. 

8. To persons disposed to haemoptysis or to pulmonary con- 
gestion, and to phthisical patients in all stages of that disorder. 

4. To feeble persons, with a weak circulation ; to the chloro- 
tic or anaemic. 

5. It must be remembered that the nervous system is much 
more readily impressed by medicinal agents, and especially by 
narcotics, soon after bleeding ; and when the patient has evident- 
ly been weakened by recent loss of blood, anaesthetics should 
be administered with great caution, if at all. 

ANJISTHBSIA IH DBNTAL 0PEBATI0N8. 

It being clearly established that chloroform and ether may 
be so given as to prevent the dread and suffering attendant 
upon surgical operations, and that the administration of these 
agents is entirely safe in a vast plurality of instances, the im- 
portant question is to be determined, In what cases is it the 
duty of the surgeon to give the patient the advantage of these 
anaesthetics 7 

Pain is the greatest of all bodily evils. Even when not com- 



AN-ESTHETtCS, 



parativeiy severe, it is dreadeJ in prospect and borne witli im- 
pBticnce, while the agony of most surgical operuliona is ap- 
palling to the stoutest heart. These operations, too, are gene- 
rally performed upon individuals whose sensibilities have been 
sharpened, and nervous systems weakened, by severe or long- 
continued suffering. They are of all others the least able to 
endure the infliction of the exquisite tortures of surgery. At 
first thought common humanity seems to require that the 
benevolent gift of heaven, anaesthetic oblivion, be dispensed to 
all whose unhappy state may drive them under the surgeon's 
knife or to the dentist's chair. 

If anwsthesia were always safe, this would be a jnst concla- 
aion, but unfortunately it is sometimes a fatal gift. How then 
shall we prescribe limits to its use ? 

In the higher surgical operations, where recovery from the 
operation is not certain, statistics seem to show that the danger 
arising from the use of chloroform is more than compensated 
by the exemption from shock and pain ; the mortality being 
less under antesthesia. In all these cases then, except where 
circumstances exist which render the inhalation uncommonly 
perilous, anaesthesia should be preferred. There can be no rea- 
son to the oontrary. The surgeon ia as fully warranted to give 
chloroform in such cases, as he would be to give opium. 

In obstetric practice, too, the degree of antcsthesia required 
to make the patient comfortable is not so profound as in surgi- 
cal operations, and the danger appears to he very inconsiderii' 
ble. In severe cases of parturition, it is evident that the 
chances of escape to the mother are increased by ana-athesia, 
therefore the administration, In the hands of 'a judicious accou- 
cheur, seems entirely justifiable. In dentistry, the operations 
do not involve life. The pain, though very great, is not so fre- 
quently inflicted upon the sick and feeble, and is generally of 
short duration. It cannot be said that anicsthoaia here olTerfl 
compensation for any mortality which accompaniea its use. Cer- 
tainly it would be bettor that oil should endure the pain ocoa- 
sionally inflicted by the dentist, than that the life of one human 
being should be sacrificed to procure them exemption. Yet 



AN^STHBTIOS. 857 

ansBSthesia has already taken maDj lives in exchange for what 
relief it has given to the subjectsof dental operations. 

Painful experience has shown that the use of ansesthetics has 
been more dangerous in the hands of dentists than of other 
administrators, death having more frequently occurred in at- 
tempts to save the patient from the pain caused by the little 
operation of extracting a tooth, than perhaps from all the in- 
stances in which anaesthetics have been administered to prevent 
the consciousness of suffering in capital operations. 

The greater danger of anaesthesia in dental operations is 
easily accounted for. 

The operation has to be performed upon an organ concealed 
in the cavity of the mouth. The preliminary stages of the ope- 
ration, adjusting instruments, &c., cannot be accomplished until 
the patient has been made unconscious. The mouth then is gene- 
rally found spasmodically closed, and cannot be forced open 
without considerable effort. In the mean time, the patient can- 
not continue the inhalation, the soporific effects of the anaes- 
thetic pass off, and by the time the operator has accomplished 
the separation of the gum, consciousness has returned. 

In an operation upon any other part of the body than the 
organs through which inhalation is accomplished, the surgeon 
having the patient in a proper position for the immediate ope- 
ration, can commence it as soon as anaesthesia is effected, and 
can proceed without interrupting the inhalation, which can be 
continued, according to circumstances ; the patient not being 
profoundly, but continually narcotized. 

But the dental operator must carry anaesthesia so far as to 
produce relaxation of the muscles of the jaw ; or what I think 
is more commonly the case, to so completely overwhelm the 
consciousness as to obviate that instinctive resistance which 
seems to linger after volition appears to be suspended. When 
the patient begins to inhale the chloroform, his mind is intently 
occupied with the anticipated attack upon his teeth, and his 
fears are concentrated upon the dread of the attack being pre- 
maturely made. By his eyes and hands ho continually gives 
signals of consciousness as long as he can, and the last effort 



of volition is to clencL the jawa aa firmly as possible. Muscular 
life being less easily overcome than intellectual, the extreme 
anaesthetic effect of chloroform or ether has to be induced in 
order to overcome the difficulty. 

Again, as the dentist cannot continue the administration of 
thfi anffisthetic while operating, at least not with any regularity, 
he is obliged to carry the auEesthesia so far aa to permit a cer- 
tain degree of it to pass off without the restoration of conscioas- 
ness. In other words, he muat produce super anceithma, be- 
cause he muat provide against the known evanescenco of the 
condition. 

Another reason why dental aniestheaia has proved so fatal, 
is, I doubt not, the position in which the patient inhales the 
narcotic vapour. 

Invariably the subject of the operation is placed in a chair, 
with the head nearly upright ; consequently, when anesthesia 
ja carried so far as to cripple the action of the heart, the patient 
readily faints; syncope, ihe almost or entire suspension of the 
heart's action, finds the patient in the worst possible condition 
for reaction, owing to the depressed state of the nervous ays- 
tom, consequently it often happens that no reaction takes place, 
and the patient almost immediately expirea. 

That this is the manner in which death occurs in moat cases 
of fatal anaesthesia appears to me evident. That occasionally 
a state resembling apoplexy may be induced, and the patient 
not recover, may be true ; but apoplexy does not destroy life im- 
mediately, generally not hastily, unless from coploua efl'usion 
in the brain, which cannot be supposed to take place in anes- 
thesia. Cases of profound and fatal apoplexy generally con- 
tinue for several days, sometimea for two weeks, before death. 
But death from chloroform is sudden, and always results imme- 
diately from cessation of the heart's action. Now the action of 
the heart is kept up under deep and fatal congestion of the 
brain, until it gradually weakens through exhaustion of vitality, 
unrenewed by alimentation, rather than from any deadly in- 
flaence acting upon the organ itself. 

Again, by regarding syncope as the cauae of death in these 



ANESTHETICS. 859 

cases, we have explained the singular fact that anaesthesia has 
been less perilous to the patient in parturition than under other 
circumstances. Parturient females are not only not prone to 
faint, but arc almost uniformly in a recumbent position during 
the administration of the anaesthesia ; a position in which syn- 
cope cannot occur until the heart's action be enfeebled to the 
last degree. 

I am convinced, then, that anceathetics should always be ad- 
ministered to the patient in the recumbent position. 

They should never be administered to a patient in whom the 
heart* s action is at the time very feeble, whether from dread or 
otherwise. 

They should never be administered to a patient subject to 
fainting fits. 

Since writing the above, I have read several accounts of cases 
of death from the use of anaesthetics, which tend to confirm me 
in the opinion that the position of the patient has much to do 
with the fatality of the inhalation. 

One of these cases happened in the chair of a dentist, and 
two in the hands of the general surgeon. In both these latter 
cases the patient seems to have died from syncope, the result of 
position. 

In one instance, the patient was a little girl, 12 years old, 
who had a tumour to bo extirpated from the thigh. The pa- 
tient was placed upon the side of the bed, in the upright posi- 
tion, supported (held upright) by proper assistance. The anaes- 
thesia eflfected, she was laid down, but the cflFect going rapidly 
off, she was again upright. The surgeon goes on to relate that 
the chloric ether was again administered until the head dropped. 
The first stroke of the knife, however, roused her so much that 
it became necessary to restrain her, and at the same time the 
surgeon directed the sponge to be applied until she should cease 
to strive. In about three minutes the struggles ceased, the 
sponge was withdrawn, and in five minutes more the tumour 
was removed. At this time the pulse and respiration caused 
alarm. Immediately they commenced giving stimulants, apply- 
ing ammonia to the nose, dashing water on the face and chest, 




rubbing and elevating the extremities, exciting artificial respi- 
ration, and using all the means recommended in such c 
without avail. The respiration became more feeble, the pulsa- 
tions of the heart hardly perceptible, and continuing in this 
state fifteen or twenty minutes, she died. 

The other case was that of a lad of 17, who came to the office 
of a surgeon about noon, for surgical aid, on account of a badly 
lacerated band. He was pale, and suffering much pain, and 
"trembled like an aspen leaf, when he was coming to the shop." 

A mixture of chloroform and chloric ether was administered 
perseveringly, as it made him sick. When under its infiuencc, the 
dressing of his hand was commenced, but very soon the assis- 
tant called the attention of the surgeon to the patient's face. 
The surgeon continues, " I saw at once that he was either dead 
or dying, and directed my assistants to help me hy him at once 
on hia back. I found the pulse at the wrist gone, the action of 
the heart very feeble indeed, and respiration in a moment ceased, 
& few heaving inspirations at long intervals, the action of the 
heart meanwhile growing more and more feeble, and all was 
quiet — my patient was dead." 

The surgeon then proceeds, at some length, to express hia 
entire inability to account for the young man's death, until he 
is relieved by the suggestion of a bystander, that he died of 
fear. Ho says, " My conclusion then is, that the fatal conae- 
quenco attending etherization in the present instance, is not 
owing to any inferiority in the article used, to want of care in 
its administration, nor to any organic disease in the patient; 
but that we must look for it in the naturally delicate organiza- 
tion of the subject, rendering him very sensitive to external 
impressions, in the shock that the nervous system had sustained 
in the injury, and last but not Icost in the influence of fear; 
not in any one of these singly, but in the three combined. 

My conclusion is, that the patient would certainly have fainted 
under the dressing, whether he had taken the chloroform or not. 
He was in a fainting condition when be came into the office, 
"pale and trembling like an aspen leaf;" and that he would faint 
if kept in an erect position during the dressing was certain. 



ANiBSTHETICS. 361 

Under these circumstances^ to lessen the energy of the nervous 
system was to render reaction exceedingly doubtful, or impos- 
sible. The chloroform was given — the nervous centres lulled 
into insensibility — the patient fainted — there was no reaction, 
and he died. 

I have not selected these two cases. They were published 
in consecutive numbers of the Boston Medical and Surgical 
Journal, for the present month, and seemed so corroborative of 
the opinion I have expressed that I have recorded them here. 
That a careful observation of the fatal cases reported will still 
further show the importance of position to the consequences 
of anesthesia, I have no doubt. I do not mean to say that to 
one in the recumbent position anaesthesia is always safe, but that 
to one in the upright position it is always dangerous. 

The dentist is rarely warranted to administer anaesthetics. 
If he does so frequently, experience may teach him to expect, 
that sooner or later he will cause the death of a patient. Upon 
this supposition he must proceed, and as he cannot pretend 
to be compelled to risk anaesthesia through the necessity of 
saving life, he must, if he employs it, assume a most serious 
and unenviable responsibility. 



31 



INDEX. 



A. 



Abscess, 74 

Acids, 44, 46 

Aconite, 142 

Acute diseases, 49 

Adhesion, 79 

AnsBsthesia in dental operations, 355 

cause of death in, 358 
Anoesthetics, 346 

modus operandi of, 354 
conditions forbidding, 355 
Aneurismal tumours, 138 
Animals, the body of a unit, 25 
Antiphlogistic treatment, 87 
Antrum maxiilare, 85 

inflammation of, 86, 

311 
dropsy of, 86, 306 
ulceration of, 84 
diseases of, 305 
suppuration of, 312 
canes, necrosis, and 
other morbid con- 
ditions of the bony 
walls, 313 
softening of do., 320 
exostosis of do., 320 
Aphthae, 83 

Arrest of hemorrhage, 233 
Arsenic, 114, 148 
Atheroma, 131 
Atmosphere, 36 

density of, 37 



B. 



Bi^elow, Dr. H. J., on Anaesthesia, 349 

Blistering, 90 

Blood, huffy coat of, 56, 70 

Bones, caries of, 100 

Bony tumours, 133 



Brown, Jenny, case of, 280 
Burns, 242 



C. 



Caloric, 37 
Cancer, 101 

of the gums, 254 
Cancrum oris, 92 
Caries, 44, 80, 95 
Causes, mechanical and chemical, 44 

mechanical, 46 

specific, 40 
Cautery, actual, 235 
Chapman, Dr., cases reported by, 214 
Chemosis, 71 
Chill, 50 

Chloroform, effects of, 353 
Cholera infantum, 180 
Chronic diseases, 49 
Coagulable lymph, 67 
Cold, 37 

a depressing agent, 39 
Complication, 53 
Compression of vessels, 233 
Congestion, 61 

Consequences of inflammation, 71 
Contagions, 40 
Continuous disease, 49 
Convulsions in dentition, 183 
Crusta lactea, 185 
Cutaneous eruptions in dentition, 181 



D. 



Darwin, remarkable cases reported by, 

220 
Death from extraction of a tooth, 218 
Debility, 40 
Dentition, first, morbid eflfects of, 168 

diseases of, 174 

second, third, 187 



364 



INDEX. 



Diagnosis, 52 
Diathesis, strumous, 123 
Digestion, 47 
Disease, 31 

definitions of, 31, 32, 33 
causes of, 34 
classification of, 61 
nature of, 61 
Dislocations, 249 

of the lower jaw, 250 
Donn^, M., his experiments upon the 

saliva of fever patients, 150 
Dyspepsia, 153 

classification of, 155 
causes of, 156 
treatment of, 157 



£. 



Ecchymosis, G3 

Effects of diseased teeth and gums, 188 

Enamel, 44 

Endemics, 40 

Epidemics, 40 

Epilepsy from dental irritation, 194 

Epulis, 253 

Eruptions, syphilitic, 118 

Ervsipelas, 66, 68 

Ether sul., 346 

compared with chloroform, 348 

Etiology, defined, 33 
treated, 34 

Exacerbation, 50 

Excitability, nervous, 39 

increased, diminished, 39 

Exostosis, 133 

of the teeth, 135 

Eye, painful affection of, cured by ex- 
tracting a tooth, 198 



F. 



Fever, 61 

inflammatory. 68 

idiopathic and symptomatic, 69 
Fistula, 109 

ofthegum, 259 
Fitch, D., cases reported by, 212 
Fractures, 245 

of the jaws, 247 
Functions, 31 
Fungus hsmatodes, 128 



G. 



Gangrene, 95, 96 

Gilman, Dr., on anaesthesia, 350 

Glands of the mouth, inflammation of, 

82 
Glands and gland-ducts, diseases of, 

277 



Gland, submaxillary, tumours of» 280 

parotid, do., 290 
Gums, inflammation of, 83 

chronic, 93 

diseases of, 253 

sponev, 260 

scrofulous, 261 



H. 

Hemorrhager231 

of the gums, 262 
Halford, Sir Henry, cases by, 222 
Hall, Peffgy, case of, 287 
Harris, Dr. C. A., cases reported by, 

204, 223, 224 
Health, 33 
Heat, 37 

an excitant, 38 
Hepatization, 80 

Hildanus, report of cases of headache 
cured by extraction of a tooth, 
219 • 
Do. earache, 220 

I. 

Ichor, 112 

Induration, 80 

Inflammation, 63 

treatment of, 87 
of the mouth and adjacent 
parts, 81 

Insects in the antrum, 332 

Intermission, 50 

Intermittents, 48 

neuralgic, 144 

Intertrigo, 184 

Introduction, 25 

Iodine, 127 

Iron, salts of, in neuralgia, 143 



K. 



King's evil, 122 

Koecker, Dr., remarks upon effects of 

diseased teeth and gums. 
190 

cases reported by, 198 



L. 

Lacerated wounds, 237 
I Language, medical, 32 
Leeching, 90 
Life, medical use of the term, 32 

definition of, 33 
Ligature of vessels, 234 
Lips, diseases of the, 264 

hare, 264 

operation for, 266 



I5DBX. 



365 



Lips, adhesion of, 268 
contraction of, 268 
operation for, by Liston, 269 
do. by Mutter, 270 
cancer of, 272 
X'Ower jaw, amputation of, 296 

Hullihen's operation, 298 
Lupus, 125 



M. 



Malaria, 40 

diseases caused by, 41 

sources of, 42 

not homogeneous, 43 

prophylactics against, 44 
Marasmus, 194 
Measles. 160 
Melliceris, 131 

Mercury, preparations of, 119 
Moisture, a cause of disease, 40 
Morbid effects of conditions of the teeth 

and gums, 165 
Morbid secretions of the mouth, 149 
Mortification, 95 
Mumps, 83 

Murray, Margaret, case of, 279 
Miitter, Dr., operation by, 255 



N. 



Necrosis, 80, 96. 99 
Neuralgia, 51. 139 

fauci, 141 

from diseased teeth, 216 
Noli me tangere, 125 



O. 



(Edema, a sign of deep-seated inflam* 
maiion, 67, 71 
of the glottis, 82 
Ossification, 56 
Osteo-sarroma, 137 
Oxygen. 37 
Ozsna, 86, 326 



P. 



Pain, 57 

of inflamed parts, 64 

Palate, diseases of, 334 

Paroxysm, 50 

Particular affections of the mouth and 
adjacent parts, 253 

Parulis, 253, 257 

Pathology, defined, 33 

Peruvian bark, 146 

Petit, M., case of headache from dis- 
eased teeth, 219 



Phlegmon, 66 

Phlvctense, 186 

Phthisis, induced by dental irritation, 

210 
Physiology de6ned, 33 
Pointing, 76 
Polypus, 129, 327 
Pregnancy, 164 
Preliminary considerations, 31 
Progress of disease, 49 
Pulse, 53 

varieties of, 55 

rule for feeling, 56 
Pus, 72 

laudable, 72 



Q. 

Quartan, 50 

Quinine, in neuralgia, 144 

Quotidian, 50 



R. 



Ranula, 277 
Reaction, 39 
Regimen, 60 
Remittents, 49 
Resolution, 87 

Rest of parts, conducive to cure, 59 
Rickets. 160 

Rush, Dr., cases reported by, 194, 195 
remarks on dental irritation, 
196 



S. 



Saliva, its acidity in disease, 150 
Salivary fistula, 292 
Salivation, 91 

mercurial, 161 
Scalds, 243 
Scarification, 89 
Scirrhus, 111 
Scrofula, 121 
Scurvy, 93, 120 

Secretions, modified by inflammation. 66 
Sequestrum, 80, % 
Shepherd, Dr., case by. 225 
Signs of disease, 52 
Simpson, Dr., views of aniesthesia, 34^ 
Smith, Dr. N. R., do., 350 
Softening, 80 
Specific diseases, 51 
Sphacelus, 80, % 
Spina ventosa, 138 
Staphyloplasty, 341 
Staphyloraphy, 342 



366 



INDEX. 



Steatoma, 131 

hiitomatuis, 83 

Strophulus, or red gum, 185 

Styptics, 232 

Suffering of no part unimportant, 27 

Suppuration, 72 

Surgery, dental, long degraded, 29 

defined, 33 
Sutures, 237 

Swelling of inflamed parts, 64 
Sympatnetic diseases of dentition, 179 
Sympathy, 26 
Symptoms, 31, 48 

local, sympathetic, general, 
48. 
Syphilis, 93 

of the palate, 337 



T. 



Tartar, 88 
Teeth, caries of, 100 
dead, 59 
necrosis of, 101 
Tertian, 50 

Therapeutics defined, 33 
Tic douloureux, 141 

diagnosis of, 141 
treatment of, 142 
Tissot, observation on diseases of the 

teeth, 197 
Tonsils, inflamination of, 82 
Treatment of diseases, 59 
Tumours, 128 

benign, 130 
sarcomatous, 131 
encysted, 131 
of the salivary glands, 278 



U. 



Ulceration, 76 

phagedenic, 79 
Ulcers, 103 

causes of, 104 

classification of, 105 

simple purulent, 105 

simple vitiated, 106 

callous, 107 

fungous, 108 

sinuous, 109 

carious, 110 

cancerous. 111 

phagedenic, 117 

scorbutic, 119 

scrofulous, 121 

venereal, 115 
Upper jaw, tumours requiring amputa- 
tion of, 294 
Liston*8 operation for, 295 



V. 



Vapour, watery, 37 
Vesication, 72 

Vitality, an operative element in inju- 
ries, 38 

W. 

Wens, 131 

Westcott, Dr., experiments by, 45 

Wounds of the mouth and face, 229 

simple incised, 230 

lacerated, 237 

contused, 239 •" 

punctured, 239 

gun-shot, 240 



HARRIS'S DICTIONARY OF DENTAL SUROERY. 



LINDSAY & BIAKISTON, PHILADELPHIA, 

HAVE JUST PDBLIBHED 

A DICTIONARY OF DENTAL SCIENCE, 

BIOGRAPHY, BIBLIOGRAPHY, AND MEDICAL TERMINOLOGY, 

BY CHAPIN A. HARRIS, M.D., D.D.S., 
Author of " The Prineipks and Practice of Dental Surgery, ^^ Sfc. Sfc 

IN ONE VOLUME, ROYAL OCTAVO. 



i^^^w>/w<^vw^^^^ww^>v* 



The work before at filli a void tbat bat lonf exifted to thoae engaged in tbe practice of dental lur- 
gerjr, and the ta«k could not have devolved upon one better calculated to perform it. Tbif branch of 
aurgery la extending so rapidly, and rising to such importance in the community, that a cyclopedia, 
enbraang saiisflictory definitions of its technicaliticf , and a compendium of neceasary, important, ana 
eHriooa coUcteral information, seemed indlspensal>le. The large and valuable medical and surgical die 
tionaries of tbe present day, although invaluable to the student and practitioner of general medical aa 
ence, contain little that is useful to the practical dentist. To supply this want, therefore, the work 
before us was undertaken. In it are contained accurate, though necessarily condensed, accounts of the 
physiological and various pathological conditions of the teeth, and the operations necessary for their 
cure, together with iUU descriptions of the instruments and materials needed in them. Tbe work ia an 
endaring nnonument to the patience and industry of its author, and one tbat we should consider India 
pensable to th^ practitioner of dental aurgery, and would gladly aee in the library of every physidaB aa# 
sargeon.— JMb^m/ Ex*mn§r, 

This is the only work of the kind in the world, it ia presumed ; and one is almost tempted to believe 
there will never be another, since whatever belongs to the subtlect is here brought into an elaborate 
alphabetical arrangement, as convenient as could be desired for reflsrence. Dr. Harris, tbe laborfona 
author, must be a roan of intense industry and activity, to bring out ao many excellent volumes as now 
bear his name, and which are unhesitatingly received by the dental flratemity, as tbe latest and beat 
authority. This dictionary is a valuable reference for tbe medical profession alao ; and may be reaortad 
to with profit in regard to a variety of diseases for which they are consulted. It is creditable to tbia 
country that such advances have been here made in operative dentistry, and that the best books extant, 
explanatory of the intricacies of tbe art, and perhaps, alao, tbe best operators, belong to tbe United 
States.— BMr»« Med. and Surf. Jtrnmal. 

A dictionary of dental science, a want which has been long and much felt in the dental |Mt>fession, ia 
now met in the fullest manner. Not only are all medical and surgical terms explained with concise 
clearness, but we have also a collection of vnluable knowledge in all that relatM to dental science 
which we can find in no single work elsewhere. This dictionary will, among physicians and surgeons* 
successfully rival our best standard medical dictionaries; whilst, among dentists, it cannot foil to com- 
mand a most unquestionable and decided preference, embodying, as it does, all that others can teach, 
and much more on which they are silent.— JaiinisV ^ Dtntal Surgery. 

This work was much needed. Before its publication, dentists knew not where to seek information 
upon medical subjects incidentally connected with their own department of surgery. The several m»^li- 
rnl ilictionaries were very deficient in information upon dental science; in general, surgical encyrlo. 
podistf had almost entirely overlooked operations upon the teeth. Dr. Harris has done his work laith' 
fiilly. Thoroughly acquainted, by former exoerience, with the wants of the profession, he lias act 
biBiaelf to supply them, with the honest earnestness and untiring indnatry characteristic of all his 
labours. Not satisfied with preparing a dictionary of dental science, he has produced one of the b^st 
medical dictionaries of the day; and the work is not only adapted to tlie wants of dentists, but will ha 
a valuable addiuon to tbe library of tbe general surgeon and physician.— BalNsiars Putritt, 




The DicmbGra of the prorcseioa, and etadccts in particular, Lave long fett the 
■itj of s treatise on DeatiBtr;, in all its brtmchea, medicitl. surgical and sechamoal, 
vbicli shcold at once be compreheaaiTe in its scope, practical in its detail, ooireet it) Its 
■rienoe, and beautjftil m typographical eiccution. The flattering manner in which Dr. 
Harris' work ba> been reoeiied, together nith its rapid tale, bai wuTOUtcd the author 
Id sparing no labaur, and the publiBhers no expense, tn endosTouring to make thia edi- 
tion the most complete work of tb^e kind. And so great has been the (MtrancenieDt of 
Dental Surgery ever siiioe the puhlicnticn nf the third eilition, that it has bo«n Ainnd 
neoeasar; to add aonaidcrabte now mutter to the booli. Among the nmnerous itnportaat 
additicns, are three ohnptera upon Filling Tootli and one on Mechanical Dentistry. 



OPINIONS OF THE PRESS. 

" We feel wamuited in saying that it embodies more practical iurormo^on than onj' 
ether work on the subject in the English langnagD ; we wonld consequently recomiDeiid 
its perusal in the moot unqualilied terms to the medical profession genereUy and to the 
Boientifio Surgeon Dentist in pnrliculur." — Soul/urn MtJieal and Surgieal JoumaL 

"This is the most complete work on dentistry that we liaTC eTei yet seen. The 
jitatsB which accompany it are admirably eie(;utcil, iind ore so arranged in the Tolmue. 
U to Afford B ready reTerenoe for the otfjefltB which they are designed to illuslrate. Wi 
beg leaTC to reeommend this inTaluable work tn ea«h member of the faoulty, m erery 
way worthy of an aCtcntiTO perusal." — Soulkmt AdvcTliur, 

" Dr. Harris has proved himself so well qualified for liis task, that it may b( safely 
asserted that no one lolame in ihe English langonge contiiins an equal amount of ear* 
rect and laluable information for the use of the students in dentistry. There are 
manifested also in Dr. Harris' volume on originality of thought and nn independence 
ef opinion equally calculated to elicit tmlh nod to expose error.'' — Journal 0/ Vtnial 
Burgerg. 

'• In every part of the volume we see evidences of great practical and theoretical 
koowlet^e, the rctult of matiy years of dose application and eiporicnco ; and the work 
b ehnraoteriied 1>y an ori^noJity of thoaght and indcpundcnee of opinion eqoally oal- 
oulated to elicit truth and expose error." — Dr. Am. Jour, of M. and P. Sdenet, 

" We rccoDimeud it to Ihe dental prorecsion as one of the most valuable and compr*- 
htntfve works extant, on the sulfjeet of their favourite anil important Mience." — £m(ch 
Ktd. and Surg. Journoi 



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A FBACnCAL TSEATISE ON DENTAL MEDICINE: 

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Daiig1i!on'a Hum in Physiol ogy, 2 (ola. 
Eirk fe Paget'! Pbyainlogj. 
Carpenler'i Mumin Phy!iiilogy. 
Carpenter'! Comparaure Ph/aiology. 
Carpenter'! B'rmeauarPhyaiDlogy. 
Rae!e'a Aoalfaii of Fhjtiology. 

mcTioiiiiis. 

Harrii'i Dictionary of Dental Surgery, and Medi- 

Dangtiaoo'a Medical Dictionary. 
Gardiner'a Mtdical Diclinniry. 
Hooper-t Medical Dictionary. 
Hoblyn'a Medical Dictionary. 
Cooper'! Suijieal Dictionary. 

oekei Medical Leiicon. 



Kecae'i 



HGDICll iUBISFRDDENCE, &e. 

Ttjinr't Mcdicil Jun.prudenw, by GnSil 
Guy. Principle! of Foienaie Hed.ciue. 



DBNTISTKT. 

Hirrii'i Dictiaaary of Dental Snrgery. 
Barrla-a Prinoplta and Practice of Dental Sur- 
gery, <th «Jilian, wilh illualrelions. 
Arthura Manual oflh* Taetb, with illualrationa. 
Goddard on the Terth. 
Fo! un the Human Teeth, by Harrii. 
Ilarherl'a furpical and MeGbaucal Deilialry. 
Haary'! Denial Surgery. 



iollya 1 



WOKKS OR nVDBOPim. 

In Chronic Diaei 



of HydropithT. 

Shew'! Hydropiihy. or Water Cure. 

Franeke'i Theory and Practice of Uydropath;. 

Juhnaon'! Resulla of Hydfqpalhy. 

Dr. SheWB Water Cure Mananl. 

Water Cure in America, by ■ WaKr PatteDt. 

Mr*. Shew'a Water Cure lor Ladlea. 

Wei!'> Handbook ofHydropalhy. 

KinCHLS FOB 8TDDBNTS, te. 

Mendenhall'a Student'* Yade Mecam, or Mannal 
of I 

Me.) 



1 
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I.qdl<.w'.Miin 
Di!ea!e! and Uy) 
Barth & Roger!' 
Percu!iion,ar 
Coalill on Puiios 
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Sniiley'a Pocket Duae B. 
Righj't- 



il'a Vade Mecam, or Mannal 
n the •arioua brancbea of 

new aod enlarged edition* ^h 

E<«n.,na..ona. M 

,eorih. Voice. ■ 

lanual of AuaculutioB ud ■ 

ediiioD. M 

pendinn. H 

e Book. ^B 

Memoranda. ■ 

le Practice orMedicJie, ^H 

irinicopala. ^1 

Pfayaiulogy. .^H 

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lUcM'a Anaiyaia of Pfayaiulogy. 

9BDIC1L JOURNALS. 

Ranking-! Half-Vearly Abatract ofMcdiei 

puaMge prepaid, •!. 
The Medical Kiaminer and Record of M*d. 

Sciencfi, (ninaihly,) (3 per annum. 
The Aiiiencan Joornal of Pharmacy, (quatterl^^ 



The London Lincei, S5. 

ni&CELLlIIEODS. 

Aliercrombie on the Slonueh, I (ol. 
Andral on the Blood. I lol. 
Aran on the Heart, 1 vol, 
Andril'a Meilicil Clinic, 3 rol*. 
Andry on the Diaeaia* of (he Heart- 
Acton on Veoereal Difeaaea, colored plate*. 
Bartltltoo Fevera, 1 vol. 
■tIakiaKin un Ihe Diaeaaei of the Cliatt. 
Burrow a on Cerebral Circuliiian. 
Ueacli'a Midwifery, colored platei. 
Baauh'* Practice of Medicine. 
Beach-! Phjaiofogy. 
Beach 'a Medical Dictionary. 
Beauinuul'a Phyaiolagy of Digeaiion. 
Barilcli* Philoaophy of Medicine. 
Barllell on Certs. nlj in Medicine. 
Baneliu* on the Kidney! and Unae, I *al. 



n Pal!y and Apoplexy. 



De Joagh oa Ct>d-Lii>er (hi. 
Day on Diaraaei nfUld Age. 
Diiflun iMi the Kar. 
UunghaoD'a Medical Bludeot. 



Fordj'cc (m Fcien, a new gdilion. 

Prick 00 HenaJ DIteiwi. 

Green on fimichitit, colored pUlW. 

Or.eD on Croup. 

Griffith'i Medical Bounj'. 

Crnu on the Urinerj Orgin*. 

eulhrie on the Bladder ind (Trelbn. 

Grave) and GErhud'a CliaiciJ Lecture*. 

Gerhard on Diieaaei oflhe Cheai, a new i 

Gulhtie on the Urioarj lad Seinel Organ 



■ ortheThrnal 
e Norrou. Sjal 






Hooper'a Phvaician'a VadeMecura. 

Uuntea on the Heart and Li>nE>. 

Hunler on the Blood, InflammaliDa, kc. 

Hunter nn Ibe Anlmel Rconomj. 

Jonei'i Ophihalmic MedicineindSurgerj. 

Knoi on the Racea orMen. 

Lawrence on the Eje, a new ediUon. 

Looii on Ferer. 

Laennee on the Cheal. 

Lalhim'a Lcoturea on Autcoltalion. 

Latham on Diieama oflhe Heart. 

Lallemind on Spermatorrhiu*. 

LiaFrtno on the Itlenii, b; Lodge. 

Lugol on Scrofnloua Diiosaca. 

LiRell on the Di>e»e< of the Eye, a new 



e Virginia Spring*. 
Uondm on Stenlitj in the Male aod Feinile. 
NunnellvDnErriipelaa. 
Neili'B Oullinea of the Nenea, colored. 
Ifeill'* Outliaea of the Arteriea, colored, 
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Phillip* on ecrofuli. 
Pereira-a Trealiie on Food and Diet. 
Fllcheron Ihe Diaeiiea of the Ear. 
Fettigrew'a Medical SuperMiliona. 
Ryui'a Philoaophf oFHarriige. 
Rayer on the t: Lin, colored plate*. 
Ricord on Venereal Diaeaaea. 
Sol If on the Brain. 



Rlokea 



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iforiheChetl. 



Tardien on Cholera. 
Tanquerel an Lead Diaeaiea, br D*«l. 
Thompaoo'a Managemeol oflh* Sick noon. 
Thomion on the Lirer and Spleen. 

pliD on the Treatment orOeftinniliea. 

lb on Ihe Diaease* of the Lung*. 

on>* Practical Treitiae on the Skin. 

ihe on Cancer, b; Warren. 4 

lami on the Reapiralorj Organ*. 

lama'a American Medical Bio^ripbj. 



Walker r 



terilitj. 



arriage. 

FBACTICiL WORKS, CUBmsm, KlTUSAl 
PUILOSOPBT, &t. 

Morlil'a Chemical and Pharmaceulical Manipu- 



I, 433 pi 



The A 



a Chen 

■ulBjr'i Drnugial 



cipta. 



I Anal' 
. . al'a Rm 



, with illoa 



ceipt B. 



Receipt t 



.lej-aCjrd. 



edia nr Practical Receipla. 
K) ReceipU. 

leliua on the Blowpipe. 

ir b Redwood'a Pharmacy. 

I'a Syllabua orChemlatry. 
Griffilb'i Chemiilry ortheSeaaona, 
Knapp'a Chemical Techoolog]', I rota. 
Bird-* Natural Philoiophy. 
Ororman'* Practical Mineralogy, Aaaayinj 

De 1( Beche'a Geotoglcal Manual. 
Kirby ft Spence'a Enlomoli 



Lirdne 



of Men. 



le Race 
a Handboo 



FAMILY MEDICAL WORKS. 



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)d Skinncr'a Farrier, I tol, l2mo. 
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LANE MEDICAL LIBRARY 



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