ft ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section.... Number _.W....^. ^__._ZL5 J- DENTAL MEDICINE, AS CONNECTED WITH THE STUDY OF DENTAL SURGERY. A PRACTICAL TREATISE DENTAL MEDICINE, A COMPENDIUM OF MEDICAL SCIENCE, AS CONNECTED WITH THE STUDY OF DENTAL SURGERY. y By THOS. E. BOND, A.M.,M.D., PKOPESSOE OF SPECIAL PATHOLOGY AND THERAPEUTICS IN THE BALTIMOBE COLLEGE OF DENTAL SURGERY. ^ '->—.» THIRD EDITION, \. fc<-? I J-, _ \ ISED, CORRECTED AND EHLAEGEflv.V^ ;" ^-ji:.;.^ '''.' PHILADELPHIA: LINDSAY AND BLAKISTON, 1863. felllp Entered according to Act of Congress, in the year 1862, By LINDSAY & BLAKISTON, In the Clerk's Office of the District Court for the Eastern District of Penn- sylvania. Wm. S. Young, Printer. PREFACE TO THE THIRD EDITION. The reception of this work has been more favora- ble than the author expected. It seems to have met a want of students of Dentistry. The author is fully aware of its imperfections, and knows that neither its plan nor execution will abide the test of critical exa- mination. But the book was prepared for a practical purpose, which it seems in some considerable degree to have subserved, and it is quite probable that such al- teration of its plan and increase of its volume as lite- rary taste or scientific requirement would demand might render it less useful to those for whom it was prepared. The author has therefore contented himself with such alterations and additions as he could make with- out risk of impairing the usefulness of the work. They will be found to be considerable, and it is hoped beneficial—and with them it is respectfully submitted to the kind judgments of those, who, knowing the de- sign of the book, will comprehend the difficulty of preparing it, and be more disposed to consider its practical usefulness than its artistic imperfections. September 1, 1862. PREFACE. The Baltimore College of Dental Surgery was or- ganized with the design of teaching Dentistry as a regular branch of Medicine, in which relation only, it can be regarded as a scientific pursuit, and the practice of it esteemed a profession. With this view it was arranged that the Faculty should consist equally of Dentists and practising Phy- sicians, and to the author of this treatise was intrusted the chair of Special Pathology and Therapeutics. Commencing the performance of his duties with no larger amount of knowledge of the subject than is commonly possessed by medical men, he has been led to discover much more importance in it than at first he could have supposed to exist. Endeavoring to avoid the very natural error of exaggerating the value of isolated facts or doubtful statements, upon matters, at once novel and from the circumstances peculiarly in- teresting, he has found that many things which at first he was disposed to regard as unlikely, are, never- theless, well attested and established facts; and, after mature investigation, he has become fully convinced that the relations of the teeth and their appendages with other, and even with vital parts, are sufficiently Vlll PEEFACE. impprtant to be carefully studied both by the Dentist and t Physician. After ten years' experience as a teacher of these sub- jects, he has found it absolutely necessary that a com- pendium of medicine should be furnished, in which should be brought together, in a small compass, such selected information as should meet the wants of the Dental Surgeon, and as none has been prepared by another he has reluctantly undertaken the task. The difficulty of performing it will readily be con- ceived, when it is observed how much was proper and how much was irrelevant: how cautious it was neces- sary to be, that no needless matter should be intro- duced, and how careful that nothing pertinent should be omitted. Without the pretension of having done it well, the author is yet gratified that it has been done at all. Though particularly intended for the Dentist, the author flatters himself that he has presented the sub- ject in such a form as will render it deserving the at- tention of the general practitioner. It is not the custom of our profession to consider any thing unworthy of attention which has any bear- ing, however remote, upon the benevolent pursuit to which we have devoted our lives, but to the most fas- tidious it may be said, that subjects which have been thought worthy the attention of Hunter and Rush, may be investigated by all without fear of degrada- tion. THE AUTHOR. CONTENTS. PAGE. Introduction, . . . . . . 13 CHAPTER I. Preliminary Definitions, . . . . .25 CHAPTER II. Etiology, . . . . . . . 29 The Atmosphere, ...... 32 Heat and Cold, ...... 33 Malaria, ....... 37 Chemical Causes, ...... 39 CHAPTER III. Symptoms of Disease, ..... 43 Progress of Disease, ...... 44 CHAPTER IV. Diagnosis, . . . . . . 47 CHAPTER V. Treatment of Disease, General Remarks on, . . 56 Catalogue of Disease, ..... 59 CHAPTER VI. Inflammation and its Consequences, ... 61 Inflammation, ...... 61 Consequences of Inflammation, .... 72 Inflammation of the several parts composing the Mouth, and of the parts adjacent, . . . .83 Inflammatory Fever, ..... 97 Treatment of Inflammation, ..... 99 Caries, ....... 112 Mortification, or Gangrene, . . . .114 X CONTENTS. CHAPTER VII. Ulcers, Local and Constitutional, Simple Purulent Ulcer, Simple Vitiated Ulcer, Callous Ulcer, Fungous Ulcer, Sinuous Ulcer, Carious Ulcer, Cancerous Ulcer,. Ulcers Dependent upon Constitutional Cause, Venereal or Syphilitic Ulcers, Scorbutic Ulcers, Scrofulous Ulcer, 121 123 123 125 126 127 128 130 131 136 136 141 143 CHAPTER VIII. Tumors, ........ 150 Malignant—Osteo Sarcoma, .... 151 Fungus Haematodes, Bleeding Fungus, Spongoid Inflam- mation, Soft Cancer, Medullary Sarcoma, . . 152 Polypus, ...... 152 Benign Tumors, ...... 154 Sarcomatous or Fleshy Tumors, .... 154 Encysted Tumors, .... . 155 Bony Tumors, ...... 156 Exostosis of the Teeth, ..... 159 Tumors occasioned by Enlargement of Blood-Vessels, . 161 Aneurismal Tumors, ..... 161 CHAPTER IX. Diseases of the Teeth and Face dependent upon Morbid Conditions, either general or of other parts, 163 Neuralgia, ....... 163 Neuralgia Faciei, or Facial Neuralgia, . . . 163 Intermittent Neuralgia, ..... 168 CHAPTER X. Morbid Secretions of the Mouth, 174 CHAPTER XI. Morbid Effects of Conditions of the Teeth, and the parts immediately connected with them, upon the ge- neral system, ..... 192 CONTENTS. XI CHAPTER XII. Morbid Effects of First Dentition, 195 CHAPTER XIII. Sympathetic Diseases of Dentition, . 207 Cholera Infantum, . . . . 209 Convulsions, .... . 211 Cutaneous Eruptions, . 212 Intertrigo, ..... . 213 Crusta Lactea or Milk Crust, 214 Strophulus, Tooth Rash, Red Gum, . . 215 Second Dentition, .... 216 Third Dentition, .... . 216 CHAPTER XIV. Effects of Diseased Teeth and Gums upon the General Health, ...... Phthisis Pulmonalis, induced by Dental Irritation, CHAPTER XV. Wounds of. the Mouth and Face, .... Fractures, ...... Fractures of the Jaws, ..... Dislocations, or Luxations, .... Dislocations of the Lower Jaw, .... CHAPTER XVI. Particular Affections of the Mouth and adjacent parts, Diseases of the Gums, ..... Epulis, .....•■ Parulis, ...... Fistula of the Gum of the Lower Maxillary, having an Exte- rior Opening at the Hollow of the Chin, Spongy or Fungoid Inflammation of the Gums, . Hemorrhage from the Gums, .... Inflammation of the Teeth, .... Absorption of the Sockets, ..... CHAPTER XVII. Diseases of the Lips, Hare-Lip, Adhesion, Contraction, 217 241 262 279 282 285 286 288 288 288 293 296 297 299 301 308 312 312 317 317 Xll CONTENTS. CHAPTER XVIII. Diseases of the Gland-Ducts, .... 322 Salivary Tumors, ...... 322 Tumors of the Submaxillary Gland, . . . 325 Notes of the Operation, ..... 330 Tumors of the Parotid Glands, .... 336 Salivary Fistula, ...... 338 CHAPTER XIX. Tumors requiring Amputation of a part or the whole of the Upper Jaw, ..... 341 Amputation of the Lower Jaw, .... 344 CHAPTER XX. Diseases of the Antrum, or Maxillary Sinus, . . 354 Dropsy, or Retention of Mucus, . . . 355 Inflammation, ...... 361 Suppuration, ...... 362 Caries, Necrosis, and other Morbid Conditions of the Bony Walls, . . . . . .363 Softening of the Bony Walls, .... 370 Exostosis, ....... 371 Fistula of the Superior Maxillary Bone, . . • 374 Ozena, ... . . . . . 378 Polypi and other Tumors, .... 379 Insects in the Cavity, ..... 384 CHAPTER XXI. Diseases of the Palate, ..... 387 CHAPTER XXII. Anesthesia, ....... 400 INTRODUCTION. The body of every animal is wisely contrived and per- fectly fitted for the purposes it is intended to subserve. Every part, however minute, is necessary to the complete performance of the work of the whole; and a beautiful unity of purpose, and a necessary dependence of parts, are obser- vable throughout the organization. So remarkable is this unity, and so certain this dependence, that a naturalist, by examining a fragment of any one of the bones of an animal, may determine the character of the in- dividual it represents. Having ascertained the size, figure, &c, of any bone, he may infer, with infallible certainty, that every other part of the body to which it belonged was formed in perfect proportion to this part, and with strict reference to the purposes for which this particular portion was de- signed. Should a naturalist ascertain that a single bone presented to him was constructed for purposes of prey, he would immediately infer that a beast so provided must have had strong muscles and bones of the neck and jaws, to ena- ble it to hold and tear the animals upon which it was in- tended to subsist; hind legs of such a formation as to enable it to spring upon its prey; claws to seize and hold it, and a digestive apparatus suited to the reception and assimilation of the food thus procured. 14 INTRODUCTION. The body of man must then be regarded as a unit, and though, for the convenience of description, we speak of its multitude of parts, it is a single organization, fed by one aliment, nourished by one blood, vitalized through one ner- vous system, directed to a common purpose, subject to one sovereign will, and pervaded by a general law of conti- nuance, decay and dissolution. As one part of the body is identified with all the others, it is necessary that a certain organic consent shall subsist between the several parts, in order that they may act in con- cert in carrying on the business of life. For instance, the eyes must act together; the muscles of the trunk must aid the muscles of the limbs, and many more agreements of mo- tion, infinitely complicated and astonishingly rapid, must subsist between different members of the body. The body has more to do than to perform certain acts by which it may be continued in being. It is, from its nature, liable;, one's own eye—actual sight of the parts of a dissected body. 16 INTRODUCTION. gans of the body. An oculist, unless a thorough physician, would be utterly unqualified to treat diseases of the eye. The obstetrician must extend his knowledge far beyond the uterus, if he would claim a participation in the fellowship of medical science. Until very recently, however, the treatment of the diseases of the teeth seems to have been considered less a proper spe- cialty of medicine, than a mere mechanical craft, requiring in the operator little more than manual dexterity and physical force. Surgeons and physicians were generally profoundly ignorant of the importance of these organs to general health, and were contented to leave them to the care of any who were willing to take charge of them. Even now, dental dis- eases are rarely mentioned in the medical schools, and eminent professors of surgery have publicly confessed themselves in- competent to teach their students how to extract teeth. In the course of time, however, men of inquiring minds and studious habits, finding themselves in the practice of a rude and imperfect art, the deficiencies of which were con- tinually forced upon their observation, have been constrained to investigate the relations of the teeth to surrounding and distant parts. Well read medical men, waiving the general practice of the profession, have turned their attention to den- tistry, and of necessity have applied their previous informa- tion to the augmentation of dental pathology and therapeu- tics : and, finally, the management of the teeth has come to be an acknowledged specialty of medical science, and is ra- pidly advancing in public and professional consideration. It is thus that other departments of the healing art have gradually won their way to their present position and import- ance. Within a period comparatively recent, surgery in all its branches was regarded by physicians with sovereign con- tempt. Barbers were the operators, and mountebanks and old women dressed the sores. Midwifery was, if possible, INTRODUCTION. 17 held to be more despicable, and even within a few years, an eminent body of scientific physicians have declared obstetrics to be unworthy the attention of a polite gentleman. It is necessary to say that surgery and obstetrics are now leading branches of the profession, and are zealously prac- tised by men of the first talents and greatest scientific and lite- rary acquirements. To our country belongs a large share of the honor of placing these two departments of medicine upon their pro- per level with other professional pursuits. The depressed condition of surgery and midwifery was the consequence of the vulgarity and ignorance of those who practised in those departments, and the bad reputation thus acquired was a formidable obstacle in the way of those who attempted to elevate them to the dignity of scientific pur- suits, but patient continuance in laborious and honorable ef- fort has eventually succeeded in accomplishing the desired result. The practice of dental surgery was long degraded, from causes precisely similar to those evil influences which so long depressed kindred branches of the art. Disregarded by educated men, it necessarily fell into the hands of the igno- rant and rude, and precisely as surgery and midwifery have gradually emerged from their barbarous state and attendant dispute, dentistry is now winning its way against all opposi- tion, to its proper consideration. It is a matter of honest pride, that our country is again foremost in this laudable work. The purpose of the present work is to treat of dental sur- gery as a distinct and proper specialty of medicine, and to present to the reader a digest of information, prepared with particular reference to the morbid connexions certainly ex- isting between the teeth and the rest of the body. These connections are far more important than is generally 2 18 INTRODUCTION. supposed by physicians or dentists. The reader of the fol- lowing pages will probably be surprised to find so great a variety of disorders treated of as directly or indirectly con- cerned in the production of pathological conditions observed in the mouth; and his surprise will, perhaps, be greater to find so many and so serious diseases of other organs traced to their primary seat in morbid conditions of the teeth. Yet the object of the author has been to condense this treatise as much as consistency would permit, and to admit nothing foreign to the subject properly under consideration. I have endeavored to present an elementary view of the disease, from which the dental student may acquire such a knowledge of common facts and general principles as may prove a guide in the application of special art, and the foun- dation for the building up of such farther scientific acquisi- tions as experience and study may win from faithful profes- sional life. My purpose will have been in good measure at- tained, if perusal of these brief chapters shall awaken desire for more extended medical knowledge, and lure the dental student into the rich fields of learning, that lie all about the narrow and comparatively barren spot occupied by the spe- cialty of dental surgery. A TREATISE on DENTAL MEDICINE. CHAPTER I. PRELIMINARY DEFINITIONS. The human body is liable to changes which more or less disturb the regular and healthful performance of the many functions* necessary to the completeness of its life, or in other words, to disease. These changes are commonly at- tended with alterations of the phenomena which experience authorizes us to regard as natural or normal, or in other words by symptoms,^ which indicate the character and seat of the change which produces them. When parts thus diseased are inspected, we generally per- ceive alterations in their usual appearance and structure. Not unfrequently, however, the changes are too obscure to be detected by our present means of investigation. Many attempts have been made to define the essential na- ture of disease, but all have necessarily failed. It is impos- sible to frame with philosophical accuracy a definition of disturbed or altered conditions, unless we perfectly under- * By function is meant the particular part which each organ performs in the mechanism of life. The liver is an organ, its function is to secrete bile. f Symptoms are those observable differences from the healthy performance of function which lead us to suspect and often to detect disease. 3 26 PRELIMINARY CONSIDERATIONS. stand the nature of the organs; and the mode of their acts. We cannot understand the ultimate cause of morbid pheno- mena, while ignorant of the essential nature of life itself, as manifested in the healthy performance of function. It is important to the student to know that medi- cal language does not pretend to the precision of abstract philosophical science. Medical definitions are not to be re- garded as accurately stating the nature of things, but sim- ply as descriptions which may serve for practical purposes. This fact has been forgotten by many eminent medical wri- ters, and their efforts to be absolutely accurate have often led to serious mistakes, and always to confusion of ideas and contradiction of facts. The study of essences belongs to me- taphysics, not to practical science, and having failed to reach any truth by analyzing mind, it will hardly prove success- ful in its attempts upon the body. We wish it then to be clearly understood, that medical terms are to be received in a conventional sense, and that, while they serve perfectly well to convey what knowledge we have of curative science, they will not bear the test of strict philosophical examination. For example, the word life, as used by medical writers, does not mean the essential vital principle, but the aggregate of the functions of the body; not the ultimate cause which sets the machinery in motion, but its effect in the production of organic acts. Disease means all the morbid phenomena observed in a case, together with the structural changes upon which these phenomena depend, and any other more remote injury which may be concerned in their production. Thus a patient may complain of nau- sea; this sickness may be consequent upon defective diges- tion; the defective digestion upon interruption of the func- tion of the liver; the interruption of the hepatic* function * Hepar—the liver. PRELIMINARY CONSIDERATIONS. 27 upon change of structure in that organ; and that change of structure upon more minute pathological* conditions. Strict- ly speaking, we might regard all this train of evils as symp- toms merely of some obscure and inappreciable change which constitutes the disease. But in that case the word would be of no practical use. This instance may suffice to illustrate our meaning, and the student may be saved much embar- rassment by keeping the fact thus presented always in his mind. Many false theories and much bad practice have re- sulted from attempts to philosophise in medicine. It is an experimental science, embodying the results of long experi- ence and protracted investigation. As such it-is true, and worthy of all confidence. It is impossible to tell why any medicine produces its effect—we do not understand the phi- losophy of it; bat we know what effect it does produce, and that knowledge is sufficient, and infinitely more important. I will not trouble my readers with a recapitulation of the many definitions of disease proposed by eminent writers; let it suffice to say that, accurate definition being impossible, all of them are improper; and many of them strangely ab- surd. We can describe disease readily enough, but we cannot detect and exhibit its primary elements. Probably we would not be practically wiser if we could do so. Life, then, may be considered as the effects produced by organization. Health, the regular and orderly development of these effects. Disease, disorder and irregularity in their manifestation, or impediment to the accomplishment of one or more of them.f Physiology^: has to do with the performance of healthy or * Pathological—nn6og, suffering, Xoyog, discourse; that which relates to diseased conditions. fRoche and Sanson, Nouvenux Elements. $, I cure. f Avartfivw, I cut up. Jx*'e> the hand, tgyov, work. $Etij, cause. CHAPTER II. ETIOLOGY. Causes of disease may be external or internal. By external causes we mean all those agents which are independent of our own organization, whether they produce their impres- sion upon the outward or interior parts of the body. Thus poison inhaled or swallowed, would be an external cause, though acting upon internal surfaces. By internal causes, we mean all such as are produced from our own organization; as by the action of one part of the body upon another; or by the connection and dependence of parts; or by the influence of the intelligence itself, which often embarrasses, and sometimes overwhelms the physical machine. By general causes, we mean such as affect simultaneously a large part of the corporeal system. By local, those which are very much circumscribed in their sphere of action. These terms, like most others used in descriptive science, are not philosophically precise, since every cause must be supposed to act upon some structures to the exemption of others; but they are sufficiently accurate to convey the mean- ing intended. It must not be supposed that general causes necessarily produce general diseases, and vice versa. A lo- cal cause, acting only upon a very small surface, may pro- duce universal disorder, while a general cause may beget a strictly local disease. A plunge into cold water, drenching the whole surface, may produce nothing more serious than a 30 ETIOLOGY. tooth-ache; while a prick of a finger may cause serious ge- neral disorder and even death. Further subdivisions of causes are based upon the charac- ter of the effects which they produce. Some stimulate or in- crease the action of the blood-vessels; others debilitate or les- sen such action. Some act mechanically, dividing, tearing, bruising, &c; others chemically, burning, corroding or de- composing. Predisposing causes are those which exert an influence sufficient to make parts more liable to disorder, without ac- tually disordering them. This term, again, is not absolutely accurate, for we cannot conceive of these causes acting in any other way than by producing disease, which doubtless they do, but in so feeble a degree as to give out no symptom bf its existence. Exciting or efficient causes are those which im- mediately precede disorder, and are reasonably inferred to have induced it. It must not be supposed, however, that these divisions are absolutely descriptive of certain agents which permanently belong to either of them. A cause which predisposes in one instance may excite in another, and vice versa. For example, a man may be exposed to intense cold, and while extremely chilled he may drink a large quantity of ardent spirits, and fever may ensue. In this instance, the cold would be regarded as predisposing and the alcohol exciting. On the other hand, a man may become intoxicated, and while thus enfeebled he may be exposed to cold, and fe- ver or inflammation might result. In this case, the alcohol and its effects would be the predisposing, the cold the exci- ting, cause. Some causes are utterly unknown, but are inferred to ex- ist as agents differing essentially from known causes, from the peculiarity and uniformity of their effects. These are called specific. The causes of scarlet fever and of whoopino- cough are examples. ETIOLOGY. 31 Almost every thing without and within us may, in some way or other, be productive of disorder to the human body. The air we breathe may carry into the inmost recesses of our system, invisible poisons, to hurt the lungs or spoil the blood; it may withdraw our heat too rapidly, or it may fail to re- lieve us of our excess of caloric; it may itself undergo chemi- cal changes which deteriorate its qualities, and render it more or less unfit for respiration. The food we eat may pain or sicken or convulse us. It may suddenly prostrate, or gra- dually destroy us. Water, even when pure, may irritate the disordered organs of digestion, and when impure, may carry unsuspected drugs into the stomach. Even the light of hea- ven may harm the delicate eye, and the sun's propitious heat exhaust the strength or inflame the brain; while that all- pervading and powerful agent which we call electricity, en- tering our bodies at will, and playing upon our nerves at pleasure, may work in us fearful but inscrutable changes. We are constantly exposed to the rude contact of bodies harder than our own, by which our tissues may be divided, broken, torn or penetrated; while other substances possess a mysterious power, to combine chemically with the elements which compose our bodies, and form of them new products, thus altering and disorganizing the parts subjected to their action. Nor are the enemies of health and life within us less active or efficient. The exquisitely organized body is continually undergoing change, and in all its parts a law is at work which impels the whole to decay and dissolution. Linked together by exquisite sympathies, traversed by numberless nerves and blood-vessels, performing most delicate and im- portant functions, and pervaded by a powerful moral intel- ligence, whose passions and appetites excite and depress the physical system to its utmost limits of endurance, the parts 32 ETIOLOGY. of the body are continually liable to become diseased, and to radiate disorder throughout the whole. It will be impossible for me to introduce into the present work a full examination of each of the many causes of dis- ease which might be worthy of particular notice. I will only ask the attention of the reader to the consideration of such as are most important to us, as being concerned in the pro- duction of those diseases which the dental surgeon is expect- ed to treat. . THE ATMOSPHERE* The air acts upon us in a variety of ways. By its pres- sure upon us it keeps us in form; without that pressure the fluids coursing within us would overcome the resistance of- fered by the coats of their vessels, and universal turgescence, interruption of function, and death would ensue. It furnishes us with the oxygen necessary to preserve the vitality of the blood. Were the natural proportion of this element increased or diminished, we must suffer hurt. It is also the vehicle by which watery vapor acts upon our out- ward and inner surface, and the medium by which caloric or the matter of heat is brought into contact with us. It is therefore the means by which we feel those hygrometrical changes which have so much to do with our health, and the vicissitudes of temperature which, as morbific causes, are hardly less important. Increase in the density of the air has been supposed to produce serious epidemic affections. Persons who ascend high mountains generally suffer much from embarrassed re- spiration, and hemorrhages and pulmonary affections have been traced to changes in the mechanical action of the at- mosphere. * The atmosphere is composed of two great elements, called oxygen and nitrogen, with a small portion of carbonic acid. ETIOLOGY. 33 Unless the supply of air be unequal to the want, the quan- tity of oxygen in the atmosphere has never been found defi- cient; but where persons have resided or been confined in crowded and ill-ventilated rooms, the most serious conse- quences have often resulted. When the deficiency of air is not so great as to produce rapid and violent results, the health often languishes, the complexion fades, the strength fails, and diseases of various kinds make life wretched, and shorten its duration. In the gorges of mountains are often found de- crepid, deformed, and even idiotic people, who bear sad tes- timony to the evil effects of depraved air. Heat and cold are universally recognized as having much to do with the causation of disease. Caloric or the matter of heat pervades all bodies, and constantly tends to an equi- librium. The animal heat which is elaborated by some ob- scure process, but little understood, obeys the common law of caloric, and constantly passes off to bodies less warm, or re- ceives increase from those more heated. Our sensations of heat and cold are therefore nothing more than indications of the loss and supply of caloric to our surface. When it passes off in greater quantity than we can supply it with com- fort to ourselves, we complain of cold; when surrounding bodies draw less from us than we are in the habit of supply- ing, or communicate to us of their own excess beyond our wants, we feel heated. These variations in our state of ca- lorification are not limited in their effect to the production of certain sensations. They are capable of causing great dis- order in the performance of function, and creating morbid conditions of the most serious kind. Heat is an excitant; cold must therefore be a depressing agent. Heat induces increased action of the heart and ar- teries ; cold diminishes that action. But in considering the consequences of agents acting upon the human body, we must always remember that it is a 31 ETIOLOGY. living machine, and is not merely passive under modeling influences. A thorn penetrating the substance of an inani- mate machine, would produce no other consequence than the mere perforation; but should it pierce the human body, it would induce a succession of phenomena, depending upon the vitality of the parts injured. Heat, acting upon a bar of iron, will expand it; cold will contract it: acting upon the human body, heat will not only expand its tissues, it will excite the parts to increased action. Cold will not only contract the tissues, but lessen action. Further, heat, if long continued, will exhaust the vigor of the nervous and vascular system, and thus debilitate the whole frame; for' it causes the or- gans to work more rapidly than usual—consequently to con- sume more of the means of action, while it adds nothing to those means. It does not increase the amount of blood, nor enrich its quality, but it causes it to be more rapidly circu- lated and consumed; it provides no additional nervous energy, but causes greater expenditure of it. In the course of such unusual consumption and expenditure, the parts ap- pear more than commonly vigorous, but the result must be that the supply of means soon falls below the usual consump- tion, and languor, depression or exhaustion results. Heat,* in other words, is an excitant or stimulant, and all agents of this class will enfeeble as a secondary and ultimate effect. Cold, being the opposite of heat, is of course depressing, as being the withdrawal of an excitant. But there is in the living body a recuperative power, which exerts itself power- fully to overcome morbid influences. This power we call re- action, and its chief phenomenon is increase of vascular ac- *It will be perceived that we use this word in the popular sense, as con- veying the idea of a certain sensation. When we speak of heat as an exter- nal agent, we of course mean the presence of caloric in a quantity so unusual as to create the sensation of heat. Caloric itself is absolutely necessary to life, and does not exhaust vitality when present in its normal or natural quantity. ETIOLOGY. 35 tion up to and beyond the natural standard. When cold is suddenly applied to the body, the first effect is to lessen vas- cular action and nervous sensibility; but unless the applica- tion be very long continued, the circulation will soon resume its vigor, a glow of warmth will succeed to the chill, and per- haps the heart and arteries may work with a force and fre- quency incompatible with health. In order to explain certain pathological conditions, of very common occurrence in every part of the body, it is also im- portant to observe that when parts are suddenly chilled by the rapid abstraction of their natural heat, their nervous excitabi- lity, or the power of being impressed by agents, is increased* Every one has remarked the extreme sensibility of the fingers on a cold day, and dentists are well aware that delicate pa- tients cannot endure protracted and painful operations in the winter as patiently as in summer. To a man nearly frozen, it would be death often to bring him to a blazing fire. Frost bites are often strictly burns in- flicted at very low temperatures, upon parts unusually sus- ceptible through the abstraction of heat. If this be true of cold, the converse is true of heat Pro- tracted heat, as indeed the long action of all stimulants, wears out the excitability, and renders the body difficult to be im- pressed. Debility or weakness may be connected with both of these nervous conditions; hence weakness alone is not a characteristic of any disease; it is merely a circumstance of it. A man half-starved would be very weak, and might be too much excited by a single glass of fermented liquor; an- other, exhausted by long continued intemperate drinking, * This is true in the case of the sudden diminution of any of the essential means of life. If food be withdrawn for a considerable time, the accumula- ted excitability of the system will make it dangerous to give the starving man an ordinary meal. If blood be abstracted, the whole system becomes more easy to be acted upon by food, medicines, &c. 36 ETIOLOGY. might be equally debilitated, but could not be excited by im- mense quantities of distilled spirit. These remarks upon the effects of cold and heat will ena- ble us to understand the mode of production of many parti- cular affections through the agency of atmospheric chan _> es. Excessive moisture in the air is also a common cause of disease, but only because the watery vapor withdraws our heat much more rapidly than dry air, at the same tempera- ture, would do. Air is also the vehicle through which aerial poisons of various kinds are brought to act upon us. We have mentioned specific causes, as the unknown agents which produce peculiar and uniform disorders. Some of these causes can only produce their effects through the air when it is highly charged with the poison; others can act at great distances from their source, and apparently when much diluted by atmospheric mixture; and others have never been traced to any local origin, and while apparently poi- soning the air over immense spaces, produce no change in it which is appreciable to our nicest tests. Of the first class are the contagious, which may be propa- gated either by direct contact or by atmospheric infection within short distances: of the second are the causes of ende- mic diseases, and of the third are the inscrutable agents which produce those wide-spread disorders which we call epidemics.* The scope of our work does not include the causes of con- 'Endemic, trtmot\ Epidemic, mtnftot. By endemics we mean diseases largely prevalent in a certain vicinity, and often traceable to a local cause, and always dependent upon such. An epidemic has no positive connection with locality, and evidently does not spring from a local cause. The yellow fever is an example of an endemic; cholera of an epidemic. Local causes however, have much influence in giving efficiency to epidemic causes. Damp and foul air has been observed to give extraordinary activity to the cholera poison. But in such cases we cannot tell whether the result is due to in- crease of the active poison or decrease in the power to resist it. ETIOLOGY. 37 tagions and epidemics; but as certain endemic diseases fre- quently exhibit themselves in the mouth and face, and very much embarrass the dentist who may unfortunately be igno- rant of their cause, nature and treatment, it is necessary for us to notice particularly the atmospheric vitiation which causes them. It has been observed, from time immemorial, that the bor- ders of sluggish streams and stagnant pools, and the vicinity of marshy grounds are unwholesome, and that persons who dwell in such places, or even remain there during a short time of certain seasons, are subject to peculiar disorders, not ob- served elsewhere, and evidently not produced from ordinary influences. To the causes of these diseases, which, though unknown in their nature, must be immediately connected with the peculiarities of the locations in which only they act, several names have been given, such as marsh miasma, ma- laria, and marsh poison. To this agent must be attributed by very far the greatest part of endemic diseases, and those which are most destruc- tive of health and fatal to life. The yellow fever of the West Indies and America, the plague of the Mediterranean coasts, the coast fever of Africa, the jungle fever of India, the remit- tent or bilious, and the intermittent or ague of many places, and many other affections which it is unnecessary to men- tion, are the productions of the poisonous emanations from wet soils. We have not as yet been able to discover the nature of marsh poisons. The most careful analysis of air selected from the pestiferous fens has not developed any alteration in the proportion of the elements of the atmosphere, nor any foreign matter whatever. Yet we have sufficient evidence to justify us in believing that the poison does act through the atmosphere, and, the failure to detect, only proves the inadequacy of our means of analysis. 38 ETIOLOGY. Malaria is evolved during the day by the action of the sun upon wet ground containing dead vegetable matter. It as- cends with the watery vapor which is simultaneously disen- gaged, and commonly requires to be precipitated and con- centrated by the cold of evening before it exerts its ma- lign influence. Hence the popular dogma that summer dews are unwholesome; an opinion based upon the experience of the fact just stated. The danger, however, is not from the dew, but from the concentrated malaria simultaneously pre- sent. In non-malarious regions, dews do no other harm than mere moisture may occasion. They never induce agues nor bilious fevers, dew owing its evil reputation altogether to being often found in bad company—an inference which purity escapes, even more rarely than it does contamination. There are cogent reasons for supposing that the cause of the endemics in question is not one and the same for all of the distinct disorders belonging to the category of malarious diseases, but that each has its separate and peculiar poison, though all are the product of vegetable decomposition under the combined operation of heat and moisture. It would be incompatible with the design of the present work to discuss this and other interesting quastions connected with these wide-spread and destructive emanations. The subject, how- ever, is well worthy of the careful attention of every man, and especially of every student of medical science. Igno- rance of facts connected with this subject which mio-ht be learned in a few hours, annually causes the death of many, who unnecessarily expose themselves to the assaults of fatal pestilence. The only known prophylactics* against malaria are the intervention of thick woods between the source of the poison and the house, and the rarification of the evening air of the dwelling by fires. * IT/Kxpuiu^c,—prophylaxis, from nfoyvkxirac*—I guard against. ETIOLOGY. 39 It is not necessary to particularise the mechanical and chemical causes which may injure the human body gene- rally, nor would it be consistent with our purpose to examine in detail the effects of ailments, occupation, &c, in the occa- sional production of disease. These considerations belong to general hygiene, and if introduced here, would swell our work to an inconvenient size. We shall, therefore, only allude to those matters as we may have occasion in the prog- ress of our discussions. In organs endowed with a high degree of vitality, the laws of chemical affinity are ordinarily inoperative, being subor- dinate, to an inexplicable and all-controlling law of life. This, however, is only true within certain limits, for some chemical agents will always enter into combination with the animal tissues, whether living or dead, when brought into contact with them. The enamel, and even the bony structure of the teeth, are acted upon very readily by many acids, both vegetable and mineral, which combine with the earthy base, lime, and form new compounds with it, breaking up, of course, the integrity of the organ. The enamel is a crystalline mineral substance, and possesses no7vital organization; consequently it is quite as liable to be acted upon by chemical agents while in its normal place, as it would be when separated from the body. It is therefore easily perceived that this external defence of the tooth may be very readily 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. Unfortunately the word is used to express an affection of the bones entirely different from the peculiar disorganiza- tion called caries of the teeth. The former is a modified vital process, analogous to ulceration of the soft parts, the latter 40 ETIOLOGY. is a chemical erosion. Dr. Westcott has published* the results of some interesting experiments made by him for the purpose of testing the activity of certain chemical agents upon the teeth. The mode of these experiments was as fol- lows: A water bath was prepared, kept constantly at 98° by a spirit lamp, and regulated by a thermometer. In these were placed vials containing the substances to be tested. In each of these was placed a human tooth—care being taken to select those of as similar organization as possible, and whose enamel was perfect. A hundred articles, such as are most commonly used as food, condiments or medicine, were thus tested, and uncom- mon care was taken to watch the progress of the chemical action upon the teeth, subjected to such application. The results of these experiments are summed up by Dr. Westcott in the following propositions: 1st. Both vegetable and mineral acids act readily upon the bone and enamel of the teeth. 2d. Alkalies do not act upon the enamel of the teeth. The caustic potash will readily destroy the bone by uniting with its animal matter. 3d. Salts, whose acids have a stronger affinity for the lime of the tooth than for the base with which they are combined. are decomposed, the acids acting upon the teeth. 4th. Vegetable substances have no effect upon the teeth until after fermentation takes place, but all of them capable of acetic fermentation, act readily after this acid is formed. 5th. Animal substances, even while in a state of putre- faction, act very tardily, if at all, upon either bone or enamel. On examining the teeth subjected to such influence, the twentieth day after the experiment, no visible phenomena were presented, except a slight deposit upon the surface of a * Vide Amer. Journal of Dental Science, Sept. 1843. ETIOLOGY. 41 greenish slimy matter, somewhat resembling the green tartar often found upon teeth in the mouth. Acetic and citric acid so corroded the enamel in forty- eight hours, that much of it was easily removed with the finger nail. Acetic acid or common vinegar is not only in common use as a condiment, but is formed in the mouth whenever substances liable to fermentation are suffered to re- main about the teeth for any considerable length of time. Citric acid, or lemon juice, though less frequently brought into contact with the teeth, acts upon them yet more readily. Malic acid, or the acid of apples, in its concentrated state, also acts promptly upon the teeth. Muriatic, sulphuric, and nitric acid, though largely dilu- ted, soon decompose the teeth. These are in common use as tonics.* Sulphuric and nitric ethers have a similar deleterious ef- fect : these are used frequently as diffusible stimulants. The acids of some of the salts also corrode the teeth. Super tar- trate of potash, or cream of tartar, destroys the enamel very readily. This article is frequently used to form an acidulated beverage. (It is also the basis of certain popular dentifrices, which whiten the teeth by corroding their surfaces.) Rai- sins 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. In fact, the combination of the elements composing the enamel is one readily broken up by the application of the most common acids, and were it not for the natural alkali- , nity of the healthy saliva which neutralizes free acids in the mouth, the ravages of caries would be even greater than they are. As it is, the devastation is frightful, and yet its cause * Tonics are medicines which invigorate the system. 4 42 ETIOLOGY. is not fully ascertained. Some persons are naturally sub- ject to the disease, inheriting either peculiarity of dental structure or of salivary secretion, which defy all efforts to arrest the ravages of caries. Their teeth begin to corrode al- most as soon as they are protruded, while the teeth of others lie in apparently unfavorable saliva, and with little sanitary attention, and prove absolutely impregnable. The liability to caries, for some reason or other, is very general and very great, and the subject deserves much more thorough investi- gation than it has yet received. CHAPTER III. SYMPTOMS AND PROGRESS OF DISEASE. All changes of normal phenomena observed to attend dis- eases are called symptoms. Sometimes we know nothing more of the disease than that it causes certain appearances, and in fact we are commonly compelled to regard the symp- toms as the evils to be combated, and to rely mainly upon experience for the proper means of relief. The skill of the physician and surgeon is chiefly exercised in interpreting these signs correctly and pursuing their indications to the desirable result. Sometimes a case will present but a single symptom, as pain in a tooth; at other times, while one particular symp- tom indicates the seat and nature of the primary malady, a number of secondary and collateral signs will claim attention and clamor for relief, and again all the morbid appearances may be so general and vague as to afford no satisfaction as to the nature and seat of the disease. Local symptoms are those which present themselves in the very seat of the disease; sympathetic, such as are manifested in other organs than that primarily affected, and which are dependent upon the distant disease, being due to their rela- tions with it through the brain, spinal marrow, and sympa- thetic nerves. General symptoms are such as affect a large part of the body simultaneously. Generally speaking, the local symptoms are the most impor- tant, as they indicate the seat of the disease upon the extent and intensity of which the suffering of the sympathizing or- gans depends. It is always exceedingly important to detect these local symptoms, and deduce from them correct know- 44 SYMPTOMS OF DISEASE. ledge of the pathological condition they represent. But this is often a matter of great difficulty, as the greater intensity and obtrusiveness 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 disturbance in the organs to which they belong. And it of- ten happens that these sympathizing organs suddenly assume diseased conditions of the most alarming character. The judicious physician will watch 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 system, when disordered, give out everywhere signs of distress. PROGRESS OF DISEASE. A disease is said to be continuous when its prominent symp- toms are not interrupted by any law of the disorder, from the commencement to the end of it. We have an instance of this in continued fever. We use the term intermittent to distinguish a very impor- tant class of disorders, characterized by regular periodical disappearance and return of symptoms. Such are agues. Remittents are those diseases which present, as a character- istic symptom, a periodical abatement of intensity, very ma- nifest, 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 acute, neces- sarily implies violence or intensity. It is true that violent disorders are commonly of brief continuance, but it does not * X^ooc—time. PROGRESS OF DISEASE. 45 follow that all diseases of brief continuance must be severe. Neither is it true that chronic diseases are less serious than those which are more rapid, for the reverse is very frequently the case. The terms acute and chronic have reference to duration, 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 intermit- tents. 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 exemption, another attack is sustained, and so the disease progresses by alternate paroxysms and departures. Each paroxysm consists of a chill or cold stage, a fever or hot stage, and a sweating stage in which the fever disappears and the intermission commences. If there be a paroxysm in every twenty-four hours, the disease is called a quotidian ;* if it occur on alternate days, a tertian,f if there be two days of intermission, a quartan,:}: &c. Sometimes there will be two paroxysms a day, or a dou- ble quotidian; sometimes two paroxysms on alternate days, double tertian; or the double tertian may consist in the daily occurrence of a paroxysm, at hours coinciding on the alter- nate days. Many other modifications of periodicity occur in the disease, but the intermission is distinct in all. The quo- tidian and tertian are by far the most common forms of ague. * Quotidian—quotidies, daily. f Tertian—tertius, third. J Quartan—quartus, fourth. 46 PROGRESS OF DISEASE. It not unfrequently happens that the paroxysms occur regularly, but do not prevent the ordinary succession of chill, fever and sweat, but merely cause excessive pain in some sensitive part, usually occupying but little space. This pain obeys the law of intermission and periodicity as other forms of paroxysms do, and is known as intermittent neu- ralgia.* 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 tooth-ache from local causes; a mistake which has caused the infliction of much unnecessary pain and the loss of valuable teeth. Remittent diseases are characterized by a remarkable di- urnal abatement of their symptoms, not amounting to inter- mission, 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. Abatement, however, is common to all diseases, as none maintain absolute unifor- mity of symptoms throughout their course. Remission is, however, a very marked and unnatural abatement, and is periodical as to the time of its occurrence. It is not an ac- cident, but a phenomenon, of disease, not really an abate- ment, but only a defect of truthful manifestation. Certain diseases always present the same symptoms, and in the same order, and perseveringly run through them all unchecked by treatment, or the circumstances of age, sex, constitution, &c, which powerfully control other diseases. The small pox, measles, hooping-cough, &c, are examples of this class. They arise from specific causes, and are some- times called specific diseases, though this term includes other diseases of an entirely different character. * Neuralgia, from vtvpo(, neuros, a nerve, and aXyo(, algos. pain. CHAPTER IV. DIAGNOSIS. Diagnosis* The art of following symptoms to their pro- per pathological cause and ascertaining the character, loca- tion, 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 symptoms are promi- nent beyond others, we may sometimes ascertain at once the seat of the disease, but even in such cases we must not de- cide until we shall have ascertained whether these local symp- toms are primary or sympathetic; an inquiry which often requires much general knowledge of disease, and a capacity for close consecutive reasoning. When our attention is first called to a patient, we often encounter a great number of symptoms of different kinds, proceeding from various organs, and all calling for relief. In the midst of this general outcry, the attentive observer will generally detect one voice of distress more earnest than the rest, and directing his inquiry to the part thus desig- nated, he frequently comes at once upon the cause of the general trouble. The local signs are always the most im- portant, 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 sym- * A<« yivuenu. I know through, or thoroughly. 48 DIAGNOSIS. pathetic symptoms corroborate our suspicions; that is, whe- ther they can all be accounted for upon the supposition that we have found the local cause, and whether any are absent which are uniformly or commonly concurrent with similar condi- tions to those supposed to exist. Sometimes we arrive at a strong probability as to the place of primary disease by a process of exclusion. Taking up all the viscera, tissues, &c, that could possibly be implicated, we decide that one and an- other are sound, and finally are left to suppose that one of whose soundness there is no such certainty, is the organ in fault. In the process of investigation, we use all means of exami- nation that reason and experience may suggest. We ascer- tain whether the function of the part be well or ill performed, —whether its sensibility be increased or diminished,—whe- ther its appearance be changed,—whether organs known to sympathize with it are suffering. We inquire into the pro- bability of this or that organ being diseased from the habits of ancestry, and previous history of the patient. When the eye can be used, we examine the part carefully to note change of size or color or relation to adjoining parts. When it can be handled, we use the touch, to ascertain whether the part be altered in form or density or position. Great delicacy of touch may be acquired by long* and careful practice in this kind of investigation, and it should be assiduously cultivated by Dental, as it is by general surgeons. Deposits of matter can be detected by the finger of one examiner, which would entirely escape the notice or confuse the diagnosis of another; and this difference of diagnostic skill will show itself in many other cases of comparison. It sometimes happens that diagnosis will detect disease in two or more organs simultaneously, or complication. It would of course be impossible for any man to conduct a diagnosis properly upon any case of disease, unless he should DIAGNOSIS. 49 be acquainted with diseased conditions generally, and parti- cularly with the relations and sympathies of parts. The den- tal surgeon is not prepared to investigate symptoms occur- ring in the mouth, until he can detect those which are sym- pathetic, and trace them to their souroe. Were he guided only by a prominent local symptom, he might make serious mis- takes. For instance, a female may complain of violent pain in a tooth, which may in fact be entirely due to sympathetic connexion with the'^uterus, and not at all dependent upon any diseased condition of the tooth in which it occurs. The mode of distinguishing dental diseases and those of the parts adjacent to the teeth and mouth is fully set forth in works of dental surgery. We will, therefore, omit any par- ticular directions upon this subject; but we would earnestly urge upon every dentist to extend his knowledge until it shall embrace at least an elementary knowledge of the entire subject of diseases and their cure. Independently of the necessity of diagnosing the local affec- tions, it is always important to ascertain those conditions which are immediately represented by general symptoms: or more correctly, it is always important to ascertain how far the nervous centres and vascular system are participating in a disorder. A number of symptoms, very variable and dif- ficult to be described, announce general nervous sympathy and the degree in which it exists, but the connexion of the vascular system with a diseased state, is, for the most part, determined by the pulse* that is, by the beating of the arteries due to the propulsion of blood through them. The artery which is generally examined for this purpose, is the radial, which is of sufficient size, and passing near the surface at the wrist, is most conveniently situated for exami- nation. The frequency, quickness, force or resistance, volume, and * Pulsus.—Lat. 50 DIAGNOSIS. any peculiar sensations given by the pulsation, are all sub- jects for observation, and contribute to the discovery of the nature, seat, and degree of disease. Since the days of Galen, judicious and successful physicians have paid much attention to the pulse as a guide to correct diagnosis and practice,-and although it is too common in this day to hear this symptom decried as uncertain, yet the fact is, that to those who know how to interpret its communications, it furnishes the most valuable of all our means of diagnosis. In order to understand the morbid pulse, it is necessary to be well acquainted with its healthy conditions, for it is only by comparing its pulsations with the natural standard that we are able to detect morbid variations. The pulse differs in frequency at different periods of life. In infancy it is much more frequent than in mature life, and becomes 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 variation. Whylt mentions a case where a healthy woman had a pulse of one hundred and twenty; and instances have been known where the natural pulse has amounted to only thirty-six or forty. The pulse of females is usually somewhat more frequent than that of men, and owing to the nervous sensibility of the gentler sex, is more readily excited by mental emotions, &c. The healthy pulse is accelerated by exercise and mental excitement. It is more frequent in the evening than in the morning, after a full meal, or the use of exciting drinks, and in pregnancy. It is also often very much accelerated after copious evacuations and under circumstances of great pros- tration. It is diminished by the horizontal posture, by rest, * Some writers, as Bill ard and Valleix assert that the pulse of young infants is not near so frequent as is generally supposed. See Chomel, General Pathology, p. 171. DIAGNOSIS. 51 by moderate bleeding, and by the influence of certain drugs, such as digitalis and the tartrate of antimony. Indeed, the frequency of the pulse is subject in so great a degree to the control of idiosyncrasy* and accident, that no positive inferences can be drawn from this solitary symptom, unless the habitual pulse of the patient be known. Chomel says, "I have seen a lady whose pulse during the paroxysms of intermittent fever did not beat above sixty per minute,, ta the great astonishment of her physician. This astonishment would have ceased had he counted the number of pulsations during the intermission, these being not above forty per mi- nute." Quickness and frequency are not synonymous terms. Frequency has reference to the number of pulsations in a given time, as a minute; quickness to the time required for the completion of a single pulsation. Shwness is opposed to frequency, not to quickness. Thus we may have a slow quick pulse; that is, one in which the beats in a minute are fewer than natural, but each particular beat is rapidly performed. For an opposite to quick, physicians frequently use sluggish or laboring. The natural pulse is soft or compressible; that is, it readily yields to gentle pressure with the finger. The hard pulse is the reverse, offering considerable resistance to the obliteration. of its channel by pressure. Tense, wiry, firm, &c, are used to express modifications of hardness. Differences are also observed in the volume or size of the pulse. Sometimes it is/uU and open, at other times, small and contracted. It is called regular when the beats succeed one another in natural order; irregular or interrupted, when the regular succession is broken by omissions of pulsation. Certain conditions, too, are attended with peculiarities of the pulse. In aneurism of the heart, or large arteries, it im- parts a peculiar thrilling sensation to the hand, which has more aptly than is usual in such illustrations, been compared to * Idiosyncrasy—«<5w ovyxpairti—peculiar constitution. 52 DIAGNOSIS. the sensation which would be imparted by the passage of a fluid through a shattered quill. Ossification of the, coats of the arteries destroys their elasticity, and of course renders the pulse very hard. The hard pulse is usually attended by a peculiar condition of the blood, which when drawn and co- agulated, presents a yellowish, lymphy surface, which is called the buffy coat; with but few exceptions, a very important sign of inflammatory action* The following precepts for feeling the pulse, though very minute, are nevertheless wor- thy the attention of those who are inexperienced in it. Long habit imparts to the fingers an extraordinary accuracy of sen- sation in this respect; but until it shall be acquired, it is not easy to form correct conclusions without all the care demand- ed 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 horizontal posture. The pulse may be examined at the tem- ples, lateral parts of the neck, arm, thigh, wrist, and wher- ever 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-carpal articulation. If the patient be up, he should be placed in the sitting posture, if in bed, he should be upon his back, so that he may neither incline to the right nor left, and thus impede the circulation of blood in the arteries. The arm should be placed nearly in a state of extension, and sustained in its whole length, so that the muscles may be re- laxed. The forearm should be nearly prone, that it may, upon the cubital edge and the radial edge, be a little raised. Care should be taken that no bandage or clothing impede the flow of blood in the axilla, at the elbow or any other point. All bandages should be removed so that there be the least possi- * The buffy coat is also seen upon the blood drawn from pregnant females. DIAGNOSIS. 53 ble compression. By means of these various precautions, we may be certain that there is no foreign obstacle to the flow of blood through this vessel. The artery of the left side should be felt by the right hand, and vice versa; the four fingers placed parallel on the same line, should be applied over the track of this vessel; the in- dex 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 fore- arm, thus affording solid support to the fingers by which the pulse is examined. The latter should at first receive a slight lateral movement in order to ascertain the situation of the ves- sel. When the fingers are all placed upon the artery, the pressure should be gradually increased and diminished seve- ral times in succession, so as to appreciate the influence of the pressure upon it, and thus more easily ascertain its different qualities. Twenty or thirty successive pulsations should in this manner be examined. It is not without advantage to ex- amine 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 ap- pear, they cannot be neglected without inconvenience.—Cho- mel, Elem. General Path. The inferences of pathological conditions to be drawn from the several above mentioned differences of the pulse, will be explained, as far as the purpose of this treatise requires, when we come to treat of particular diseases. Pain is one of the most common and important symptoms of disease. It is this which usually gives the first intimation of disorder, and drives the patient tcrmedicine for relief. It 54 DIAGNOSIS. 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 sympathize with a local disease seated in a distant and dissimilar organ. It also 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 attacked. 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 de- gree of the disease which causes it. Some parts are much more sensitive than others, the most important organs being least sensitive. The quality of sensation does not necessarily belong to living bodies, but is distributed to the several parts, arbitrarily, yet with wonderful wisdom and mercy. Pain is intended to warn us of danger and compel us to preserve the integrity of the body; it is therefore set as a sentinel chiefly upon the outposts of life: the external surfaces being much more sensitive than others; those most carefully protected being least profusely endowed with this watchful property. Hence it happens that the brain, heart, and lungs may be very seriously diseased without causing much, or indeed any local pain, while an unimportant injury to the eye or skin will create great distress. The nature of the disease may often be guessed from the character of the pain, as it is burning, scalding, fixed, fugi- tive, darting, throbbing, &c. As pain does not point out with certainty the seat of the'disease, and as its intensity does not DIAGNOSIS. 55 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 sufferings, by morbid conditions of the nervous centres, or the nerves themselves; or by absolute loss of vitality. It sometimes happens that the sudden ces- sation of violent pain is a most fatal symptom, as showing that mortification has occurred in the diseased part. Pain is often intermittent, and disappears only in obedience to a law of disease, not of health. The importance of the symptom depends not upon the question of absolute suffering, but upon the cause of it. A temporary whitlow often occasions much more severe suffer- ing than a fatal disease. Spasmodic pain, occasioned by vio- lent irregular muscular contraction, is, as a general thing, not nearly so serious as the continued and increasing pain of in- flammation. Neuralgic pain, the most severe, is the least alarming of all. The severity is due to the seat, not the de- gree of disease. It requires experience and judgment to dis- tinguish the pain of spasm from that of inflammation. Com- monly the pain and the sensitiveness to pressure enable us to determine the question. In inflammation, the vascular system is more inclined, and the part is sensitive, often ex- quisitely so, to pressure. Spasm is less likely to be attended with high arterial action, and the seat of it is often gratified rather than distressed by pressure. These distinctions, how- ever, are not always to be relied on. It is often very diffi- cult to distinguish spasm of the womb from inflammation of the organ and its appendages.; and even colic is sometimes attended with inflammatory symptoms—more or less compli- cation of spasm and inflammation existing. CHAPTER V. GENERAL REMARKS ON THE TREATMENT OF DISEASE. The first step towards the cure of disease is to remove the cause which has produced it. Unless this can be done, we must be very much embarrassed in our efforts to relieve, inasmuch as the morbid conditions are continually liable to renewal. The impracticability of doing this effectually, forms the most serious obstacle to the successful treatment of many disorders. Children teething during very hot weather are subject to the action of combined causes, which often induce diseases which are very serious and very difficult to be controlled, while the causes continue to act. Dead teeth remaining in the mouth may provoke a series of unpleasant and even danger- ous evils, which cannot be removed while the cause of them remains. It must not be supposed, however, that the removal of the primary cause of the disease will necessarily procure the sub- sidence of the disease itself. If a man pierce his flesh with a thorn, the wound will remain and may give great pain after the foreign body has been extracted; the effects of a wound from a bayonet or musket ball may manifest themselves in serious and fatal disease long after the instruments of the in- jury have been withdrawn. The same truth holds good in all kinds of injuries by whatever class of agents they may be produced. The absolute rest of a diseased part, when the nature of its function permits, and the least possible exertion of others, is very conducive to cure. TREATMENT OF DISEASE. 57 There are, however, certain exceptions to this rule. Certain mordid conditions of the articulations are improved by exer- cise; a particular mode of ocular affection requires the light, &c.;—but the exceptions are few and the rule general. The regimen of the patient, that is his diet, clothing, exer- cise, employment, &c, require judicious- management. Finally, the most important part of treatment consists in the skilful application of .therapeutical agents, and surgical means; but of this part of the subject we will treat particu- larly when considering special diseases. The natural idea of remedies is, that to each disease there is an antidote or direct curative, and that good practice con- sists in so distinguishing the one as to be able to prescribe the other. Nothing can be more untrue. We have few me- dicines that even seem to antagonize disease directly, and those, no doubt, act mediately, as other medicaments do. These few medicines we call specifics. They are drugs, the administration of which is often followed by the disappear- ance of certain well-marked disorders, the nature of which is very obscure. The practice of prescribing medicines which act mysteriously to cure disease is called empirical. It may be, nevertheless, good and scientific practice. But it is only in a few instances that empirical practice is justified by long and sure experience. Any system of medicine that is based upon the principle of antidotes or antagonism,-is radically wrong, and must be practically destructive of health and life. The human body is not a machine, consisting of isolated parts related to each other only by position, and capable of being separately altered, repaired, or renovated. Nor is disease an abstract thing, to be dealt with directly and overcome by force applied to its own hurtful quality. The human body is an exceedingly complicated organism, whose aggregate ef- forts constitute one life. The nature of the organs and of. 5« 58 TREATMENT OF DISEASE. their life is incomprehensible. Disease is, when appreciable to us, only a modification in the structure or function of an inscrutable organ, attended by more or less embarrassment in the work of other organs and inconvenience to the whole life. By certain means we have the power to exalt, depress, and modify the vital activity of parts, and our reason and ob- servation teach us that in the use of these means we may aid very materially in the effort at restoration which nature con- tinues to make until life is extinguished. The treatment of disease consists in thus aiding nature, and requires the exer- cise of the most general knowledge, the closest observation, the purest reason and the quickest intelligence. There is no employment in which the practitioner should rely more on himself and less on his means. Medicine is the most purely intellectual of the professions. The knowledge of the powers of medicines is a remembrance of facts acquired in the long experience of mankind, especially of men, professionally as well as naturally qualified, to make observations on the phe- nomena of the life of the human body, as they have been de- veloped under the presence of substances not ordinarily used upon it. The use of these medicines requires much more than a recollection of the circumstances under which they have been used before, and the apparent results of their use. It requires a capacity, derived from various sources, to de- termine whether medicines ordinarily followed by given re- sults- are likely to be useful in a present case, differing more or less from all others. No two diseased conditions are found to be exactly alike. Though nature admits of boundless re- semblances, she positively forbids identity. % 59 CATALOGUE OF DISEASE. Many of the morbid alterations which seem to constitute disease, or to cause symptoms, have been observed upon the living and the dead subject: many others have as yet escaped detection. We are unable, therefore, to compose a full list of these different conditions of parts, but those which are of common occurrence, and are well ascertained, may be de- scribed as follows: 1. 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 the body; it is called inflammation* The local symptoms of this con- dition are heat, redness, swelling, pain, and diminished, al- tered or suspended function. The general symptoms are py- rexia, or fever, of a particular type, seemingly connected with altered state of the blood. 2. Stuffing or engorgement of the veins, or congestion. The symptoms are not so well defined as in the first kind of affection. The local suffering is generally much less, though when certain organs, such as the brain and heart, are the seat of congestion, the pain and discomfort are often very consi- derable. The function of the congested organ is greatly em- barrassed, or altogether suspended. The general symptoms are commonly such as mark diminished action. 3. Red indurations; vegetations; fungi, polypi. 4. Vesicles, pustules, suppuration, erosion, ulceration, per- foration, gangrene. * ring, fi^—from the burning sensation and heated appearance of patients in fever. (5)* 60 CATALOGUE OF DISEASE. 5. Thickening, granulations, thickness of tissues naturally transparent, adhesions, effusions of serum, false membranes. 6. Conversion of one tissue into another. 7. Gray induration, gelatinous degeneration, tubercles, en- cephaloid matter, cancerous matter. 8. Contraction, dilatation and complete obliteration of na- tural canals. 9. Accidental canals, fistulas, accidental tissues, cysts. 10. Development of gas in cavities. 11. Living bodies in organs. 12. Effusions of blood, collections of blood. 14. Chalky, stony, hairy, horny, and melanotic* produc- tions. 15. Changes of form and relation, wounds, ulcers, disten- tion, lacerations, ruptures, fractures and dislocations. 16. Foreign bodies. 17. Vices of formation.f The fluids of the body, especially the blood, are doubtless capable of undergoing change primarily, and communicating distress and disease to other parts. But the pathology of the fluids is but very little understood. The same may be said of the nervous matter, of the nature of which we know nothing. The above catalogue is therefore very defective, as it takes no notice of some of the most common and most important of all diseases, such as fever; and describes as diseases, con- ditions which are only incidental to other, previous, and more important phenomena. Nevertheless, it is as accurate, or nearly so, as the present state of medical science will permit. It is my purpose to select from this list such pathological conditions as are particularly connected with the pursuits of the dentist, omitting none, which, even in a remote degree, concern him, and passing by those in which he has no pro- fessional interest. * M^oc—black. f Roche & Sanson, Path. Med. Chir. CHAPTER VI. INFLAMMATION AND ITS CONSEQUENCES. The most common, and by far the most important of all morbid conditions, is one, the prominent characteristics of which are pain, redness, swelling and heat. This is called Inflammation, and may occur in any part, naturally possess- ing sensibility. It is an unusual, though, we cannot say always perverted, condition of the vessels and blood of the parts concerned; at- tended with, alteration or suspension of its natural function often accompanied with entirely new vital acts, through which tissues are destroyed and reconstructed, vessels perforated or permanently closed, and devastation or renovation of the so- lids procured. It is the great destroyer and preserver of the body, or rather it accompanies the extraordinary vital con- ditions through which organization is broken up or preserved, and often seems as inseparable from the one as the other- Hence it has been called "Nature's Surgeon," though but for it, surgeons and physicians would have little to do. Cer- tainly a degree of inflammation is often inseparable from re- cuperative processes, and though we may imagine the process to be present, without the attendant inconvenience, we are obliged to submit to the union, and invite inflammation to do what neither knife nor ligature can accomplish. From this fact, considerable confusion has arisen among medical philoso- phers as to the terms which should be used in speaking of inflammation; but practically, there is little perplexity about 62 INFLAMMATION AND ITS CONSEQUENCES. the matter. The student of disease soon learns to distinguish the inflammatory condition that is likely to end well or ilL and to know whether he should interfere to abate or exalt the process. In surgery, inflammation is often not only tole- rable but desirable—in Medicine, it is almost always a thing to be dreaded, prevented, and abated—but even in Medicine there are a few occasions when the physician watches for the active inflammatory process, as the mariner on a dangerous coast watches for the light of day. Inflammation is, in fact, a very comprehensive term, applied to a great variety of conditions in which local vascular activity and deranged cir- culation are prominent features. The influx of healthful blood freighted with reconstructive fibrine—that comes to repair a sudden breach of continuity, and with little distur- bance of surrounding sensibilities, deposits its precious lymph between the gaping lips of the wound—is attendant with red turgescence and is called inflammation. The more copious flow that distends unruptured vessels and forces through their coats a serous exudation, is called inflammation. Should lymph be thrown out, and a mixed tumor be formed, and a new product be created amidst burning and throbbing and gene- ral distress, we call the process inflammation. And should local ruin ensue, and the blood dissolve and tissues break up and chemical laws assert their dominion, we say that inflam- mation has done it all. Nevertheless there is no essential difference between what has been called "healthy and unhealthy inflammation." There are circumstances under which the most unexceptionable character and quality of inflammation proves fatal—and any quality of it may rapidly change and become unhealthy by a modification of the action of the diseased condition,—not reaching to a change in the essential nature of the disease— " Healthy inflammation " is nothing more than such an inflamed condition as, under the circumstances, is likely to end well INFLAMMATION AND ITS CONSEQUENCES. 63 —"its healthfulness" is not in itself, but in its circumstances. An abscess on the surface, and containing perfect pus, an- nouncing certain cure, would be a very "healthful" affair, but a similar one in the liver would be a very "unhealthful" tumor; or the same superficial abscess, without ceasing to be inflammatory, might suddenly throw out a very unhealthy pus, or cease to provide any, and put on appearances indica- tive of destruction. Certain appearances give reason to believe that the inflam- mation is proceeding towards cure. While these exist, we call the inflammation " healthful." The process of inflammation, supposing a case to go regu- larly through what may be presumed to be its natural stages, is as follows: The exciting cause being applied, (whether it be immedi- ately exciting or depressing, is of no consequence, inasmuch as high action may ensue upon either provocation) blood is sent through the part with augmented velocity. The cause of this is no doubt due to modification of the nervous sensi- bility of the part, but the manner in which this acts is in- scrutable. The capillaries and minute arteries are distended. This may arise from the fact of their being naturally diluted under a certain degree of irritation, as is evident from the reddening of the skin by friction and the phenomenon of blushing; or from their mechanical distention under increased pressure. Capillaries which previously contained but single files of the red corpuscles, now admit of them rolling through in masses; and these come crowding in. Vessels naturally invisible, are visible now, shooting over clear white spaces like lines of fire. A burning pain, modified by the sensibi- lity of the part concerned, accompanies this stage of inflam- mation, and the function of the organ is seriously impaired in proportion to the extent of it involved. The eye, for in- stance, is rendered useless from a moderate degree of super- 64 INFLAMMATION AND ITS CONSEQUENCES. ficial inflammation. As dilatation increases, the blood is checked in its progress through the distended vessels; more sluggish turgescence ensues, and the thinner part of the blood transudes, and the parts adjacent become more or less dis- tended with extravasated serum, or with the "liquor san- guinis." This condition may amount to little more than healthful excitement; the vessels being a little too full, and tending to throw off some of their fluid contents; or it may amount to serious obstruction in the circulation. The condition may remain for a brief period and then sub- side, or may advance to a more vigorous stage of inflamma- tion; or it may become persistent or chronic, the sensibility becoming accustomed to the new condition, the pain disap- pearing and slow modifications of function or constituent or- ganization resulting. Inflammation increasing, there is ex- tension of the excitement to the arterial trunks that supply the part. More blood and of altered character is sent to the inflamed spot. The capillaries no longer maintain their vi- tal elasticity; they enlarge like mere material tubes under the severe pressure. The circulation moves heavily through the part; "the red corpuscles are no longer limited to the cen- tral current, but encroach more and more on the lateral and clear " lymph spaces." Exudation is more copious than in the previous stage, and of a different kind. It consists chiefly of " liquor sanguinis," and this is altered from the healthy standard. The fibrin is increased, not only in quantity, but also in plasticity, or tendency to become organized."* Some of the small vessels very commonly give way and permit the altered blood to flow out. The fibrine is diffused among the tissues. Even that which is regularly supplied becomes excessive from the arrest of formative power in the * Miller's Surgery. INFLAMMATION AND ITS CONSEQUENCES. 65 disordered part, and tends to form new structures to be changed into an excretive substance—a fact that plays an im- portant part in the immediate and remote consequences of inflammation. The state of things is thus summed up by the author already quoted:— "The over-distention of the capillaries is established; the capillary power is, for a time, gone; perhaps in consequence of-diminution or actual suspension of their nervous influence, and the coats of the capillaries and other vessels are spongy, softened, and impaired in cohesion, being themselves the sub- jects of structural change. The languor of circulation ap- proaches stagnation, and at some points this has actually oc- curred; every part of the distended capillaries is occupied by crowded colored and colorless corpuscles . . . Altered liquor sanguinis is exuded in profusion. The attenuated and soft- ened capillaries also give way in their coats, and from the lesion blood is extravasated in mass. Suppuration is in pro- gress by extra-vascular degeneration of the fibrinous exuda- tion, or as some suppose, by a secretive elaboration of it ere yet it has left the vessel. The parenchyma, infiltrated by li- quor sanguinis, pus, and blood, softens and is broken up, and the disintegrated texture becomes mixed with the escaped contents of the vessels. The formative power has ceased, and the opposite condition, a tendency to disintegration from di- minution of vitality, has become established. Disorder of function is complete. Secretion for example, being in the first place arrested, and, when restored, more vitiated than before. In the circulation of the part truly inflamed all is sluggishness and stagnation, but that of the parts around is unusually active. The arterial trunks in the vicinity con- tinue to play with increased energy; blood continues to be sent, but cannot now be transmitted in its direct course. In the inflamed parts it meets an obstruction, and being sent round another way, it throws a stress on the collateral ves- 66 INFLAMMATION AND ITS CONSEQUENCES. sels; these, however, retain vigour sufficient for the aug- mented labor and pass the current briskly round." " While the apparatus of deposit is thus unusually busy, that of absorption is in abeyance. During inflammation, the lymphatic and minute veins do little or nothing as absor- bents." The regular sensible progress of inflammation may then be said to be from a condition of morbid excitation, attended with simple serous effusion through a higher grade of disor- der, attended with exudation of plastic, fibrine and liquor san- guinis; altered condition of the blood; feeble capillary ac- tion; and more complete arrest of function, to the ultimate stage of inflammation, a condition in which there is extrava- sation of blood, destruction of texture and formation of pus, of more or less perfect quality. Mr. Miller shows very clearly that something like this is a natural gradation of inflammation, by pointing to familiar examples, where we constantly observe the several conditions in the natural relation to others of comparative distance from a common centre. In a common abscess we find the cen- tral portion broken up, and the seat of suppuration soft and fluctuating. Beyond this is a less prominent and h-arder portion marking where the inflammation has been of less active grade, and only caused fibrous effusion; and exte- rior to this a soft oedematous circle where serous effusion has relieved the smaller vessels. When the suppurative or destructive condition has been reached, inflammation may be said to be at an end, and we have to deal with its consequences. But one of these consequences is inflammation of tissues adjoining those thus greatly impaired, and so—as we rarely lose sight of inflammation in the treatment of the case—we are in the habit of regarding the results above described as terminations or natural conclusions of, or incidents to inflam- mation. It matters little, however, what we call them INFLAMMATION AND ITS CONSEQUENCES. 67 Pain is a very characteristic symptom of inflammation. It commonly begins with the formation of the disordered con- dition, increases with its augmentation and declines with its abatement. It is therefore a very valuable index to the com- parative condition of the part, and where we cannot see the color, nor note the swelling, nor perceive the heat, we have to rely a great deal upon the single local symptom observable by us. The subject, therefore, is worthy of particular atten- tion. The cause of the pain in an inflamed part is not very ob- vious. The mechanical pressure of distended parts and strongly pulsating arteries upon irritated nerves, has more or less to do with the suffering. This is evident from the fact that increased pressure intolerably aggravates the pain. The slightest touch sometimes gives agony. In inflammation of the peritoneum, the patient will not bear the pressure of bed-clothes. Indeed,^this sensitiveness of an inflamed part to pressure is so characteristic, that it enables us to distinguish spasm and neuralgia from inflammation. Yet it is plain that pressure is not the only cause of pain. The sensibility of the nerves is exquisitely exalted. As we have already said, a touch will sometimes cause a severe pang. The pain ap- pears before the distention, and where distention exists to the most fearful extent there is often no pain at all. Patients die of deep congestions without any acute sensations in the distended parts, and dropsies that press the viscera and distend muscles and skin to a frightful extent, create no 4 such pain as would be felt in a moderate inflammation of the coats of one of the organs subjected to pressure. The pain of inflammation is, as we have said, continuous with it, and is indicative of its degree. It is also characteristic as regards the tissue or organ in which it is seated; a valuable fact in diagnosis. Sudden disappearance of acute inflammatory pain indicates 68 INFLAMMATION AND ITS CONSEQUENCES. the occurrence of a change in the condition of the part, but commonly a very unfavorable one. Inflammation does not suddenly get well—but free effusions may cause abatement of pain—so may the formation of pus—and the occurrence of mortification may relieve it altogether. Patients and their friends are often misled by the natural association of pain with disease, ease with cure. The degree of pain is affected by the natural sensibility of the organ in which it is seated. The skin being exquisitely sensitive, as the sentinel on the outpost of life must be, suffers much more when inflamed than muscle or cellular tissue. The parenchyma of or- gans is much less sensitive than the membrane that invests them. The hard unyielding character of the bones makes the process of inflammation in them very painful, until free discharge of inflammatory products is obtained. The inflamed mucous membrane gives out the burning sensation of the skin, but in a degree proportionate to the distance from the exter- nal tegument. The serous membranes are affected with a sharp, darting, lancitive pain. That of the cellular membrane differs very much according to its positions and relations. When in connexion with the skin, it partakes of the pun- gency which characterizes the inflammation of that sensi- tive organ; when the cellular structure of the internal vis- cera is inflamed, the pain is usually dull or obtuse, in conse- quence of the manner in which these viscera are supplied with nerves. When nerves are the seat of inflammation, very acute, darting pangs are felt, and the surrounding structures are ge- nerally very sore, tender, and more or less inflamed. In in- flammation of the muscles, the sensation is aching, mingled with a feeling of fatigue. The pain is greatly aggravated by motion. Inflammation of ligaments occasions sensations not very different. Pain is more or less severe in proportion to the degree of INFLAMMATION AND ITS CONSEQUENCES. 69 the inflammation, the natural sensibility of organs, the yield- ing or unyielding character of parts affected, and the nature of the disease accompanying the inflammation. Certain spe- cific affections, such as cancer, occasion a peculiarly distress- ing, darting, and burning pain. Slight inflammation of the pulp of a tooth occasions intolerable agony. It is very important to study the natural expression of suffering peculiar to each organ, and indicative of the several forms of disease. Pain is not only characteristic, but it has its own symptoms in the correspondence of position, move- ment, and particularly of the countenance. These are often much more reliable than the words of the patient. The higher the grade and the more rapid the pace of in- flammation, the sharper will be the pain. The danger is not always proportionate, for the disease may benumb or depress the sensibility, and in such case the anxiety as to the result will be in inverse ratio to the pain. Spasm, or violent morbid contraction of a muscular part is attended with great pain. But it appears in full severity at first, relaxes and returns, and is not increased, often some- what relieved by pressure. For instance, a man in spasmo- dic colic presses upon his abdomen; in inflammation of the bowels he lies upon his back and draws up his knees to re- lieve pressure to the utmost. In neuralgia the nerve is the seat of violent irregular sen- sations of an exquisitely painful kind; but it remits, disap- pears and returns,—is attended with little vascular excite- ment, and is easily distinguished from the persistent ad- vancing pain of inflammation. Pain is not always reliable as indicating the true place of disorder. The ramifications of the nerves and the mysteri- ous laws of sensation that affect them not uncommonly cause the pain to be felt at a distance from the seat of injury. It frequently occurs that a painful tooth is sound, but is lend- 70 INFLAMMATION AND ITS CONSEQUENCES. ing its nerve to a diseased neighbor. The whole arch of the jaw may be thrown into violent suffering by a single dis- ordered member. The shoulder may ache for the liver, and the knee for the hip, and the head for the stomach. Variety in the pain of inflammation indicates the change of stage in the process of the disease. In the early stage, before organic changes have taken place, the pain is burning or stinging. When suppuration is taking place, it becomes deeper and throbbing. This sensation seems to depend on the great obstruction existing, and the energy of the excited arteries in their attempts to overcome it. It is regarded as a symptom of a suppurative condition, or one that will terminate in sup- puration. The swelling of inflammation depends upon the distention of the vessels, and the accumulation of extravasated fluids. It is greatest when the tissues are least resistant, and by no means measures the amount of disease or danger. Where there is least swelling, as where the inflammation is confined by tight dense structures, the pain is excessive, and destruction of parts certain, unless artificial relief be given. Extravasation relieves the distended vessels, both mechani- cally and by taking off their highly stimulating contents. Redness. The redness of an inflamed part is caused by the greater amount of blood in the part. The vessels are dis- tended with redder fluid owing to the transudation of the se- rous elements. Capillaries ordinarily invisible are made red by an unwonted circulation, and extravasated blood adds its deep, sometimes livid, hue to the picture. The degree of redness varies with the ordinary vascula- rity and transparency of the part and the intensity of the in- flamjuation. Inflamed skin is less red than mucous membrane, and tendons less red than either. The tint indicates the cha- racter of the inflammation. When the disease is of a high character, the parts being in condition to make vigorous re- sistance to change, the color is bright—in reverse conditions INFLAMMATION AND ITS CONSEQUENCES. 71 we find it darker, even to purple; "great attendant biliary derangement gives a yellowish red." The color of inflamma- tion is fixed with great tenacity. It cannot be made to dis- appear before the inflammation subsides. Even fainting does not remove this color. It is, therefore, an important signal to the observer. Seat. A sensation of heat, sometimes very distressing, is one of the most common incidents to inflammation. It is partly a sensation and partly a fact. The thermometer shows an actual elevation of temperature, but the distress is out of proportion to the cause. The increase of caloric is no doubt due to the contact of an unusual amount of blood with the capillaries, one of whose functions is to separate oaloric from the blood. The disordered and hyper-sensitive condition of the nerves accounts for the exaggerated sensations of the pa- tient. Disorder of functional sensibilities attends inflammation. The eye, even when slightly inflamed, cannot bear the light necessary to vision. The brain cannot endure the stimuli to its ordinary activity. The bladder will not retain its com- mon quantity of fluid. Inflamed, nature seeks rest and re- fuses activity. Hence functional activity is impaired or com- pletely suspended. The secretion of secreting organs is checked, suspended, and then altered. Sometimes it is thicker, more tenacious; at others, thinner and acrid, reddening, or even excoriating the parts over which it flows. An abundant discharge of thickened secretion often precedes and seems to cause the re- lief of inflamed parts. Inflammation is capable of propagation. It always extends more or less from the point of commencement, but in bodies possessing ordinary power of resistance it is speedily limited, unless the cause of it continue to act. Inflammation spreads more readily in continuous tissues—as the skin, or mucous 72 INFLAMMATION AND ITS CONSEQUENCES. or serous membrane—along which, under favorable circum- stances, it progresses very rapidly. When the powers of life are feeble, this spreading is more likely to take place. In some cases, there seems to be no power remaining to produce the changes necessary to prevent the continuous course of inflam- mation, and then a very trifling commencement may rapidly induce the most serious result. Inflammation sometimes spreads by the absorption of poi- sonous products from one part and conveying them to an- other. CONSEQUENCES OF INFLAMMATION. Inflammation never continues long without the superven- tion of certain results, often of greatly more importance than the primary phenomena we have described. Premising that when it passes away through mere subsi- dence of the heat, redness, swelling, and pain, without the formation of new products or destruction of tissue, the pro- cess is called Resolution, we may enumerate the consequences of inflammation as follows. Chemosis, (Edema, Suppuration, Vesication, Ulceration, Ef- fusion of fibrine, caries, and gangrene or mortification. Chemosis is the extravasation of blood. This is a mecha- nical result brought about both by the distention and pres- sure, and a change of quality in the blood itself. When thus effused it does not coagulate, and it remains in the tis- sues until it is absorbed, which often requires a slow process. (Edema is the extravasation of the serum, or watery parts of the blood. It is apt to attend debilitated condition, and seems to mark a lax condition of the coats of the vessels by which it is exuded. It is generally found in loose cellular structures, where the looseness of tissue affords little support to the walls of the vessels. It often attends a very low de- gree of inflammation, in debilitated subjects, and is unfavor- INFLAMMATION AND ITS CONSEQUENCES. 73 able to recovery; rather as a sign of debility than from any evil which it is likely to cause. (Edema may exist without inflammation, as when the veins fail to return their blood in due proportion to the rapidity of their supply, either because of mechanical pressure, disease of the heart, or any other cause. (Edema also attends certain specific conditions, as scarlet fe- ver, and may be produced by medicinal agents, as arsenic. When oedema is general, it is called "anasarca."* It is readily detected by the bloated translucent aspect of the skin, and by its loss of elasticity observed by its pitting un- der pressure. Vesication, or blistering, is the effusion of serum under the cuticle and rete mucosum, elevating them above the le- vel of the surrounding surface, and separating them from the cutis vera. This may occur as the result of topical ap- plications of an irritating kind, or in consequence of local and constitutional disorders. This condition is frequently pro- duced as part of medicinal treatment, and gives the name of vesicatories to a class of means employed for this purpose. Suppuration, or the formation of a peculiar fluid substance called pus, is one of the most common and important of the consequences of inflammation. Pus, when pure, is thick, cream-like, yellowish, of a faint and peculiar odor, and somewhat sweetish of taste. It is not at all irritating. To this kind of pus, the terms laudable and healthy have been applied. That which is thin, dark, and irritating, being considered unhealthy, because of the indica- tion it affords of the bad condition of sores, &c, which secrete it. Although it is true that such pus as is called "healthy," indicates a convalescent state of an ulcer or abscess, yet the inference to be drawn from its appearance attaches exclusively * Ara rttql—throughout the flesh. 6 74 INFLAMMATION AND ITS CONSEQUENCES. to the parts which screte it: while it may herald the abate- ment of local inflammation, it may, nevertheless, give clear evidence of a state of disease incompatible with the integrity of organs, or with life itself. Suppuration of the eye, of the liver, or of the lungs, would be a very serious matter, how- ever " healthy " the pus might be. Some writers have considered suppuration a curative pro- cess, and have regarded the pus as a very valuable covering for the granulations. Although it is true that suppuration often intervenes be- tween inflammation and cure, and that the painful symptoms of inflammation abate or disappear after the copious secretion of pus, yet we must regard the formation of this matter, how- ever pure, as a great evil, though certainly preferable to others which occasionally affect inflamed parts, and it is one of the greatest cares of the surgeon and physician to prevent it. Pus may form in several situations. First. It may be found free upon the inflamed surfaces of parts, as the skin, the eye, and the mucous membranes, without any other apparent change of organization than an increase of the natural vascu- larity. Secondly. On the naturally unexposed surfaces of the body after they have acquired a new organization by in- crease of red vessels, and usually, if not always, by the addi- tion of coagulable lymph,; for it may be questioned whether in any instance the surfaces of the cellular, synovial, serous, and medullary membranes, the pia mater or periosteum can furnish genuine pus, without the deposition and organization of some coagulable lymph. The third situation in which pus is generated is the sur- face of the peculiar structures, called granulations, the vascu- larity of which exceeds that of all the natural surfaces of the body. The pus formed on the granular surface of an ulcer is the best example of this kind * * Macartney on Inflammation. INFLAMMATION AND ITS C0N3EQUENCES. 75 Some parts of the body have a much greater disposition to form pus when inflamed, than others. The cellular tissue, skin, and mucous membrane are very prone to suppurate, while the fibrous tissues manifest no disposition to it. Pus is modified by the nature of the part where it is formed, by the constitution of the individual, by various accidents, occurring in the process of its formation, and by certain ob- scure laws which control the phenomena of those affections which are called specific. It will also present different ap- pearances, as it may be mixed with other fluids, as blood, saliva, bronchial mucus, &c. If pus mixed with blood, serum, &c, be long confined un- der dressings, or in cavities, it becomes very offensive, and often irritating. If it be produced from the irritation of dis- eased bone, it is also very fetid. When thin, mixed with blood, and evidently "unhealthy," it is called "sanies." When pus is irritating, it is so, not to the surfaces which secrete it, but to the adjoining healthy structures over which it flows. Pus is heavier than water, and this quality frequently ena- bles us to distinguish it from mucus. It is coagulable by muriate of ammonia, which Mr. Hunter considered a pecu- liarity sufficiently marked to distinguish it from mucus, and all other natural secretions, but the accuracy of the test is disputed. From the fact that hard inflammatory tumors in the course of inflammation become soft and yielding, and filled with pus, it was naturally supposed that the original solid parts were converted into this fluid. It is now well ascertained that such is not the case, but that pus is furnished by the ar- teries. When pus is enclosed in a cavity formed in the progress of inflammation, the condition is called abscess * * Abscedo—I depart, denoting the loss of substance. 76 INFLAMMATION AND ITS CONSEQUENCES. The phenomena of abscess are very curious, and through them nature succeeds in relieving the body of foreign mat- ters, and repairing extensive injuries. When a part capable of suppuration is subjected to in- flammation of the required intensity, some of the small vessels give way, and blood is effused into the surrounding parts. Simultaneously with this rupture, or nearly so, the arteries begin to throw out a peculiar plastic matter, which is called coagulable lymph. This is capable of becoming organized, and being thrown around the diseased parts, and between them and those which are healthy, it forms a barrier to the infil- tration of extravasated fluids. By some strange process, to us altogether inscrutable, the walls of lymph become vascular, and capable of performing the vital functions of secretion and absorption, and by them the pus is furnished. As this process proceeds, the previous contents of the abscess, in- cluding the effused blood, are gradually absorbed, and fresh pus deposited in their stead, so that if the tumor be opened at an early stage, the pus will be more or less mixed with blood, but if the opening be delayed, the cavity will be found to contain only pure pus. The process of suppuration is an- nounced by some relief of local symptoms, and a change in the character of the pain. It loses its burning sensation, and becomes throbbing, at the same time the tumor becomes softer, and at last fluctuates readily under pressure of the fingers. Very often, and especially when the disease is extensive, or when it is seated in the viscera, the formation of abscess is announced by shivering or chill. While the arteries of the walls are depositing the pus, other processes equally obscure are moving the abscess to- wards the surface, and preparing for its evacuation. The bottom of the cavity is constantly contracting and filling up, while the opposite side is thinning and expanding. The ab- sorbents at one side of the abscess are busily engaged in re- INFLAMMATION AND ITS CONSEQUENCES. 77 moving matter, while the arteries at the other are as actively supplying new material; at the same time, a temporary organ made for the occasion, faithfully performs its peculiar func- tions, supplying pus, and removing mixed fluids from the cavity. The parts lying upon the summit of the abscess are ra- pidly thinned, the tumor is pushed towards the surface, the skin ulcerates, an opening is made, and the pus evacuated. Though an abscess may discharge itself anywhere, there is evidently a strong disposition in such tumours to find their way to the outside of the body. In order to effect this, they will often traverse dense opposing structures when a nearer opening through more yielding tissues might readily be ef- fected. Sometimes, when an abscess occurs in an important viscus, artificial adhesion will be formed between its surface and an adjoining structure, and a continuous canal being pierced through, then the pus will be ejected upon the sur- face of the body, or into another organ which has external communications. These most curious and interesting facts are so conclusive of wonderful design and contrivance, that it is impossible to regard them in any other light than as manifestations of di- vine and superintending Providence. Foreign bodies are removed precisely in the same way as pus. When the abscess has reached the surface, a thin point appears, which is soon perforated by a very small opening, through which the pus slowly oozes. The appearance of this thin projecting spot is called " pointing." Sometimes the parts which surround the abscess are too dense to permit the passage of the matter. When this is the case, great pain is often caused by the pressure, and the irri- tation produced by the vain efforts of nature to relieve the parts, may occasion very serious disease in adjoining struc- 78 INFLAMMATION AND ITS CONSEQUENCES. tures. In some instances of this kind, as in abscess of the gums, or gum-boil, the pus failing to be evacuated, seems to be ultimately absorbed. When the attempt is made to form an abscess by weak or scrofulous constitutions, and in situations where the cellular substance is lax, the progress of the disease is very different. The first extravasation is serum, which passes easily into the loose cells of the cellular membrane with little or no injury to their structure. The parietes of the tumor are not com- posed in the beginning of organized and vascular lymph; no genuine pus, therefore, is found in such cavities in the first instance: the fluid they contain is serous mixed with coagu- lable lymph, parts of which are found as flakes floating in the serum. As the cavities of chronic abscesses are not pro- voked, either by severe tension or the quality of the contained fluid, there is no preparation made for some time to remove their contents. These collections, therefore, often traverse a considerable distance along muscles or under plates of fascia, before they arrive at the skin, which ulcerates very slowly; after which the cavities may inflame, their interior surface become more highly organized, and secrete genuine pus* Ulceration is the process by which solutions of continuity are affected by vital processes and open secreting sores pro- duced. Inflammation is by no means necessary to this result, and some of the best writers upon pathology have declined to recognise it as one of the consequences of inflammatory action. Nevertheless, as ulceration does frequently occur in the progress of inflammation, and is an evil to be guarded against by the dental practitioner especially, it seems proper to consider it in this connexion. The process itself is very curious, and at first sight, the facts explanatory of it are hardly credible. It is not easy to comprehend how a body can destroy itself and take itself * Macartney on Inflammation. INFLAMMATION AND ITS CONSEQUENCES. 79 away; and the difficulty is not solved by the fact that only small portions are thus removed. Yet, there can be no doubt that such is the case, and we may silence, if not satisfy, the objector, by suggesting the equal difficulty of understanding how parts form themselves; both facts, as Mr. Cooper ob- serves, are equally well confirmed. Every part of the body is continually undergoing waste and reparation. It seems that the molecules of tissues are constantly becoming effete, and having undergone some mys- terious change, are taken up by the absorbents and carried off to the several waste gates of the system, from which they are ultimately discharged. The bowels, the kidneys, the skin, the lungs, all the emunctories are continually at work, and all ultimately discharging the debris of the system. At the same time that this disintegration is going on through the action of the absorbents, another set of vessels, the nutritive arteries, are every where depositing new mat- ter. Bone receives bone, muscle is supplied with muscle, and viscus with its peculiar organic matter, so that the in- tegrity and form of each part, and of the whole, are exactly preserved. By some wonderful and inscrutable law, the ba- lance of supply and demand is equally adjusted, yet not so positively as to lead us to infer that the action of the one set of vessels regulates that of the other. In childhood, the supply exceeds the waste, and the body grows: in maturity, the supply is regulated more by the wants of the man than the activity of the absorbents. If his vocation calls for in- creased strength of arm, the very use of the organ, instead of consuming, augments its volume. In truth, the two sets of vessels seem to be independent of one another, yet, like other parts, they naturally work to- gether for the production of the phenomena of life. It will readily be perceived that if any circumstance should increase the activity of the absorbents of a part beyond what 80 INFLAMMATION AND ITS CONSEQUENCES. is usual, and should not simultaneously stimulate the nutri- tive vessels; or, should any circumstances render parts unu- sually susceptible of absorption, that the result would neces- sarily be an obvious loss of parts, and the interruption of their continuity. It is also obvious that the converse of these conditions would be attended with similar results; for if nu- trition be impeded, either through defect of supply or any cause rendering the part less capable than usual of convert- ing blood into its own tissue, loss of volume, and breach of continuity might occur. For the most part, however, ul- ceration is nothing more than molecular devastation and waste, th,e products of which do not enter the absorbents at all, but are passed out with the more legitimate fluid pro- ducts of inflammation. Ulceration may result from any of these causes. Pressure is a common cause of ulceration, and acts probably by inter- rupting the circulation and nutrition of a part. Pressure may produce absorption and waste without causing ulceration, and the dentist, when fixing artificial pieces in the mouth, must be careful so to adjust his plates and springs as to avoid both of these evils. Inflammation probably produces ulceration in a manner somewhat similar; viz.: by causing such impediment to cir- culation as prevents nutrition from being properly performed. It is also probable that the blood itself undergoes changes under the influence of inflammation, which render it less ca- pable of supplying the loss of parts. Diseased parts, and those which from any cause have become useless, and these only, are liable to be wasted by absorption. Unhealthy products, such as fungus,* are often removed with wonderful rapidity, and even bone will be removed when be- ing no longer needed, it has become foreign matter. The roots of the deciduous teeth are thus entirely removed, and * Fundus—a mushroom—proud flesh. INFLAMMATION AND ITS CONSEQUENCES. 81 the dead fangs of permanent ones are subjected to continual waste from the same cause. That they are not entirely re- moved, is due to the comparative shortness of time which the present term of human life allows for the process, rather than to any resistance they are able to offer to the action of these all-subduing lymphatics. Extraneous substances are generally removed by ulcera- tion. Thus, a ligature will be separated from an artery, or a foreign substance from a wound; no more of the surround- ing substance being absorbed than is necessary to loosen and dislodge the intruder. The process here is immediately de- structive, not vital. By ulceration, also, dead parts are separated from the living, and the decomposed fragments removed to make room for new matter. Sometimes ulceration seems to produce great devastation, and is then called phagedenic* In such cases, it is evident that the ulceration is only the consequence of the destruction, not the cause; for, until the parts have become too much en- feebled to subserve their natural purpose, they will not be subject to this rapid waste. All parts are not equally prone to ulceration. Skin, are- olar or cellular tissue, and mucous membrane ulcerate far more readily than blood vessels, nerves, or muscles. It is not uncommon to see these laid entirely bare of skin and cel- lular tissue, and bathed in pus, yet resisting disease. Ul- ceration would be much more destructive to parts and fatal to life but for this wise arrangement. The effusion of fibrine, more or less plastic, is a very im- portant result of inflammation. Exuded on the free surface of a membrane, it forms an adhesive layer upon it, called/a&e mmbrane. The presence of this product is often fatal. Fi- brine may be exuded into the interior of parts, separating and * Qccytiv—I eat. 82 INFLAMMATION AND ITS CONSEQUENCES. compressing their molecules, impeding their function, and producing inflammation and suppuration in them. If the process be gradual, and the infiltrating fluid consist princi- pally of fibrine, it may harden, organize, and induce perma- nent induration of the invaded part. Under other circum- stances it may cause softening. Tumors may be formed by the deposition of successive layers of fibrine, or organs may be effectively destroyed by its presence, and the accidents that ensue. Organized fibrine is always of feebler texture than natural or original tissue, and the higher the grade of inflammation under which it has been effused, the less likely is it to be per- manent. Adhesions formed with the least attendant vascular excitement are the most secure. Adhesion is often consequent upon inflammation, though it does not require the previous inflammatory process. By the exudation of coagulable or organizable lymph, parts natu- rally separate or artificially divided, may be united. The process is of immense importance in arresting bleeding, closing wounds, and providing means of safe transit for pus, from deep-seated parts to the surface. Mr. Hunter calls ulceration the natural surgeon, and de- clares that even in the spreading of an ulcer there may be considerable advantage; and another writer very properly observes, that the same remark would apply to the effusion of lymph. The one acts like the surgeon that unites parts; the other like the one who removes them, because they are not fit to remain; and it would not appear more justifiable to call adhesion and ulceration inflammatory processes, than to consider the operations of surgeons themselves as particu- lar modes of inflammation. The most disastrous result of inflammation is the absolute death of a part, reducing it to the condition of a foreign body, and subjecting it to the play of chemical affinities. INFLAMMATION AND ITS CONSEQUENCES. 83 When this takes place in soft parts, it is called gangrene or mortification; in bones, necrosis. The dead soft parts, when separated by ulceration from its connexion with living parts, is called sphacelus,* or slough, a fragment of dead bone is called sequestrum.f Caries is a condition of bone somewhat analogous to ulcer- ation of soft parts. Caries of the teeth is the result of chemi- cal agents acting from without, and decomposing their struc- ture: they are, however, subject to necrosis as other bony tis- sues, and the fact of their being liable to a peculiar erosion, does not probably exempt them from the kind of caries ob- served in similar structures. If such idiopathic caries does occur in the teeth, it must be very rare, and is always con- founded with the erosive caries peculiar to these structures. CHARACTER OF INFLAMMATION. Inflammation may exist in any degree of severity, and move to its results with much difference of velocity. Yet it is common to speak of it as acute or chronic, though the dividing line cannot be exactly determined or accurately de- fined. By a chronic inflammation we mean one which progresses slowly, develops its results uncertainly, and does not tend to merge itself in those definite and well marked results which conclude active inflammation. It is sluggish in its movements, does not produce the acute distress of active in- flammation, occupies a long time without accomplishing a crisis, mostly stops short of suppuration and gangrene, fa- vors fibrinous exudation, and declines with hesitating, im- perfect convalescence. Chronic inflammation very often results in change of struc- ture, is at the bottom of a great deal of mysterious ill health, *2 A somewhat red-colored, thin, and generally very acrid matter, termed ichor. 3d. A more viscid, glutinous kind of matter, called sordes* While discharging matter of a kind like any of these, an ulcer will not heal. The granulations become dark, and waste away; the matter, especially that called ichor, is very acrid, and renders the sore very irritable and painful. It frequent- ly excoriates the surrounding parts over which it flows. These vitiated ulcers are more apt to occur upon tendi- nous and aponeurotic parts, than in situations abounding with cellular membrane, owing to the frequent motion of these parts, and the continual agitation of the sore. Where- ever an ulcer is seated upon a part of this character, abso- lute rest is necessary to preserve its simple and convalescent character. The cure of these ulcers depends principally upon re- moving the cause which has operated to change their cha- racter for the worse. If the vitiated condition depends upon constitutional causes, these must be combated by the means found most successful in the practice of general medicine; if any local irritant has caused the evil, it must be removed as speedily as possible; if motion of the part has been in- dulged, it must be restrained. * Benjamin Bell. 126 ULCERS. The local treatment consists in soothing, emollient appli- cations, as it has been found that all those means which al- lay the pain in such sores, tend also to alter their condition to that of the simple purulent ulcer. When the sore is seated in the mouth, but little oppor- tunity is afforded for local applications. The best, perhaps, is warm water, frequently taken into and held in the mouth; or the vapor of hot water received into it repeatedly, and for a considerable time. The dentist should look closely in such cases for causes of irritation in diseased teeth and fangs, and also ascertain whether constitutional, causes are inte- rested in the production of the troublesome sore. The difficulty of protecting ulcers in the mouth from the contact of its secretions, and the food and drink, and the im- practicability of dressing them with applications elsewhere serviceable, should make the dentist extremely cautious lest a careless or awkward movement of an instrument in his hand should produce a wound and sore extremely painful to the patient, and difficult of cure. The Callous Ulcer. When ulcers become inactive and sta- tionary, rather than progressive, secreting but little, and that of a bad quality, and being little sensitive, they are called indolent; if, in addition, the edges become hard and thick- ened, they are called callous. Very often these callous ulcers are attended with an en- larged condition of the veins of the part, which is called va- ricose. This condition of the veins is very embarrassing to the surgeon, and sometimes produces fatal hemorrhage. Callous ulcers are most common upon the extremities, and owing to the mechanical difficulty in the return of blood from these parts, they are, in these situations, most frequent- ly attended with varicose veins. The callous condition of ulcers is the consequence of neglect and bad management. ULCERS. 127 Their cure consists in restoring them as soon as possible to the condition of a simple purulent sore. When the sore is merely indolent, the surface is yet struc- turally capable of producing healthy granulations. All that is needed is to bring it to the right suppurative action. Sometimes the inactivity of the sore results from irritation, either from local or constitutional causes. In such cases it must be soothed by position and soft sedative-applications, as warm poultices, or the constitutional impediment to the local action must be removed. When the indolence is not connected with irritation, gently stimulating means can be used to rouse the vessels to greater activity; in short, to increase the inflammation. When the surface is callous, it must be removed, and this is best effected by lunar caustic. (Nit. Argenti.) A blister over the ulcer is not unfrequently resorted to, but it is less manageable than the caustic. Mechanical pressure is very useful in the management of these sores, particularly where they are seated on the legs When the margin is not elevated and hard, a common roller passed around the entire limb to a point considerably above the sore, will be sufficient. When the edges are ele- vated and hard, strips of adhesive plaster carried tightly across from edge to edge, in addition to the roller, create ab- sorption of the indurated parts, and excite active suppura- tion. Whatever means are used, the object is to convert the sore into the simple purulent ulcer, to which condition all must be brought in their way to convalescence. The presence of some foreign matter, or decaying portion of bone, or tendon or fascia, or the passage of some excretion caused to flow from its natural through the artificial chan- nel. Fungous Ulcers. When granulations are large and pale, 128 ULCERS. grow rapidly and rise above the level of the surrounding parts, bleed freely upon touch or slight pressure, and make no attempt at cicatrization, they are called fungous or proud flesh. Generally they are soft and spongy, but by very long continuance they may acquire considerable hardness. Fungus is not uniformly sensitive; generally it is not at all remarkable in this respect; occasionally, however, it is very sensitive. It is but imperfect granulation, and may arise from any cause which tends to interrupt the convalescence of an ulcer. Long-continued inflammation of cellular struc- tures and caries of the bones are very apt to be attended by fungus. It sometimes occurs in\dcers of young and vigorous subjects merely as a kind of exuberant growth, which can hardly be considered as giving an unfavorable appearance to a sore, as it is readily removed by mild escharotics. Where fungus depends upon a mere defect of action of the vessels of a part, and not upon the presence of any irri- tating cause vitiating the character of the ulcer, it may be destroyed very readily by sprinkling upon it some burnt alum, or touching it with lunar caustic. Fungus has not sufficient vitality to resist the impression made by agents of this class, and generally the application of the escharotic will excite the surface of the ulcer sufficiently to cause the growth of firmer granulations. The Sinuous Ulcer.—This name is given to a sore commu- nicating with long and narrow canals, penetrating the cellu- lar membrane and running irregularly under the skin or be- tween the muscles. These sinuses generally have more than one opening through which pus is discharged. Originally they are the artificial channels through which the contents of abscesses or the fluids produced from carious parts escape from parts deeply seated or so placed as to be unable to pass off matter in a straight line; but the sides of the canals themselves becoming inflamed, and secreting mat- ULCERS. 129 ter, the whole presents the appearance of an irregular ulcer, connected with some primary source of matter, and forming openings wherever the nature of the part causes a determina- tion of matter to the surface. Should the sinus remain for a long time without cure, its sides and the edges of its orifices become hard, and it is then called a,fistula* The cause of sinuses is the want of a free passage for mat- ter, which seeking the most dependent point", readily pene- trates the yielding texture of the cellular membrane and ulti- mately produces ulceration at a point distant from its source. The cure of these sinuous ulcers depends upon making a free passage for the matter in a direct line from its source, and then bringing the edges of the canals together and causing them to unite, or removing the foreign matter, or restoring the wandering excretion to its former, or, at least, more convenient channel. After this, pressure should be used upon the sinus; if that should faiL stimulating or caustic applications may be used with advantage. Sometimes it is necessary to lay open these tortuous canals to the primary abscess, a process which at once gives free escape to the matter, and by exposing the sides of the sore to the influence of the air and proper me- dicinal applications, generally causes a wound which readily heals from the bottom with healthy granulations. Sinuses situated in the mouth should always be treated in this way, unless they are connected with diseased bones or teeth, or are so situated as to make the free use of the knife dangerous. "Where the sinus is both deep and extensive, it is not necessary to incise its whole space. The inner half will pro- bably follow the curative processes of the outer." (Miller.) * Fistula—a pipe. 130 ULCERS. Carious Ulcers are those which are connected with caries or necrosis of bony structures. They are often sinuous, but may be seated immediately upon the caries which causes them. The discharge from carious ulcers differs from good pus. It is thinner and fetid, and at last becomes blackish, and of- ten very acrid and irritating. Mr. Bell thought that the fetor of carious ulcers always afforded a sufficient means of diagnosis. The surfaces of carious ulcers are usually softer and more flabby than natural; and instead of a florid red, they have rather a dark brown with somewhat of a glassy complex- ion. The granulations generally grow rapidly, but are exube- rant and fungoid. Should the orifice heal either by the ef- forts of nature or the appliances of art, the apparent cure is of short duration, for the pent-up matter soon finds another vent and produces another ulcer. When a probe is pushed dow n to the bottom of a carious ulcer, it generally encoun- ters a roughness of the surface of the bone, which plainly indicates its eroded condition. When obstinate sinuses are observed in the gums, dis- charging fetid matter, and containing fungous granulations, we may always be assured that the cause is to be found in the presence of some decayed tooth or root, or to caries of the alveolus, jaw or some other bony structure. As a carious ulcer is nothing 'more than an accident at- tending caries, the treatment of it must always be secondary to that of the disease which produces it. The removal of the carious or necrosed part, and the employment of the means which will best prevent a return of it, are to be re- garded as the proper means of curing the carious ulcer. When the caries is seated in the cancellated structure of bone, it can only be thoroughly eradicated by the terrible ULCERS. 131 energy of fire, and the actual cautery must sweep over the diseased surface and rouse it to the exertion of its vitality. When a tooth is the subject of caries, no such frightful treat- ment is necessary. The tooth being passive in the matter, and being acted upon by chemical agents only, all that is required is to remove the caries and interpose between the fluids of the mouth and the parts of the tooth thus exposed, a bar- rier which must be impenetrable to the action of the fluids which caused so much mischief. The only substance by which a cavity in a tooth can be successfully filled is gold, as it only, of all the metals, possesses both the physical and chemical-qualities necessary to the purpose. If gold cannot be used, tin, though far inferior, is the best substitute. All the mercurial amalgams are exceedingly deleterious, both locally and constitutionally, and ought never to be used as dental fillings. The Cancerous Ulcer—Cancer, or Carcinoma. This terri- ble affection occurs under two forms, called occult and open, or scirrhous and ulcerative. The former variety generally, though not always, precedes the latter, and presents itself in the form of a hard, dense tumor, of slow growth, generally seated in a glandular structure, at first, in most cases, nearly insensible, and subsequently causing very sharp darting or burning pain, or twinges, which radiate from the scirrhus as from a centre. As the disease progresses, the skin ad- heres to the tumor, corrugates or puckers, changes color, becoming of a livid or leaden hue, then ulcerates and ushers in the second stage of the disease, the open or ulcerating cancer. The ulcer thus produced is exceedingly painful and irri- table. It discharges a thin fetid ichor, sometimes very exco- riating. Its edges are hard and irregular, reversed and con- torted. Its surface is generally irregular, showing depres- sions or excavations. The sore manifests no tendency to 132 ULCERS. form healthy granulations, but spreads among the surround- ing tissues which successively harden and ulcerate, and be- come cancerous. The lymphatics propagate the disease to the nearest glands, which are found swollen and indurated, and often ulcerated. The pain of cancer is a burning or scalding sensation, and generally exhausts and destroys the patient long before the devastation of parts can interfere seriously with the func- tions of life. As blood vessels are destroyed in the progress of the dis- ease, bleeding, more or less profuse, occurs. Cancer, however, presents various appearances. We have seen it occur without preceding scirrhus, present an equal smooth surface with little secretion; and many other appearances of this ulcer have been observed, as it has been modified by accidental circumstances. The characteristics of cancer may be considered to be an irregular, phagedenic sore, with hard reversed edges, ex- ceedingly irritable under all common dressings, and causing a burning pain. When such a sore has resisted the treat- ment which is found to be successful in ordinary irritable ulcers, and especially when it is seated in a glandular part and follows scirrhus, there can be no doubt of its malig- nant character. Cancer, in all its stages, is altogether intractable to any treatment which has yet been devised, and all but the most soothing applications are found to accelerate its progress and add to the intolerable acuteness of its pain. The only mode of cure now attempted is thorough extirpa- tion, and this is confined almost eutirely to the latent or scirrhous state. The open cancerous sore rarely yields even to surgical remedies. It is even a mooted question whether the removal of scirrhous tumors is advantageous. Some surgeons contend that where true scirrhus is removed, can- ULCERS. 133 cer soon makes its appearance elsewhere, often in a more malignant form and in a worse location, and that the life of the patient is often shortened by the painful operation en- dured in the hope of cure. It is not by any means easy to settle this question. Sur- geons are in the habit of removing all chronic tumors which are hard and painful, whether they present decidedly carci- nomatous symptoms or not. Many of these are probably not cancerous, yet the operations by which they have been removed enter into the statistics of cancerous extirpation. Where but one possible hope is left, we should be very careful not to extinguish it, and we therefore recommend the exsection of scirrhous tumors. To be successful, however, the operation must be performed before the disease has manifested activity by changing the surrounding parts into its own peculiar texture. • Even when the cancer has reached the condition of a foul, wasting, and tormenting sore, extirpation by the knife will sometimes be desirable, for the temporary relief it may give the victim. Six years ago, a neighbor of ours was re- lieved of a sore of this kind by amputation of the arm. Since that time, he has been able to attend to the duties of life, the cancer has not reappeared in a decided form, and as he'is an elderly man, and carcinoma proceeds slowly in old persons, he may escape a return of the disease, at least, in the aggravated character in which it existed before the am- putation. There is a form of carcinoma called " medullary," "spon- goid," or "fungus hsematodes," in which the tumor is elas- tic, grows more rapidly, and after ulceration presents a pro- truding fungous appearance, with a strong tendency to wasting hemorrhages. This kind of cancer is the result of a more thorough pervasion of the constitutional disease, and 134 ULCERS. less power of resistance to the. unnatural growth. It is rapidly fatal, and if excised commonly reappears, often in some vital place. The cause of cancer is also a matter of controversy. It is often excited by a wound, especially a bruise or pinch; but this can only occur where there is a constitutional tendency to the affection. On the other hand it frequently appears without any exciting cause. Some writers, in view of these facts, contend that cancer is primarily a local affection, having a strong tendency to infect the whole system with its own poison. They, therefore, very rationally conclude that if it be extirpated in its latent state, the patient may be entirely relieved from it. Others believe that carcinoma is a consti- tutional disease, manifesting itself in local changes of the kind described; that it is, therefore, useless to remove the local effect, and the constitutional cause being beyond our control, they prefer, in the present state of medical science, to refrain from all attempts at cure of the disease. On each side of the question are presented observations and pathological demonstrations, and authoritative names, and without troubling our readers with a recapitulation of the facts and arguments brought to bear upon this subject, we will content ourselves with suggesting the practical in- ference which seems most rational upon the whole; which is, that eradication of scirrhus may be attempted with good hope, though not with certainty of success; that the exci- sion of open cancer will be an experiment very doubtful, yet if the reports of surgeons are to be believed, not abso- lutely hopeless; and finally, that under all circumstances the operator must be prepared for a recurrence of the dis- ease. Many specifics have been suggested for the cure of cancer, and many nostrums are yet vended for the purpose of curing these sores. For the most part these are useless nostrums, ULCERS. 135 which have not the least control over cancerous degenera- tion. Some of them are caustic applications, which actually extirpate the diseased part, and are as useful as excision would be. In some cases, caustic has the advantage over the knife, and probably has been too generally abandoned by surgeons. Cancer doctors often get reputation by at least temporarily relieving patients abandoned to their fate by scientific practitioners. To be sure, the empirics in their ignorance of the distinction between malignant and analogous sores, often apply their escharotics where they do great mischief, but these blunders do not go before the pub- lic, while apparent cures are trumpeted throughout the land. One young lady, whom we knew, was killed by some appli- cation of the kind, supposed to be an arsenical paste, to a benign ulcer. Cancer sometimes attacks the tongue. We saw a case of this kind, which seemed to have been provoked by the abrasion of the organ against fractured teeth. The sides of the tongue presented a jagged edge, which gave out sanious matter. The whole body of the organ was scirrhous, and the neighboring glands manifested a similar condition. A cause so slight as the retention in the mouth of a bro- ken or eroded tooth, seems, in this case, to have been suffi- cient to excite this fearful malady, in a part, too, where the greatest possible inconvenience and distress must result from its presence. The lips, too, are very frequently the seat of cancer, and the dentist should be careful not to wound these very vas- cular and sensitive parts by careless or awkward handling of the sharp instruments he wields. As the several varieties of cutaneous ulcer are not likely to require treatment from the Dental Surgeon, we will not consider them, but refer the curious reader to the several 136 ULCERS. surgical works in which they are accurately described and their proper treatment pointed out. ULCERS DEPENDENT UPON CONSTITUTIONAL CAUSE. Venereal or Syphilitic Ulcers.—Impure sexual intercourse has engendered a poison which is capable of producing local and constitutional disease of a distressing and dangerous character. With the consideration of local or primary sy- philis we have nothing to do, but as the secondary or con- stitutional disorder develops itself in the structures of the mouth, it is necessary that the well-instructed dentist shall be prepared to detect and treat it, when thus manifested. Syphilis usually presents itself in the form of ulcers, which are called chancres—it also causes cutaneous erup- tions, swelling of glands and disease of the periosteum, fas- cia and bones. The ulcers vary considerably. Generally they are remark- able for their hardened base, feeling like cartilage under the skin; the borders are red and sharp, the bottom gray- ish, and the sores painful, and not tending to heal. In the throat, tonsils and mouth, the disease generally shows itself at once, without much previous tumefaction, so that the tonsils are not much enlarged; for when the vene- real inflammation attacks these parts, it appears to be always upon the surface, and it very soon terminates in an ulcer. These ulcers of the throat are to be Carefully distin- guished from all others of the same parts. The disease in the throat is uniformly ulcerative; this being the first appear- ance of disease in that part* The syphilitic ulcer always begins superficially, and is not preceded by observable, or at least, by any notable degree of inflammation. This fact will be sufficient to distinguish * Hunter on the Venereal Disease. ULCERS. 137 these sores from the ordinary open abscess of the sup- purating tonsil. There is also an indolent swelling of the tonsil accompa- nied by an exudation of lymph, which at first sight might be mistaken for an ulcer, and indeed such exudations, when they accompany scarlet fever, are often miscalled sloughs. They may be detached from the subjacent membrane, which is found unbroken. There is another complaint of those parts often mistaken for venereal, which is an ulcerous excoriation running along the surface of the parts, becoming very broad and some- times foul, having a regular termination, but never going deep into the surface of the parts. Mr. Hunter says that there is no part of the inside of the mouth exempted from this ulcerous excoriation, but it occurs most frequently about the root of the uvula, and spreads forward along the soft palate. The same writer observes that the true venereal ulcer in the throat is a "fair loss of substance, part being dug out as it were from the body of the tonsil with a determined edge, and is commonly very foul, having thick white matter ad- hering to it like a slough, which cannot be washed away." These ulcers never heal spontaneously, and generally spread rapidly. When the sores are seated upon the pharynx, they produce great distress in deglutition, cough and puri- form expectoration, rapid sloughing of the soft parts, ex- posing the bones and destroying them even as far as the ver- tebra by caries. The palate is frequently destroyed, throw- ing the nose and mouth into one cavity, preventing distinct speech, and causing great discomfort and distress. The den- tist will often be required to supply this serious loss of bone by an artificial substitute. "At other times, especially in cases of long standing, these 10 138 ULCERS. sores extend not by sloughing, but by rapid ulceration. The aspect is less formidable, but its progress is scarcely less de- structive. This variety is most commonly seen on the soft palate. The surface is foul, but the slough which occupies it is of little depth. The sore is edged by a very narrow fringe of yellowish slough, and beyond this for the extent of a quarter of an inch, there is an inflamed margin of a deep crimson color; but there is not much general sloughing of the surrounding parts. Yet the sore extends daily with ex- traordinary rapidity. The substance of the part seems to melt away under the ulceration, and the greater part or the whole of the soft palate, is often destroyed befoTe it can he arrested, though no distinct slough can be seen to separate through the whole of its course."* Phagedenic venereal ulcers, like cancerous sores, have thickened edges; a characteristic rather of the unhealthy character and spreading tendency, than of any specific qua- lity of the sore itself. There are several kinds of venereal affections observed in the bones. The periosteum may be thickened and in- flamed. This is a very painful affection, the pain being greater at night; and may be mistaken for rheumatism, when the bone is so deeply seated as to prevent the distinct feeling of the swelling. This periosteal disease generally ends in permanent enlargement of the bony structure from depo- sition of bony matter. Sometimes the periosteum suppu- rates arid causes exfoliation of the bone. Caries of the bone frequently commences in the cancellous structure, and gradually perforates the external plate, and then appears as a soft tumor, which may be seen and felt externally. If this tumor is laid open, a glairy fluid is eva- cuated; the periosteum is found to be somewhat thickened, * Babington. ULCERS. 139 and the bone beneath is denuded, and in the centre of the denuded part, is found a small hole which perforates the cortical plate and communicates with the interior of the bone. This affection is very common in the skull, and may be seen in the tibia, jaw and ulna. In its worst forms, it con- stitutes the worm-eaten caries.* In determining whether a sore in the throat or a caries of the bones be syphilitic, it is absolutely necessary that the ob- server shall obtain all the collateral information which may aid the diagnosis; for it is often impossible to decide posi- tively from the mere appearance of the ulcer, whether it be venereal or not. Very often cutaneous eruptions of a syphilitic character attend the venereal sore throat, and the presence of such eruptions would be sufficient to decide a doubtful case. Unfortunately, however, it is not easy to detect with cer-- tainty all forms of syphilitic eruption; yet, when suspicion; is aroused by the appearance of the throat, and corroborated by that of. the skin, or vice versa, there must be extraordi- nary reasons for inferring the cause not to be venereal. Syphilitic eruptions may be tubercular. That is, they may appear in the form of hard lumps, covered by red in- flamed skin, and often by dead cuticle. These often ulcerate and leave behind them a peculiar copper-colored blotch. Another form of syphilitic eruption, is that of small red acuminated pimples, sometimes scattered regularly over the surface, at others arrayed in groups. Scaly eruptions are also common, and sometimes a pus- tular affection attended with a large, hard, conical scab or crust (rupia) is observed. These may all be due to other causes, but when occurring together with a suspicious sore throat, they very much strengthen the probability of vene- real origin. * Babington, 140 ULCERS. Mr. Hunter says, when syphilis attacks the tongue, it sometimes produces a thickening or hardness in the part; but this is not always the case, for it very often ulcerates as do the other parts of the mouth. If the character of the disease be clearly venereal, or if it be probably so, it is important that proper remedies be at once administered, for when the virus has become so gene- rally diffused, as to produce the remote symptoms observed by the dentist, the life of the patient is in imminent peril. There has been much controversy as to the means of curing cyphilis, one party contending for the use of mercurial means, and the other denying the necessity of these medicines. Without pretending to any claim to decide a question so ably supported on either side, we will briefly remark, that mercury will certainly cure the disease, except in a few un- common cases, where it exists in a kind of combination with scrofula; and secondly, that mercury will do this without injury to the patient, and generally with as little inconve- nience as can attend the use of less certain remedies. With- out hesitation, therefore, we recommend its use; especially, in constitutional or secondary syphilis, where no time must be lost, and no risks must be run. As to the particular preparation of mercury most proper for the purpose, there also is difference of opinion. As a ge- neral rule, however, we prefer the proto-chloride or calo- mel to any other preparation. It is more certain than blue pill, and perhaps than any other mercurial medicine, and can be used with more safety than the deuto-ehloride (corrosive sublimate.) Our common practice is to give a grain of calo- mel, to which is added one-twelfth of a grain of opium, night and morning, until the ulcer disappears or the gums get sore. It is rarely necessary to produce salivation—a mere tender- ness of the mouth will generally indicate the predominance ULCERS. 141 of mercurialization in the system, and be attended by heal- ing of the venereal sores, and disappearing of other symp- toms of that disorder. Corrosive Sublimate in the dose of a twelfth part of a grain three times a day will often succeed; and, in secondary syphilis, is thought by some to be superior to calomel. When calomel acts too freely upon the bowels, as it some- times does, even when administered together with as much opium, as it is prudent to give, corrosive sublimate or blue pill may be tried. Should these purge also, resort must be had to inunction; the patient being rubbed with mercurial ointment until his mouth begins to acknowledge the mercu- rial influence. When scrofula exists in union with syphilis, the iodide of mercury may be used. . Scorbutic Ulcers.—Scorbutus is a barbarous half Latin name, given by medical writers to scurvy, a constitutional affection depending upon privation of vegetable food, under circumstances calculated to weaken the energies of the sys- tem, and which was long a terrible scourge to seamen, soldiers and the inmates of prisons. It has frequently been con- founded with other affections, a mistake which has led to se- rious consequences. In the year 1700, the celebrated Boer- haave treated with mercury four hundred soldiers thus af- fected, and killed them all. The term scurvy, is applied to sponginess and ulceration of the gums from any cause, but this is an impropriety. Scorbutus, or true scurvy, is always a constitutional affection, never occurs when patients have lived upon diet sufficiently vegetable, and, in short, can only be expected to occur in ships, camps or prisons: happily since its character has be- come known, it is rarely seen now, even in these places. As it would be of little use to our readers, we will not in- troduce here a full discussjon of this subject, which has ceased to be of much interest, even to the general practi- 142 ULCERS. tioner; but will content ourselves with a very few remarks upon it, referring those who may be curious to know more of this subject to a very interesting article upon it in the Cy- clopaedia of Practical Medicine, written by Mr. Kerr. Scurvy is a general disease characterized by debility, fce- tor of the breath, sponginess and turgidity of the gums, livid subcutaneous spots, particularly of the roots of the hairs, ecchymoses, spontaneous hemorrhages and frequent contrac- tion of the limbs. The face becomes bloated early in the disease, and the lips are of a pale greenish hue. The countenance looks sad; the patient complains of extraordinary lassitude, and becomes breathless after slight exertion. The gums soon become swollen, itch and bleed upon touch; they are deep red, soft and spongy: soon fungous and putrid. Bleeding occurs fre- quently from the mouth and other parts, and the breath is very offensive. The skin is usually smooth and shining, with a suffusion of black or livid spots. Old wounds or sores break out afresh, and ulcers frequently occur. These sores secrete a thin, fetid sanious fluid; their edges are generally livid and puffed up; a coagulum soon forms, which with great difficulty can be wiped away or separated from the subjacent parts. These are soft, spongy and putrid* A soft, bloody fungus, of considerable size, soon rises from the ulcer. When scurvy approaches its fatal termination, the livid and painful swellings break, and assume the fungous appearance characteristic of scorbutic ulcers. The hemor- rhage becomes more profuse and general; the increasing dyspnoea is accompanied in some cases with pain under the sternum, but more frequently in one of the sides. In others, however, without any complaint of pain, the respiration be- comes suddenly quick and laborious, and death unexpect- edly puts a period to the disease. * Cyclop. Prac. Med. ULCERS. 143 The prevention and cure of scurvy consist simply in pro- viding a proper vegetable diet, and keeping the patient warm and dry. Where this cannot be done, as is the case at sea, the purpose can be effected by administering lemon juice freely, and making the men as comfortable as possible. Me- dicine has little to do in the matter, though it may render occasional aid. It is always important to distinguish the symptoms of scurvy from those of other diseases; fortunately there is no longer much danger of mistakes in this respect. The subject does not belong to practical dentistry, though the disease of the gums connected with it makes it proper for us to mention it; our chief purpose in doing so, however, is that our readers may have a proper knowledge of the mean- ing of a word which is continually misused by dentists, by applying it to a local fungous affection. Scrofulous Ulcer.—Scrofula. This word is derived from the Latin word Scrofa, a hog—why, it is not easy to per- ceive ; but it is singular that the corresponding Greek word is also derived from a word (p^o0 signifying a hog. • Whether those who originally described the disease were aware that swine are subject to it, or whether, as is most probable, they intended to portray the dirty appearance of those afflicted by it, we have no means of determining. Scrofula is also known as Struma, and the word Strumous is frequently used instead of Scrofulous. Scrofulous tumors and ulcerations are also vulgarly called King's Evil, from the loyal superstition which for many years attributed to the touch of a sovereign the miraculous power to heal the disease. Multitudes of cases were touched by the monarchs of England, from Edward the Confessor to Queen Anne. A similar practice existed in France. Scrofula is a constitutional disorder which manifests itself in a great variety of local affections, and is among the most distressing, and in some of its forms, the most fatal of all the ills that flesh is heir to. 144 ULCERS. The pathology of scrofula is not well understood. It seems to affect particularly the lymphatic system; the glands, especially the subcutaneous and mesenteric, being most fre- quently the parts which first manifest the local influence of the constitutional vice. Very often, however, its ravages are confined to internal organs. The lungs are especially liable to be affected by it, assuming that well known and so far incurable diseased condition, which is called phthisis* or pulmonary consumption. Although persons of all temperaments are subject to scro- fula, yet those who possess what is called the lymphatic tem- perament, are much more liable to it than others; and as this system is predominant in children and women, they are more exposed to scrofula than adults and men. Yet men are by no means exempt, but those of the male sex in whom the lymphatic temperament predominates, are most liable to it. It is common to distinguish the scrofulous disposition by certain external marks which doubtless indicate, with con- siderable accuracy, the presence of the constitutional vice. These appearances, from the strong disposition to phthisis which they manifest, are frequently called "consumptive." These marks are a fine white skin; light hair; rounded plump figure; delicate complexion, with rosy cheeks; large lips; large lower jaw; yellowish teeth, or teeth, whatever their color, which are soft and easily attacked by caries; a large head; straight and narrow chest; large abdomen, and soft and flabby flesh. Persons presenting these external ap- pearances are generally amiable, and often very sprightly Phthisis, from