The Project Gutenberg EBook of The Brooklyn Medical Journal. Vol. II. No. 2. Aug., 1888, by Various This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org/license Title: The Brooklyn Medical Journal. Vol. II. No. 2. Aug., 1888 Author: Various Editor: Joseph H. Raymond Alex. Hutchins Glentworth R. Butler Joseph H. Hunt Fred. D. Bailey Release Date: October 13, 2019 [EBook #60493] Language: English Character set encoding: UTF-8 *** START OF THIS PROJECT GUTENBERG EBOOK THE BROOKLYN MEDICAL *** Produced by Richard Tonsing and the Online Distributed Proofreading Team at http://www.pgdp.net (This file was produced from images generously made available by The Internet Archive) THE BROOKLYN MEDICAL JOURNAL. PUBLISHED MONTHLY BY THE MEDICAL SOCIETY OF THE COUNTY OF KINGS. EDITORIAL COMMITTEE: JOSEPH H. RAYMOND, M. D., ALEX. HUTCHINS, M. D., GLENTWORTH R. BUTLER, M. D., JOSEPH H. HUNT, M. D., FRED. D. BAILEY, M. D. VOL. II. BROOKLYN, N. Y., AUGUST, 1888. NO. 2. 97 ORIGINAL ARTICLES. PAIN, WITH SPECIAL REFERENCE TO ITS DENTAL RELATIONS. BY WM. M. THALLON, M.D. Read before the Brooklyn Dental Society, May 28, 1888. Mr. President and Gentlemen:—Some months ago, when sitting in the operating-chair of your Chairman of the Committee on Subjects, he asked me if I would not read a paper before the Brooklyn Dental Society. In the helpless condition in which I then was, with literally a gag in my mouth, robbing me of the prerogative of free speech, and under the shadow of a formidable mallet, I somewhat timorously signified an assent. Under those circumstances I know of few men who would have had the moral and physical courage to have resisted such an appeal. When in the course of his further practices, he asked me what my subject would be, I promptly replied by mentioning the thing then most vivid in my mind: Facial Neuralgia. I hardly realized my rashness and what I had undertaken, until I received your printed bulletin of subjects. But it has seemed to me on further thought that we might perhaps spend an hour profitably together in comparing notes about that borderland of facts and problems, which you touch on the one side as dentists and I on the other as physician. And I trust you will be lenient with me in your judgments if I go astray in my talk, and I pray you to remember that we doctors labor under great disadvantages compared with you dentists, contrasting the width and vagueness of our territory of research with the precision and accuracy of yours. I have again and again envied the exquisite dexterity and the certainty of adapting means to ends which I have seen exhibited by members of your profession, and vainly longed for the same in my own. But on the other hand, I think it may justly be urged that the dentists have not contributed as much to the general stock of knowledge, especially to the solution of disputed questions of pathology, such as the relation of micro-organisms to disease, as their unrivaled opportunities for observation would allow. I shall therefore not hesitate, Mr. President, to somewhat dogmatically present my views on certain subjects, but I ask you to believe it is mainly because I hope the gentlemen present will honor them by frank and full discussion. I shall also ask permission to change the subject of my remarks from the announced title to one of a little wider scope, namely, Pain, with special reference to its dental relations. I presume the symptom of pain is the one for which the overwhelming number of your patients, as the majority of ours, apply to us for relief. And yet common as this sensation is both in ourselves and in others, it is very remarkable how little settled opinion is, as to its nature. If you have never had occasion to try and put into the form of a definition the idea of pain, and proceed to consult the authorities, you will be surprised that so many different views could be held of what at first seems so common and obvious as to be beyond dispute. As you proceed in your inquiries, the question instead of becoming simpler apparently becomes more complex, for as you think of the different forms of pain, and contrast, for instance, that of an inflamed rheumatic joint, with its definite structural changes and well-marked constitutional symptoms like fever, with an idiopathic neuralgia, pure and simple, often lacking in any outward manifestation other than the pain itself, you wonder if the pains resulting are not as different as the diseases producing them. But the common consciousness of mankind which has given the same name to the sensation produced, whether by an inflamed bowel or a carious tooth, is sure to be right in believing that there is essentially the same substratum in each. Now what is the nature of that substratum? It is evident that whatever else it is, pain is a disagreeable sensation, and the word sensation further obliges us to remember that it involves a central nervous system (in its simplest type a single cell), capable of feeling impulses, conveyed to it from without, or else generated within itself. Now, it is very evident that pain must consist either in some change in the nature of the impulses sent to our central cell, or else in some change in the condition of the receiving centre. So eminent an authority as Prof. Erb defines pain simply as an increase in the ordinary sensory stimulus, a heightening more or less intense of ordinary sensation. On the other hand, Anstie defines pain as a perturbation in the nervous system, especially of the central cells, involving a lowering of function, a diminution of ordinary sensation. It is very evident that both of these great authorities cannot be exclusively right, and I propose to see what light we could get on this subject from the abundant clinical evidence you have. This question is no mere quibble about words or definitions, but it is one of the utmost practical importance in its relation to treatment. According as we settle in our minds whether a given case of pain is an exaggeration or a lessening of the ordinary physiological condition, our treatment will logically be either narcotic or stimulant. Leaving for the present the question as to the nature of pain, let us examine some of the modes in which it expresses itself; and as far as practicable I will limit myself to the various pains about the head, for all the varieties are there manifested. The first point which strikes every observing man is the difference of individuals in their susceptibility to pain. It is not merely or even mainly a question of the amount of courage of the patient in bearing pain, but it is far more a question of inherited or acquired sensitiveness. The same amount of injury, as nearly as we can judge, in two differently organized individuals will produce extremely differing degrees of pain. In general it may be stated that the unduly susceptible individual has either inherited a weak nervous constitution as regards pain, or else that some depressing agency has lowered his power of resistance. When I speak of a weak nervous constitution as regards pain, I do not mean that it need be a generally weak physique. Perhaps a more happy word would be unstable. You remember the physicists talk of bodies being in stable equilibrium when after a disturbance they tend to return to their bottom, or centre of gravity; while unstable equilibrium is that state where a little shove off the centre, results in a 98 99 big tumble. Now, the people who are markedly susceptible to pain, who have recurrences of it, may be said to have a nervous system in a state of unstable equilibrium. In other respects these same individuals may be splendid types of muscular or mental development. The same condition holds good with pain’s first cousin, muscular spasm. The analogue to the sensory crisis of attacks of neuralgia is seen in the muscular convulsions of attacks of epilepsy. And yet some of the greatest men of the world’s history in mental vigor have been epileptics, notably Napoleon Buonaparte and Julius Cæsar. Although at first we may not be able to see any outward manifestation of such attacks of pain as I have spoken of, if they recur sufficiently often they are sure to leave their traces behind. If we prosecute our inquiries in the other direction, to find what has predisposed our patient to recurrences of pain, we find in a large number of cases that his immediate progenitors have suffered from similar or allied manifestations. By allied manifestations I mean such other nervous diseases as epilepsy or chorea (St. Vitus’ dance), or insanity. Moreover, there is one predisposing cause that I believe to have quite peculiar efficacy, and that is the tendency to phthisis. Again and again I have verified the truth that where a member of a tubercular family escapes consumption, he is extraordinarily liable to develop one of the graver neuroses, preferably recurrent attacks of pain. Now, the first point we may consider settled, as to the mode in which pain expresses itself is in an inherited susceptibility, a lessened power of resistance, and this can only reside in the central nervous system. But, as we have already said, the lessened power of resistance may be acquired, it need not be inherited. Without stopping to dwell very long on this part of our subject, it will suffice to enumerate one or two of the principal efficient agents. And the first and far the most important of these is malnutrition of the nerve tissues, whether accompanied by the signs of anæmia and general constitutional malnutrition or not, the main cause being our civilization, with its excessive nervous wear and tear, no less in the educational period than in the intense competition of mature life. No more striking verification of this fact is needed than the results obtained in the relief of pain by physiological rest, by systematic feeding, especially of certain kinds of food, particularly fatty food. It is the general rule that in these cases there is either an indisposition to take sufficient food, or else that certain necessary ingredients are omitted owing to the patient’s repugnance. In the familiar example of sick-headache, or migraine, the patient invariably ascribes his condition to a disordered stomach, and scrupulously avoids such foods as eggs and milk and fat, which he will tell you always make him bilious. It is the hardest thing in the world to convince him that he has put the cart before the horse, and that the real fact is that the nervous trouble, the neurosis of the ophthalmic division of the fifth, is the cause and not the effect of the gastric disturbance. I am convinced that much of the suffering in the dental branches of the fifth nerve can similarly be traced to the nervous malnutrition of insufficient food, and, in addition, the local condition of the teeth is pathologically influenced by their not getting their proper physiological stimulus in the quantity or character of the food to be chewed. Of all the means at our command in combating the neuralgic condition, the regulating and increase in the quantity of rest and of the food supply should stand first. These facts have been known and recognized for a long time; but it is due to an American, Dr. Weir Mitchell, of Philadelphia, to have intelligently systematized their use. The principles of his treatment of nervous prostration, spinal irritation, and allied disorders, in which pain is often a prominent symptom, consists in a system of rest and forced feeding by which a larger quantity of nutriment is gotten into the system, and the waste eliminated by means of artificial exercise, by massage. It is evident that in this process the increased food absorbed into the blood goes indifferently to nourish all the tissues; but inasmuch as the muscles are not the seat of the trouble, if left alone unexercised, they would become diseased under the very stuffing process. That is where the kneading and shampooing, and movements supplied from without, are so valuable; the muscles get their healthy action without drawing on the forces of the enfeebled nervous system to set the process going. And so the nervous system has a chance to lie idle and grow fat. Similar remarkable results have been obtained in another disease whose hereditary relations to pain I have spoken of, namely consumption, by a process of forced feeding. The recent results obtained, more especially in France, by stuffing phthisical subjects, have constituted by far the greatest advance in the treatment of this disease in recent years. But in these cases the massage is entirely inapplicable because the waste of tissue is already too great. The lessons taught by the treatment of these two classes of diseases are invaluable in combating the more inveterate forms of pain. The next acquired condition to which I would invite your attention, which may act as a cause of pain, is the presence of certain poisonous compounds in the blood or system. These are more especially the poisons of malaria, of syphilis, of gout and rheumatism, of alcohol, of certain drugs, and lastly of certain metallic poisons, as mercury, phosphorus, lead and arsenic. Although this group includes a tolerable number of members all together, it is less important than either the preceding division of nontoxic malnutrition of the nervous tissues, or of our first class, in which heredity plays the main role. Still the toxic cases are sufficiently common. What we have already said as to treatment here holds good, but we must superadd the means of combating the particular poison. In the malarial cases the pain is often entirely relieved by quinine or one of its substitutes; on this all are agreed, whether homeopaths or allopaths, or outside of any regular path. It is quite curious how the malarial neuralgias preferably locate in the first division of the fifth. But one word of caution, the mere fact of recurrence or periodicity, more or less regular, does not suffice to establish the diagnosis of 100 101 102 malaria, for all neuralgias are apt to be more or less periodic. You must get definite symptoms of chill or fever before you can be sure. Once sure, the treatment is plain: efficient doses of the antiperiodic. When we come to the syphilitic cases we enter more debateable territory. The pains about the head, especially the teeth, are sometimes not due to the disease, but to the means taken to combat it. I do not intend here to take up the question of the treatment of the secondary stage, except to enter my protest as to the harm done, especially to the teeth, by routine overdosing with mercury. Fortunately this abuse of a most valuable remedy is much lessening. In the third stage of syphilis you sometimes get most remarkable pain manifestations, and I had one in my practice that I cannot refrain from quoting. A gentleman, aged between 40 and 45, had suffered for years from recurrent attacks of pain of great severity. When I saw him the pain, although more or less present constantly, had very marked exacerbations every afternoon. It was located in the great occipital nerves, especially on right side. Had formerly had considerable pain in distribution of right inferior dental nerve. His occupation was sedentary and involved considerable mental application. He stated on questioning that some eighteen years before he contracted syphilis. From this he believed himself cured. He had subsequently married, but had no children. Having suffered for six or eight years from these attacks of pain at varying intervals, he had consulted numerous physicians with only temporary benefit. He was very despondent; his sufferings were very intense, and only the most powerful anodynes gave relief. After some investigation, I made up my mind that the syphilitic dyscrasia lay at the bottom of his suffering. I therefore began specific treatment with iodide of potash. Prof. Seguin, who saw him in consultation, concurred in both diagnosis and the line of treatment. He suggested pushing the iodide until its therapeutic limit was reached. This was done; but it was not until the enormous dose of one-half ounce thrice daily was reached that the pain yielded. During one week this patient took over one pound of iodide of potash. A course of mercury in small doses completed the cure. Two years have now elapsed, and the patient has had no recurrence of pain. Gout and rheumatism were formerly ascribed a much more important role in the production of pain than they now occupy. Leaving out of account the acute manifestations of these diseases, their influence is slight as predisposing causes in the production at least of facial pain. There is perhaps one disease of the dental apparatus to which I shall allude later on, in which gout may act as an efficient cause. On the other hand, the class of pains due to the action of the chronic abuse of certain therapeutic agents is unhappily an increasing one; I allude to alcohol, opium, cocaine, chloral and other drugs, originally taken for the relief of pain, which induce a pernicious habit in their unfortunate victims, of which pain is one of the main expressions. It is an undoubted fact that this class of sufferers is on the increase. Much of this tendency is due to the excessive wear and tear and the unhealthy competition of our modern civilization. It has always been the refuge of the weak, the attempt to escape from the moral evils of our lot by means of something that will temporarily dull our consciousness of the trials we have gone through and the apparently greater trials that lie ahead of us. The moment the competition for existence and for wealth becomes keener, the greater will be the temptation of the unsuccessful or depraved to seek oblivion for their failure in some narcotic, which will for the time being quiet their disappointed consciousness. When in addition you have an inherited weakness on the part of your patient in his susceptibility to pain, or in a condition of pain actually existing, can you wonder that so many fall by the way? It seems to me that a terrible responsibility lies upon us all, especially upon us physicians, lest by our treatment we encourage this tendency. Nor do I think that as a profession we can be altogether acquitted of carelessness, to put it mildly, in this regard. It is so much easier to relieve the symptom pain, when called to a sufferer, by a dose of morphine, and then when the next attack comes on to repeat it, than to analyze the complex group of phenomena on which that pain depends. You will perceive that the question with which we started as to the nature of pain is of vital importance in this regard. The last group of constitutional agents which act as pain disposers is one with which you are all familiar, namely, the action of certain metallic poisons; of these the most important are mercury and phosphorus. It is highly significant that they have their main action in the structural changes they cause in the periosteum of bones, the peridental membranes. In the case of phosphorus, I think it is now pretty generally believed that its poison has very little effect in the mouth unless there exist a precedent caries of a tooth or its socket. These facts almost suffice to take these agents out of the group of constitutionally acting into that of peripherally irritant causes. In this class of agents, as in the preceding one, the first indication in treatment is the complete removal of the sufferer from their baneful influence. We have now briefly reviewed the main agencies which act constitutionally in the production of pain. It is apparent, to recur to our simple illustration, that they must have their main efficiency in the action they have on the central cell, and not on any modification of the impulses sent to that cell. It cannot be denied that in rare instances these various agents are productive of pain referred to a particular nerve, when we cannot find anything in the nerve itself or in the tissues supplied by it to account for the morbid manifestation. We are, therefore, constrained to believe, at least for the present, that morbid manifestations, sensations of pain, may originate in the cell itself and thence be referred outward. But I would remind you that the whole tendency of modern medical thought is to more accurately localize the starting point of disease, and to circumscribe the area of cases in which such outward cause of disease is unknown. So long as men were satisfied to cover up their ignorance in such vague phrases as “humors of the blood,” “rheumatic diathesis,” etc., etc., few were tempted to carefully examine the local conditions for an explanation. But the last fifty years have seen an enormous change in our attitude of mind to these problems. It is a change which is one of the greatest in the history of the human mind. And while I do not 103 104 for a moment wish to underrate the great importance of a due regard to the constitutional causes of pain, especially of the malnutrition of the nerve cells, I believe that in the main they must be classed as predisposing causes and not as efficient ones. When we come to the question of why pain is located or referred to a particular nerve, I believe the answer in the overwhelming majority of cases will be because there is some peripheral abnormality in that nerve or in some other nerve with which it is intimately associated; for we have to recognize in the philosophy of pain the same fact that we do in the philosophy of the human mind, namely, that our ideas are so closely associated that one thought will almost necessarily suggest another. Just as, if we have always been accustomed to see Smith and Jones together, we can hardly think of Smith without Jones also putting his nose in; so in feeling sensations, certain ones get so closely intertwined that one will almost inevitably causes the other. This, then, leads us naturally to the second great division of our subject, and that is the influence of peripheral irritation in causing pain. From what I have just said, this may be of two kinds—a reflex or associated pain expressed in some other nerve than the one affected, or else it may be due to direct irritation in the nerve itself. A very common example of the former is seen in the headaches from which many women suffer, from the menstrual congestion (irritation of the nerves) of the ovaries and uterus. It is, however, quite outside the scope of this paper to enlarge on this curious and obscure part of our subject. I prefer to take up the more understood and more common form of direct peripheral irritation, and especially the irritation arising from diseases of the teeth and jaws. In that delightful book, “Rest and Pain,” by Mr. John Hilton, the eminent London surgeon, he narrates a case, which is so instructive in illustrating the mode in which peripheral irritation may cause not only pain, but local disease, that I cannot forbear from quoting it: “A gentleman, aged 63, came to consult me about an ulcer situated upon the left side of his tongue. On examination, I found an elongated, very ugly-looking ulcer, nearly as large as a bitter almond, and of much the same shape. The surrounding parts were swollen, hard, red, and much inflamed, and a lymphatic gland was enlarged below the horizontal ramus of the lower jaw on the same side. I saw in the mouth a rugged tooth, with several projecting points upon it, opposite the ulcer. This gentleman observed to me: “Having suffered a good deal from earache on the left side for a long time, without experiencing any relief from medical treatment, it was thought that I must be gouty, and I went to a surgeon who treats gouty affections of the ear. This surgeon paid great attention to my ear, but certainly did not do it the slightest degree of good. I accidentally mentioned to him that I had for some time past something the matter with my tongue. On seeing it, he immediately began to apply caustic vigorously; moreover, not satisfied with applying it himself, he gave it to my wife that she might apply it at home. I have gone on in this way from day to day, until the pain in my ear is very considerably increased, and the ulcer on my tongue is enlarging; so I have come to you for your opinion regarding my state; for, to tell you the truth, I am afraid of a cancer in my tongue.” I thought I saw the explanation of this patient’s symptoms. The pain in the ear was expressed by the fifth nerve, and there was a rugged tooth with little projections on it, some of which touched a small filament of the lingual-gustatory branch of the fifth nerve in the surface of the ulcer. I detected this little filament by placing upon it the end of a blunt probe. It was situated near the centre of the ulcer, and was by far its most exquisitely painful part. This exposed nerve caused the pain in the auditory canal which led him to go to the aurist, and the aurist, instead of confining himself to his own department, seized the tongue, put nitrate of silver upon the whole of the ulcer, and increased the mischief. I simply desired that the ulcer should be left at rest; that the patient, to avoid touching the tooth, should neither talk nor move his tongue more than necessary; that he should wash his mouth with some poppy fermentation, and take a little soda and sarsaparilla twice a day. In three days about one-third of the ulcer was healed up, actually cicatrized, the enlarged gland nearly gone, and the earache much diminished. “This rapid improvement might appear something like exaggeration, but all surgeons know that the tongue has those elements within it which contribute to the most rapid repair of injury. I do not know any tissue that repairs itself more rapidly. It is abundantly supplied with capillaries filled with arterial blood, and has an enormous distribution of nerves, and these are two elements that contribute to rapid reparation. It was quite clear that the treatment was in the right direction, viz., that of giving rest to the tongue and ulcer. After a few more days I requested him to consult a dental surgeon with respect to the propriety of taking off the points of the tooth. This was afterwards done, and the patient soon lost his anxiety about cancer, his earache, and all his other severe symptoms.” I cannot doubt that the starting point of a large number of similar painful ulcers and of true cancer of the mouth is to be looked for in disease of the teeth. When we come to the teeth themselves, the pain lies in the irritated nerves of the pulp. Of course it cannot be denied that the pulp itself may be the original seat of the pain, but, if so, the number of such cases must be few. When we reflect on the mode of nutrition of the tooth, it seems almost self-evident that any depressing agency which could lead to disease of the pulp must, by an augmented action, cause greater disease in the structures which depend on the pulp for their nutrition to start with. At most, disease and pain in the pulp alone must be nothing less than a pathological curiosity. Such, however, is not the case in the vast multitude of cases dependent on caries, in which the pulp has lost in part or in whole its protection from external morbid influences. The origin of caries is one of the most interesting subjects in the whole domain of surgery. I have been astonished to find that among dentists it is not more definitely settled. So able a writer as Wm. Henry Potter (of Harvard) says: “In the first place, it may be said that caries of the teeth does not resemble caries of the bone. The term caries, as applied to the teeth, is a misnomer, given at a time when the true nature of the process was not understood.... The pathological change which occurs in caries is a decalcification and disintegration of the several tissues of the teeth.” 105 106 I confess that strikes me as a very excellent description of what surgeons usually term caries, namely, a molecular death of bone tissue. Nor can I see any difference in the essential nature of the two processes, if you make due allowance for the morphological modifications of tooth structure from bone structure, and the different environment under which the process takes place. If I were asked to define dental caries, I should say it was a molecular death of the tooth structures, especially the dentine, due to the action of micro-organisms; that in the course of the process lactic or other acid is developed, which decalcifies the teeth, is doubtless true, but the very presence of acid fermentation in a normally alkaline cavity necessitates the assumption of the action of micro-organisms. I would remind you that the conditions favorable to the activity of such organisms are all apt to be present. They are: 1st. The presence of the micro-organism. 2d. The existence of a suitable pabulum. 3d. A certain degree of moisture. 4th. A certain degree of warmth. 5th. A certain amount of oxygen or air. 6th. A lessening of the resisting power of the tissues affected, as compared with health. All of these first five conditions are notoriously present in the mouth. That we do not oftener suffer from their effects is due to the absence of our sixth element, the lessening of the resistance of the tissues. Thus, in health, those organisms which flourish best in an acid secretion have their baneful activity held in check by the alkaline saliva as well as the resisting power of the dense enamel. But once let the alkalinity of the saliva be lessened, or changed to an acid reaction, or let ever so small an abrasion occur in the enamel, and the myriads of these agents find a foothold for starting the morbid train of symptoms. Similarly, even in the tissues themselves, the enamel, no less than the dentine, suffers from those predisposing causes of constitutional malnutrition, which are so important in their effect on the central cell, and which act in lessening the normal resistance of the periphery. It would be a work of supererogation to trace the progressive course of caries and the mechanism of the production of pain through irritation of the pulp. But when we come to the question of treatment, the two main considerations to be accomplished are worth our study; these are: the relief of the pain, and the arrest of the carious process. The arrest of the pain is what the patient comes to you for, and prompt action is eminently desirable. I was much impressed with this in a case I saw a few weeks ago, in which an active business man, somewhat run down by overworking, suffered from toothache (I think due to caries) for several days before consulting his dentist, my friend Dr. Jarvie. The pain in the third division of the fifth nerve gradually subsided after treatment, but was followed by a well-marked neuralgia in the great occipital nerve of the same side. He again allowed some days to elapse before sending for me, and I found him suffering from a very intense crisis when I called. It was promptly relieved by the use of a remedy to which I invite your particular attention, namely, aconitia. It has seemed to me for some time that this agent should form parts of the armamentarium of every dentist. From the fact that I have found it unused or unknown by some of your most progressive men, I shall not hesitate to say a few words about it to bring it before you. Aconitia, or aconitine, is the active principle of the familiar drug aconite. Although discovered fifty years ago, it is only within the last ten or twelve years that it has been intelligently used. It is an extremely potent remedy, and must be used with great caution. In large doses it acts as a dangerous heart depressor, and paralyzer of motion and sensation. But in physiological doses it is without danger and is pre-eminently useful, because of a special action it has in relieving pain of the fifth nerve. In other neuralgias it is, for some unknown reason, far less potent. Our excellent Brooklyn pharmacist, Dr. Squibb, has put upon the market a most reliable preparation of this drug, an oleate, containing two per cent. of the crystallized salt. This seems to me a form which is peculiarly adapted to dental work. Ordinarily in prescribing this remedy internally I begin with 1 200 of a grain and repeat it every hour; often one or two doses will suffice to relieve the pain, and it is seldom that more than four are required. In using it locally if you wished to begin with the same doses, it would be necessary to dilute one drop of Squibb’s oleate with three drops of bland oil for each drop of the mixture to contain 1 200 of a grain. An application of this medicament would be more effective, I believe, in relieving the pain of an exposed or inflamed pulp than those remedies now in use. I can testify from personal experience of the frequent inefficacy of the local application of oil of cloves and chloroform, while the use of the stronger remedies, as ninety-five per cent. carbolic acid or pure creosote, can only be efficacious by more or less coagulating and therefore in so far destroying the nerve tissue and the pulp. And this I take it is always to be avoided when practicable. I hope therefore, that some of you will give this remedy a trial, and verify practically my suggestion. Having relieved the pain by one way or another, what means do you adopt to stop the progress of the caries and restore the tooth as a useful member of the economy? Now if our considerations as to the origin of caries were true, that it is a disease due to the agency of septic micro-organisms, the logical consequence is that successful treatment must be in the line of antiseptic treatment. I presume this will cause a smile at the presumption of an outsider venturing to enter on so practical a subject, and perhaps some one will mentally quote the line about “fools” rushing in where angels fear to tread. But it is possible that much of your practice may have been truly antiseptic, just as the wise surgeon’s has been, long before we knew the why and wherefore of what experience has now taught us to be true. We are all more or less like the hero of Moliére’s comedy, who was astonished to find when he arrived at middle age that he had been talking prose all his life without knowing it. Now if we analyze your proceedings in the treatment of caries, and thus relieving the painful or 107 108 109 inflamed pulp, let us see if they are not based on antiseptic principles, even though unconsciously employed. First of all I take it you aim to remove all the carious material by means of your instruments, and the success of the operation is dependent on the thoroughness with which that is done. Does not that seem as if you were removing a true infective centre, and thus obviating the first condition favorable to the development of caries—the presence of micro-organisms. Now let us see how you combat the second favoring condition, and that is the presence of a suitable pabulum; is not that done by the simple mechanical interposition of your filling between the diseased surface and the fluids in the mouth? Again we found a certain degree of moisture needed, do you not scrupulously dry as well as clean out your cavity, and is not your filler non-absorbent as far as possible? Fourthly. We found a certain degree of warmth was favorable; that is, of course, always present in the living body, and in choosing a good non-conductor of heat as your plugging material, it is with reference to the secondary effects of caries, the pain caused by thermal extremes, and not with special reference to the disease itself. Indeed, could we obtain a substance which would combine the resistance to organic and chemical action that gold does with the poorness of conducting power of gutta percha, it would be a great advance. The presence of air in the decayed tooth is also prevented by the mechanical means; while lastly you substitute an artificial tissue to resist in place of the dentine and enamel that is gone. Indeed it seems to be that the whole process of successfully filling a decayed tooth is one of the most perfect examples of antiseptic treatment I am acquainted with. I doubt not there will be further advances made in your technique, but the principles will not change. I believe it quite likely that it will prove desirable to more thoroughly disinfect the carious cavity before filling than is always done now, and it may prove possible to devise some material which, either by its hardness or by its chemical constitution, or by some antiseptic incorporated with it, will longer resist the destruction due to attrition and to chemical and micro-organic action than the ones now in use. To recur to the main problem of our paper—the relief of pain—is it not true in this class of cases that after the first effects are stilled, its recurrence is prevented by affording artificially that immunity to the pulp from peripheral irritation which it possesses in health? Disease of the peridental membrane causes a characteristic pain, but one which need not long detain us. From the fact that it is nearly always secondary and not primary, its treatment should first of all necessitate the removal of the originating cause. The spread of inflammation or decomposition from the pulp to the periosteum which so often occurs can be better accounted for by the hypothesis of the action of micro-organisms than by any other supposition. Moreover, in the advanced cases, where pus has formed, the same cardinal indication of treatment, viz., proper drainage, obtains here as in other departments of bone surgery. We have already spoken of the constitutional poisons, syphilis and mercury and phosphorus, which may be causes of this form of trouble, and I would only like to say one more word, and that is in the way of treatment. Occasionally it has seemed to me that you can stop the further progress of a periostitis, if you get it in an early stage, and prevent it from going on to suppuration. I remember one case of a gentleman who applied to me for a very painful gumboil in his lower jaw opposite the first molar. The gum was swollen and reddened, and a well-marked phlegmon could be felt. I gave him fairly large doses of mercury for a couple of days, and it gradually melted away. There was no suspicion of syphilis in this case. Another remedy I believe to be of great value in treating neuralgia of the face starting in periosteal irritation, is phosphorus. The best form in which to administer this remedy is the preparation known as Thompson’s solution. I can testify to this from personal experience. Some twelve years ago I suffered from periostitis of the first bicuspid of the upper jaw on the right side. A couple of years later, while working hard, I had an attack of intense neuralgia of the entire second division of the fifth. When it subsided, it left some periosteal thickening at the exit of the nerve from the infra-orbital foramen; and ever since then, whenever I get run down by overwork or worry, the same pain crops out. But I have found that a few doses of phosphorus will completely hold it in check; and in one or two patients, since then, I have seen the same fact, that in the neuralgia due to periosteal irritation this remedy holds a high place. It has seemed to me highly significant that the two drugs, mercury and phosphorous, which in continued toxic doses cause this very class of diseases, should in physiological doses be curative. But this is in entire consonance with the general laws of tissue irritation, and the therapeutic fact that certain drugs acting through the nervous system stimulate in small doses and narcotize in large ones. The last type of dental pain I will speak of is that arising from pressure due to hypertrophy of the cement. Where this is not due to the peripheral irritation of a carious tooth, the causation is both interesting and obscure. It has seemed to me that we must postulate the agency of a constitutionally acting cause to account for certain of these cases. I think it quite probable that in certain cases a well- marked gouty diathesis will be found underlying this form of disease; and a similar constitutional error must be invoked to explain the allied cases of calcification of the pulp. We have now briefly reviewed the main forms of peripheral irritation, which act as the efficient causes of dental pain, just as we have glanced over the main constitutional causes that predispose to it. I think you will all agree with me that for the successful treatment of these cases, especially in the chronic and inveterate type, local and constitutional treatment have both to be employed. It seems to me there is great need for the more intelligent co-operation of physicians and dentists to attain the best results. 110 111 Attention to one side of the question is not sufficient. For the permanent cure of our patients, the treatment of the local mischief has to be supplemented by attention directed to the constitutional conditions that predispose to it. One of the cases I quoted illustrated the important fact that a local irritation may set up a condition of pain in other nerves which the cure of the original lesion entirely failed to relieve. This fact is borne out by many similar conditions which we meet with in other departments of medicine. On the other hand, while a particular attack of pain may be relieved by constitutional remedies, its recurrence can only be prevented by curing the local condition, which acts as the exciting cause. The enormous preponderance of cases of pain of the fifth nerve, compared with other nerves, is to be accounted for by the liability of the delicately adjusted mechanism of the organs supplied to get out of order. This is especially the case with the eye and the teeth. It is beyond the scope of my paper to take up the various constitutional remedies of which we can avail ourselves, rest, the influence of food, the use of the various drugs, the employment of counter-irritation, of electricity, and, lastly, of those surgical procedures, exsection and stretching of painful nerves, which are our last resort. I will more than have attained my object if I have pointed out, however imperfectly, some of the many interesting points at which our respective fields of work touch. Those points where we need your help, and you ours, to accomplish the best results. And now, in conclusion, if we revert to our original question as to what it is that constitutes pain, I think that we will find that both the great authorities I quoted are wrong, and both are right; each has stated half of the truth. If your observation and reasoning agree with mine, we will be forced to believe with Anstie that pain in its essential nature consists in a diminution of the vitality of our central cell, but to further allow with Erb that this is occasioned, or first brought to our notice in most cases, by an increase in the impulses sent to that cell by means of peripheral irritation. 112 BACTERIA, WITH A METHOD OF STAINING FOR DIAGNOSTIC PURPOSES. BY JOSEPH KETCHUM, ESQ. Read and Demonstrated before the Section on Microscopy of the Brooklyn Institute. In presenting the subject of Bacteria, I wish to disclaim any originality for the matter offered. I have endeavored to collect from such sources of information as I have access to the important dates, names and facts which have marked the progress of bacteriology up to the present time. So far as we know, the first observer of bacteria and the so-called infusoria was Leeuwenhoek, who, with a simple magnifying glass, noticed in a drop of putrid water the multitude of little granules moving about in it. This was in 1675, and his observations were communicated to the Royal Society of Sciences in the same year. In the following year he recognized bacteria in the tartar from the teeth, and though he did not name them, his description of their forms and his drawings enable us to identify them as vibrios. There appears to have been no important investigations carried on until nearly one hundred years later, or in 1773, when Müller, a Dane, attempted to classify the organisms then known. He called them all infusoria, from the fact that they were the product of infusions, and divided them into two genera—the monas and vibrio. The monas he subdivided into ten forms and the vibrio into thirty-five; but his descriptions of them are so faulty that it is at present impossible to identify them from his writings. During the following century the study of bacteriology attracted more or less attention, and in 1829 Eherenberg, who is the Humboldt of the science, commenced his investigations, which for fifty years he pursued with an ardor and enthusiasm second to not even Darwin himself. He, in 1838, classified the family of vibrioniens, and with the additions made by Dujardin in 1841, placed them in a scientific category. Of course during this period many were the disputes and discussions as to specie, genera or family, each newly discovered member belonged to. And we have to come to the period of Hallier, Hoffmann and Cohn, and many others, before the questions, which had up to that time been in dispute, were settled. Ehrenberg’s original classification was into: 1. Bacterium, or rod-like—three species. 2. Vibrio, snake-like and flexible—nine species. 3. Spirillum, or spiral, but inflexible—three species. 4. Spirochœte, spiral, but flexible—one species. Dujardin, in 1841, in his Natural History of the Zoophytes, accepted the classification of Eherenberg, except that he unites the spirillum and spirochœte, calling them all spirillum. Up to this time all bacteria had been considered animals, but a close study of their life history and habitat by those who followed declared them to belong to the vegetable kingdom, and as such they are accepted to-day. In 1853, M. Chas. Robin pointed out the relationship of bacteria to Leptothrix, a form of fungi closely allied to that of mildew; and M. Davaine, in 1868, clearly demonstrated their relationship to the vegetable world. From this time the progress of bacteriological investigation has made rapid strides. Prof. Pasteur in the organisms of fermentation and the role they play therein; Davaine and Hallier in demonstrating the specific relationship of bacteria with charbon or anthrax; and the work of Koch, Nageli, Kohn, Bilroth, Miguel, Burdon, Sanderson, Klein, Weigert, Klebs, Ehrlich, Sternberg, and many others, are too recent to require special mention. Few have more than the faintest conception of the minuteness of these organisms. Prof. Cohn, justifying himself for the unscientific method of comparison which he uses in class instruction by Prof. Tyndall’s argument on the scientific use of the imagination, says he compares man to the cheese mite, as the Strasburg cathedral to a sparrow. Of the animalcules which Leeuwenhoek discovered, they are to man as the bee is to the horse. As improvements have been made in microscopes, just so fast have we penetrated into the world of micro-organisms, until now the proportion between the smallest we can see and man, is as man is to Mont Blanc. Of course, with these exceedingly minute structures, nothing can be made out except points. Among some of the larger forms, a few have been able to see cellia, and in some cases the growth of the spores; but in the present state of microscopical optics the work is slow, and progress in this direction is waiting an advance in the science of optics. Like all living organisms, bacteria propagate themselves. The most usual method is by fission or by partition, though Magnin and Cohn have recorded their observations on the formation of spores and sporangia, and I have myself witnessed the last named method. It is of importance to note that while the bacterium is killed by continued exposure to temperatures of freezing or 176° F., the spores will germinate after protracted exposure to temperature as high as 205° F. or as low as °123 F. These spores will also withstand complete desiccation, and it is in this form, mixed with the air we breathe and move in, that present the conditions from which all zymotic diseases originate. Miguel has shown that, while the air contains very few adult bacteria, it contains myriads of their spores. To the researches of Koch, Pasteur, and others, we are indebted for the certain information that, while these omnipresent germs withstand such vicissitudes of temperature, they require certain food for their maintenance; and though we cannot as yet tell what that food is, we know that when nutrient material is submitted to their action they thrive for a time, and when the particular principle which supports them is exhausted they die. This is particularly true of pathogenic germs, and the accepted theory of the bacillus tuberculosis, or the germ of consumption, is a good illustration. It has been demonstrated by Koch, Klein, Pasteur, Frankell, Sternberg, and others, that they require some product of inflammatory action for their support within the body of their victim. This is also true of cholera, at least so far as their dietary requirements are concerned. The animal cannot be infected with tuberculosis by merely introducing the germ-laden 113 114 material into the stomach or upon any of the mucous membranes; but if an inflammatory condition be present, either due to the puncture of the introducing needle or scalpel, or to extraneous causes, such as a catarrhal condition of the lungs, tuberculosis is as sure to follow as the sun is to rise again. The human mind can scarcely comprehend the enormous numbers of...