Part 1

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.

_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 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 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 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: