Part 2

“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.”

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 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. 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.

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.