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:
“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.