on that method for more than six months trying to get some of stress under the influence of maternal environment results and I used the most results, with entirely negative or of factors. The therefore, must careful methods. It shows how difficult it is to these hereditary fetus, get at be prepared to pass through not only intra-uterine things. periods of stress, whose dental mark has already been indicated, but post-uterine periods as well. PERIODS OF STRESS AND THEIR DENTAL The child has not attained its full development at MARKS. the time of birth. It has within it certain potentialities, JAMES G. KIERNAN, M.D. some of which are never fully realized. There is a con- Fellow of the Chicago Academy of Medicine; Foreign Associate stant struggle between the central nervous system and Member French Medico-Psychological Association. certain bodily functions for preservation of the indi- CHICAGO. vidual and for preservation of the race, through which Despite embryologic teachings, that old notion that the central nervous system fails to reach the height man is an entity who undergoes development alone, still indicated in the child. This struggle for existence after controls pathology and physiology. The human being, birth is keenest at certain periods. Each period is however, is a animal in whom have marked by dental phenomena. The first is the period compound organs the their own nervous system and their own life under con- of first dentition. Here, coincident with-teething, is its trol of the cerebrospinal system. The child is not an the child gaining impressions of the outside world. undeveloped man, but man is an imperfectly developed is learning to walk and talk, and is also developing its child. The embryo has to contend with retrogressive eliminative organs, especially the rectum. These varied as well as factors, and the same is true of functions constitute a strain on the system, effects of progressive which most man after birth. Vertebrate embryos are of common are often evinced through the teeth and The to are an type at their origin and assume successively many com- jaws. conditions charged teething expres- mon forms before The sion of constitutional strain finding its outlet through definitely differentiating. higher the vertebrates contain in essence the organs and possibil- point of least resistance. During this first dentition, ities of all lower vertebrates. The human organism is the strain of development forces attention to the teeth, therefore a balance. While the balance is maintained and thereby leads to neglect of other factors. The teeth the organs work in unity, though there is a constant at this period should be regarded as a meter of consti- struggle for existence between them. tutional strain, and not a cause of it. Within the next During embry- 2 onic existence this struggle is more intense and diversi- period, between and 6, occurs the first great check to fied than after maturity, because of the influence of continued development of the brain. Man has learned three contending forces: remote atavism or throw-back to use his brain despite this check, but had it not he a brain to primitive types, immediate atavism or throw-back to occurred would have had higher type of to less remote ancestors of the same type, and im- use. Sometimes during this period the brain gains in finally in mediate heredity. Remote atavism tends to preserve size, albeit not balance, at the expense of the general In no structures which occur in the normal embryo only to system. small degree the struggle for existence disappear. The human heart passes through all verte- during this period of stress centers around the develop- brate heart phases. This is likewise true of the teetb ment and eruption of the 6th year molar. With the During the life of the embryo the tooth system wavers-- eruption of this molar, premature puberty, sexual pre- at one time between the polyphyodont and the diphyo- cocity, epilepsy, insanity, gout, rheumatism, obesity, dont. At this period, should the diphyodont tendency and other nutritive degeneracies, may occur. All have of man be arrested, the polyphyodont takes its place and been charged to the eruption of the 6th year molar, the human being sheds teeth as do reptiles. On the whereas its irregular or difficult eruption is, like them, other hand, should immediate atavism gain the ascend- an expression of constitutional stress. Hygiene of the ancy over remote atavism shown in polyphyodontia, teeth at this period means also constitutional, mental diphyodontia occurs. When the struggle for existence and moral hygiene. Epilepsy, for example, is not a between the two is keenest a period of stress results, disease, but a symptom of weakness of certain vasomotor which affects the organism as a whole. This stress inhibitions. The first convulsion does not constitute expresses itself most strongly in dental and maxillary epilepsy. Through a law of the nervous system, nerve action once irregularities, since the jaws and teeth are among the roused tends to repeat itself. In this way most variable structures in evolution. Under what is are established normal and abnormal habits, of which known as the law of economy of growth is governed last epilepsy is one. In its early stages a habit normal the relation of the organs to each other, and the process or abnormal is easily checked. The first convulsion, whereby one structure is sacrificed for the development therefore, could be prevented were its premonitions known. A recurrence could also were of another or for the development of the organism as be prevented the a whole. Since certain parts in the evolution of organs constitutional origin recognized. Observation of the gen- disappear and in the evolution of organisms certain eral constitution at this time, because of irregular .erup- organs through suppressive economy and since the dis- tion of the 6th year molar, would enable the physician appearing and developing tendency of necessity centers to nip epilepsy, and many other allied conditions, in around the time when certain functions are to be lost the bud. Reflex notions, however, must be flung over- by the disappearing and others gained by the developing, board. All irritations should be removed and any con- periods of stress occur around which the law of economy stitutional irregularity treated. of growth centers the struggle for existence between The obese child of 6 years, even though the obesity parts of organs and between organs themselves. It is be not excessive, should be looked upon from, a health because of this that physiologic atrophies and hyper- with There is to their standpoint suspicion. liability disease, trophies and reverse occur. Nearly all conditions and marked to weakness when under of physiologic disturbance result at these tendency systemic may periods morbid influence. These children are particularly liable Read in the Section on Stomatology, at the Fifty-second Annual to rheumatism, etc., and from Meeting of the American Medical Association, held at St. Paul, gout, profuse hemorrhage Minn., June 4-7, 1901. slight causes. Youthful obesity is sometimes associated

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015 with precocious maturity and resultant early senescence. narcotics. The struggle for existence between the de- More often it co-exists with extended infantilism, as in veloping alimentary and other systems between the the case of Dickens' "fat boy." 2d and 6th year had produced effects which are most E. S. Talbot, examining 267 corpulent school children felt during the 6th to 12th year. Provided this struggle- and adolescents, found marked of is between normal limits, the average child does not stigmata degeneracy. incur it. Ninety-two per cent, had deformed ears to a marked permanent danger from If, however, from' defect or degree. Sixty-six per cent, had arrested development, heredity, congenital improper environment,, as with their age, while 12 cent, development of the system does not proceed equably, compared per presented then strain which this excessive development. Thirty-four were too young to results, produces, during period, determine the form and size of the jaw. In 33.5 per not only the conditions already described, but the fol- cent, of the thirty-four the molars, incisors, cuspids lowing as well: and bicuspids were present. Ninety-six per cent, of NEUBOSES. PSYCHIC TYPES. these had small teeth. Eighty-seven per cent, (of the Convulsions. Hallucinations 233) had arrested development of the upper jaw; 22 Nervous laughs Anomalies of character cent, arrest of lower per cent, had Nervous coughs Aberrant sentiments per jaw. Sixty-four Love or or their Hiccoughs V-shaped saddle-shaped arches, modification, Renal and protruding teeth. Seventeen per cent, had hyper- Jealous)' of the alveolar cent, Hepatic Anger trophy process. Eighty-three per Gastric Obsessions or imperative con- had small teeth. Twenty-seven per cent, had extra Vesical cepts tubercles upon the molars. Eighty-two per cent, had Genital Pur« stenosis of the nasal cavity more or less marked. Thirty- Pulmonary Attended by impulsive acts six per cent, had deflection of the nasal septum to the Adenopathic Arson left and 29 per cent, to the per cent, Cardiac Suicide right. Twenty-one Metabolic wore-glasses for eye defect. In 58 per cent, there was Homicide of the and in 7 cent, Stuttering Alcoholism enlargement thyroid gland, per '•Tier," Theft arrest of development of it. In 296 cases of early lipo- matosis male and 116 under Neuralgias Rape (180 females) coming my Neurasthenia Non-criminal acts own there were 10 6 observation, cryptorchids, hypo- Ecstasy Night terrors spadiacs and 3 cases of pseudo-hermaphroditism. Three Hysteria Idiocy females had infantile bifid uteri. Four had enlarged Chorea Imbecility clitorides; in one of these the urethra perforated the Epilepsy Mania clitoris, as in the female shrew. Of 40 girls who had Somnambul ism Acute confusional insanity reached 18, only 3 had menstruated normally. The Melancholia others were amenorrheic or dysmenorrheic, or had neu- Transitory frenzy rotic storms during the period. There were 160 hebe- Stuporous insanity the number. Of these 120 had mas- Stupor phreniacs among Katatonia turbated excessively. Ten had been nymphomaniac or Paranoia satyriasic. the sexual appetite having become completely Cyclothymia extinct at 18. of the never Fifty non-hebephreniacs These are to occur at as a showed of sexual Three of the apt this time reaction to any signs appetite. disturbances of health. The were sexual inverts, while 80 temporary temperature hebephreniacs practiced at which disturbances in a is a various Of the 10 were psychic begins child perversities. non-hebephreniacs fair index of its brain 30 had acute forms of 10 were stability. Neuropathic children, cyclothymiacs, insanity. on a in or 15 had had chorea. very slight rise temperature even without it, epileptic and hysteric. Thirteen to Ninety-seven had difficulty in learning to speak and 30 are subject attacks of unreasonable elevation, during stuttered. which they are quite beside themselves, rushing about always wildly, shouting, fighting, and without clear conscious- The appearance of the first permanent molar is there- ness of their With this last of to surroundings. picture fore great significance stomatologist and sociolo- stomatologists are very familiar in children to and moral deficiencies brought gist alike. The mental usually them for care of the teeth. During this period such present will interfere with proper care of the teeth disturbances have to be taken into account in cases where indicated in cases where such deficiencies particularly maxillary and dental treatment and regulation are indi- occur. While the eye has received much attention as a cated. the teeth and as a sociologie guide jaws have, rule, The of should include the from been much of even more period puberty period neglected, although significance the of the menses or until the than the functional disorders of the appearance spermatozoa eye. completion of the 25th year. The appearance of the The next important period of stress is practically wisdom tooth at this time marks human maturity, which that of the second dentition. Here there is a foreshadow- was the reason that 25 was selected for the age of matur- ing of the mental and nervous phenomena of the follow- ity by the code of Napoleon. During this period it is ing period of stress. Sexual development now fre- possible to correct dental and maxillary irregularities quently receives its initiative. What is true of neuro- with benefit to the subject. Every one of the conditions pathic children earlier is true at this time of ordinary enumerated are due to strain during the period between stress. is children. under conditions of There irregu- 6 and 12 may appear. In addition there occurs a type larity of disturbed sleep, irritability, apprehension, of mental disorder called hebephrenia, or insanity of strange ideas, great sensitiveness to external impressions, puberty, which is practically incurable after its devel- high temperature, delirium, convulsions from slight opment. This is an insanity peculiarly charged to causes, disagreeably anxious dreams, romancing, intense cigarette-smoking, masturbation, overstudy, religious feeling, periodic headache, muscular twitching, capri- excitement, and "love," all of which are the expressions cious appetite and marked intolerance of stimulants and of the defects and not their cause. These subjects in

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015 the earlier stage of their psycliosis peculiarly require jUst exact.y how it comes about, but where the teeth are meved teeth In some cases, strain from the tooth by springs, ligatures and all kinds of appliances, they can not regulation. held irregularity may have sufficed to upset the unstable be perfectly firm. Later in life absorption of the alveolar mental balance. The next of stress in process occurs at this very point, due to osteomalacia or al great periods veolar Later in life sets in from human life are those of the climacteric and of the senile absorption. gingivitis regula- tion of the teeth, the are never restored to health and the The first is the in jaws period. accompanied by menopause absorption goes on until the teeth become loose and are lost. women and prostate in men. The dental con- change 1 want to call attention to the a four and one ditions these two of stress are your picture, marking periods generally half months old All have seen children that have involutional in or embryo. character and require prothesis treat- the of with little hairs the face and not correction. appearance age, upon ears, ment, with wrinkles in the face, the hair frequently gray in spots, DISCUSSION. the skin drawn up and the fingers long and slender. In such patients, dentists should be very careful in the regulation of Dr. Eugene S. Talbot. Chicago—I have been interested in the teeth and in all operations. They always have irregular- this subject for years and 1 have spent a great many years in ities and the greatest care is necessary because of the unbal- the study of these conditions. I have never heard a paper so anced nervous system. define those conditions as the one that has been clearly just Dr. Vida A. Park, 111.—It is a read. Someone has said that the discussion of dental Latham, Rogers good thing subjects to have the tension made clear on pathologic principles. Many has been exhausted, but a of the conditions of the knowledge teachers have made the statement that it is absurd to suppose mouth so far as hereditary environment and embryology are that the changes are made through the nerve functions. concerned is still in its There are some which They infancy. points can occur tension, not but it is deserve attention. Dentists often remark that if their through perhaps permanently, patients one of the factors this or it may be were more careful with their teeth would not and underlying development, they decay, through a case of retrogression. When we think of the enor then a course of treatment handed down for decades. prescribe mous amount of force that on in the of the The old is told of the recommend- goes development same story brushing teeth, teeth four dental and of the the use of certain etc. As Dr. Kiernan coming through cycles, congestion ing preparations, said, which involves the vasomotor and vasoconstrictor we evolution of the teeth is towards extinction. of systems, tending Decay may come to the conclusion that it is due to the period of the teeth is a natural process and all the treatment on earth first stress. I have heard men advance the that —as now not save them in the individual. argument applied—will except pathologic stress is absurd ; that it can not come from such It is not a but it has become a national only personal calamity, a source, and was a excuse for of some one. of the teeth and of the of only poor ignorance Study jaws peoples Europe local condition. shows teeth of men deteriorating, where the peoples are not of a nervous tendency, as they are in other countries. Through Dr. G. V. I. Brown, Milwaukee—I can not say very much Greece, Turkey, Russia, Norway, Sweden, France and England, on this subject without encroaching on the paper that I expect in the order mentioned, is evident degeneracy of the jaws and to read later on. I shall be obliged to disagree with Dr. teeth. There are no peoples in the world whose teeth are decay- Talbot concerning the regulation of teeth, because I have to ing to-day like those of the English people. There are no ir- begin to regulate the teeth of these young patients before they regularities of the teeth like those of the English. In England are entirely destroyed, and from all of which I have demon it has become a national calamity and the authorities have ap- strated I can not agree with him. In regard to what h'e says pointed committees and have furnished money to investigate the of the disastrous results following the regulation of teeth in cause of decay of the teeth. All attention, the best methods of children and young persons, I think it was rather the fault of treatment will not save them. the method than the age of the patient, and I am convinced Another question of the jaws and teeth that Dr. Kiernan 1 hat where that continual absorption went on it was due to the has discussed, is the evolution of the second set of teeth. Den- effect of occlusion of the jaws on account of malposition, which caused an irritation of the tissue around mouth. tists think they are able to treat pyorrhea alveolaris or gin- the givitis, and some claim to cure every case. With them it is Dr. James G. Kiernan, Chicago—I only wish to correct a simply a matter of local application, a peculiar sense of touch little terminology which I think might be desirable in this with instruments to remove all visible deposits. The condition Section. There is perhaps no word so misused and misleading is an atavistic one, and the disease is preventive to a certain as "degeneracy." The question is whether there is general extent. Still, should the individual live long enough, he would degeneracy or whether it is a disappearance of certain parts lose his teeth. This is a process of osteomalacia and nothing- for the benefit of the organism as a whole. It is true, a great more than atavistic. As Dr. Kiernan has said, change of the many changes occur in this way for the benefit of the organism teeth is going on continually. Where one tooth is shed in the as a whole. The teeth are decreasing in number. There is lower vertebrates after it has done its duty, another takes its very good reason to believe that man at one time possessed Where the are place. temporary teeth shed by absorption the at least two extra incisors. There is also very good reason second set takes its place. This absorption goes on with the for believing that the wisdom tooth is tending to disappear. second set and the teeth are lost in time. This occurs not in There is also good reason to believe that the human tooth is all cases, however, but in the majority, if the person lives long becoming mierodont rather than macrodont, rather smaller enough. Dr. Kiernan showed you a picture of the degeneracy than larger. This is along the general line of evolution with and arrest of development. This is a picture where the child reference to the face and jaws. The human jaw itself with has grown to manhood, yet remained arrested in development. all its beauty, the human face, with all its beauty, is degen- If internal of the structures the body were examined arrest of erate. For biting purposes and chewing purposes, it is not as would evident. All seen development be have such cases, since valuable as the jowl of the lower races. It is an embryonic they are very common. This particular condition illustrated, feature. It has lost space for the benefit of the brain. The has arrest of the and face. Dr. development of jaws Kiernan brain has been absorbing more and more space at the expense remarks that structures that are temporary are changing from of the bones of the face. Therefore, in dealing with this ques- generation to generation. tion of irregularities it would be wise to look at it in certain For this reason dentists should be careful in regulating cases as a normal process. In certain cases it is wise to study teeth, especially in children of from one to twelve years of age. the teeth not only from the point of regulation, but also from These children are in the condition shown. In this neurotic the standpoint of removal a little more than is done. No condition the nervous system is very easily involved and also human hand can turn back the clock of time, retain a high other organs of the body. Children are often invalided for type of man, and yet restore the jaw of a prehistoric ancestor years by having their teeth regulated and dentists should be who lived on food in which there was an enormous waste. very careful on that point. Another point about regulating The native or prehistoric races had beautiful teeth; but those rteeth in such patients needs attention. Dentists can not tell teeth could not exist with the environment of the civilized races.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015 Civilized man does not waste his food so much; he does not theria may be found in perfectly healthy mouths and need to do so much chewing and tearing, in the only animal throats, ana the fact that these germs remain in the that can be compared with man, the dog, similar changes are mouth and throat for long periods after the clinical signs taking place, and these changes of domesticity are coincident of the disease have the with the in civilized man. disappeared, suggests probability changes occurring Another factor that these diseases be transferred from to also influences these There are race may patient changes. many types unclean instruments. Well instances with different jaws and different teeth. No races are pure patient by proven this are rare considered from this but all races are intermixed. of kind indeed ; yet this mode of infection is standpoint, of It is safe to say that every one of the English-speaking races worthy attention. has some primitive race element in them. Every one of the The germs of diphtheria are sometimes found in tooth Teutonic races and every one of the Eur-Afriean races have cavities or in a healthy throat, and although they may the same elements in them,, and also the Eur-Asiatic. These not cause the disease in that individual because of his races have different types of jaws, different sizes of teeth: natural resistance, when carried to the mucous mem- from their mixture comes the so-called Aryan race. These brane of a susceptible person they may produce the dis- people are subjected to a new environment. It is therefore a ease in a virulent form. The bacillus of to how far in one case removal of the teeth in a diphtheria may duty study be the cause of all of sore throat, from a certain be a benefit in and grades simple type might correcting irregularity, acute catarrh to an intense membranous inflammation how far in the other it might be injurious, and deal with the into the nose and mouth; so that the true question from that standpoint. It can not be dealt with in a extending nature of a sore throat may not be and the general way, but the individual conditions to which man is recognized bacilli from to on instru- exposed must be studied. There is much nonsense talked about spread patient patient septic as is so the degeneracy of the teeth. This is usually ascribed to ments often done by infected spoons and forks. luxury. The degeneracy is often an expression of the advance Diphtheria bacilli usually remain in the throat two of the human race. When man gets fewer teeth, then there weeks after the membrane has disappeared, but have would not be so much irregularity, nor so much trouble in been found five or six weeks afterwards in some cases. other directions. The infectious nature of purulent discharges following scarlet fever, such as a rhinitis or pharyngitis, are now INFECTIOUS DISEASES. fully recognized, so that, if after one of these infectious diseases catarrhal inflammations are the neces- ALICE D.D.S. present, M. STEEVES, sary precautions can be taken to prevent new cases of CHICAGO, ILL. the disease. A knowledge of the possibility of transferring infec- In the same manner, erysipelas, which begins so often tious diseases from one to another means of at the juncture of the skin and mucous membrane, and patient by cocci instruments or otherwise, and of the character of the pus from suppurating processes in the mouth may infection itself, is of the greatest practical value. While be transferred from patient to patient; and it is easily the necessity for proper precautions to avoid these acci- conceivable that the bacillus of tuberculosis could be dents has long been recognized, the recent advances in taken from the mouth of a tuberculous patient on dental the of the mouth and throat cause the sub- instruments and be deposited in the mouth of another bacteriology and then its into ject to assume new importance. patient find way the lungs. Of all diseases in which the infection is frequently DISCUSSION. carried from the mouth of one to that of patient another, Dr. Vida A. Latham, Rogers Park, 111.—This is a subject most In affection perhaps the important is syphilis. this that is scarcely touched upon by dentists, but in connection are in or two different lesions formed about the mouth, with the physician we can accomplish a great deal in this direc- each characteristic of the disease, and appearing at dif- tion. Many cities have a quarantine law, and in that way we ferent periods in its course. The primary sore is fre- can control these diseases in large cities, but it is more difficult quently to be found upon the lips or within the mouth. where a physician is allowed to use his discretion in placarding This is especially true in children. The mucous patches a house. There is a great latitude in that method. If a honest and he can of the secondary are usually seen in the mouth, physician is not perfectly upright, probably stage be fees or some other to favor the where their seat is on the inner surface of the lip, the persuaded by higher way A man will tell him that he has got to go to business, the or the fauces. In size are from family. tongue, palate, they and the result is the physician does not quarantine the father of an to half an inch in diameter, and while eighth they the family, and he goes to the bank or to his business without extend superficially they are never deep. They are hindrance. whitish in color, with rounded edges and raised rather I have had two horrible eases of infection in little folks two sources of than depressed. These lesions are the through the non-disinfection of instruments, more especially most of the infection, which causes new cases of the dis- forceps. In one case that was referred to a specialist, a ease, the virus being carried by actual contact, surgical syphilitic lesion was caused in the upper jaw through the use instruments, household utensils or other accidental of unclean instruments. In another case a woman contract"" means ; and to unaccustomed observers they may be over- primary syphilis and as I did not care to be in a malpractice looked or neglected, or considered harmless because their suit, it was referred to a specialist. The cause was using in- true character is not recognized. fected forceps in extracting her teeth. In dental schools how students are trained to see The with which these conditions occur and many frequency cases of in the oral cavities? do not see them the attached to them should warn syphilis They great danger every because are not out. I have seen them, be- oral to be to them and to take they pointed only surgeon ready recognize cause I have medicine and Few dental to himself and others. practiced dentistry. proper precautions protect schools make any effort to classify or make a clinic for such Modern research into the bacteriology of the mouth diseases. Unquestionably, students ought to study and know and throat has suggested new possibilities in the matter these conditions. Most of us, if we should see a case, would of carrying infection from patient to patient. not recognize it. Therefore, I hope the teaching of surgical The discovery that the germs of scarlet fever and diph- cleanliness will be broader and deeper in all its branches. Dr. George T. Carpenter. Chicago—The ordinary practi- Read in the Section on Stomatology, at the Fifty-second Annual tioner will not the conditions, of the American Medical Association, held at St. Paul. recognize particularly syphilitic Meeting and it is a difficult matter, even where he Minn., June 4-7, 1901. lesions, very suspects

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