7.-Difficult Dentition. Dentition is a purely physiological process. In the healthy infant, with an organism in no part of which there exists any strong predisposition to morbid action, it is attended in general with little suffering or danger. It may, nevertheless, give rise to much suffering, or even be the exciting cause of some violent and quickly fatal malady, whenever the irritability of the infant's system has become unduly augmented-when its energies have been impaired, and a tendency to disease in the alimentary canal, in the brain or in the respiratory organs, has been developed by bad nursing-or by an impure, heated, or confined air. It is usually between the fifth and seventh month that dentition, in the ordinary acceptation of the term, commences. In different cases, however, the period when the teeth begin to protrude from the gums, will be found to vary-in some, the teeth appearing earlier, and, in others, not until some weeks or even months later. As soon as dentition commences, there is very generally an increased redness, attended with considerable heat and tenderness of the gums, and an increased secretion of saliva. Occasionally, there is a slight febrile reaction-redness of the cheeks, watering of the eyes, and augmented thirst. The child is often fretful, and disturbed in its sleep. The discharges from the bowels are more frequent and fluid than usual, and occasionally of a greenish hue; the stomach is morbidly irritable, the matters discharged from it having often a strong acid smell. Occasionally, eruptions appear upon the skin, particularly upon the forehead and cheeks. In some cases erythematic inflammation and ulceration occur behind the ears, and not unfrequently a slight tumefaction of the salivary glands. As the advancing tooth approaches the surface of the gum, the fingers of the child are frequently held in his mouth; and he presses firmly between his gums the nipple in sucking, or any object which he can readily seize and convey to his mouth. This appears to ease some uneasy sensation experienced by the child, as does also pressing or rubbing the gum with a finger. In some children, however, the process is attended with such slight inconvenience, that the first two incisors are frequently cut without attracting the slightest attention, until their points are seen protruding beyond the gum. It is principally when there is a disproportion between the development of the teeth and jaw, as when dentition commences very early, or when a number of teeth are cut at the same time, that much pain or difficulty occurs. The molar teeth are, also, cut with more difficulty than the incisors. Even when the symptoms we have just described occur, all that is necessary is, to confine the child to the breast of a healthy nurse, and to supply him, occasionally, with moderate portions of fresh water, in which a small quantity of gum acacia has been dissolved. If he has been weaned, to restrict him to a diet composed chiefly of milk and farinaceous substances, and for his drink, to toast, barley, or rice-water; animal food, all stimulating drinks, and every kind of spice being withheld. The child should be kept in a pure, fresh air, and not overheated either by too much clothing, or by too great a temperature of the room he occupies. His head, in particular, should be kept cool, as well during the night as in the day. daily use of the tepid or warm bath will be advantageous; and if the weather permit, daily exercise in the open air should not be neglected. The Little attention need be paid to the diarrhoea that usually attends upon dentition-it is seldom very profuse. If accompanied with considerable griping, an injection of thin starch, or of a decoction of flaxseed, with the addition of a little sweet oil, will, in general, be sufficient. If the griping still continue, a few grains of calomel may be given by the mouth, followed, in the course of four or five hours, by a dessert-spoonful of castor oil. If, as occasionally happens, the bowels, in place of being more free than usual, are constipated, a dose of magnesia, or of castor oil may be given. The eruptions which often appear about the face, and the inflammation and ulceration which occur behind the ears, demand no particular attention. The latter may be washed night and morning with some mild mucilaginous fluid, as water in which the pith of sassafras or the inner bark of the slippery elm has been infused. The eruptions and ulceration very commonly disappear when the teeth have protruded beyond the gums. As infants appear to derive relief from a slight degree of pressure upon the gums during dentition, something should be allowed them for that purpose. A substance that will yield to the pressure of the gums is to be preferred. An oblong piece of gum caoutchouc, two or three inches in length, and half an inch in breadth, will probably be the best; it should be suspended round the neck by a ribbon or tape. All hard, rough, or unyielding substances are positively injurious. A variety of washes for the mouth have been recommended, by different writers, to "soften, soothe, and refresh the gums, during dentition." When composed of any simple mucilage, these washes do no harm. They are unnecessary, however, if the child be supplied with cold mucilaginous drinks. The good effects that have been attributed to them, in allaying the irritation of the gums, is referable, we suspect, entirely to the gentle friction produced by the nurse's fingers, in their application. It is not always, however, that the process of dentition is accomplished with so little inconvenience. In children of very irritable habits; in those who are gross and plethoric, or in whom there exists a strong tendency to disease in one or other of the organs, dentition may become the exciting cause of some of the most serious and fatal maladies incident to the period of childhood. In such cases inflammation of the mouth or gums, terminating in ulceration. or gangrene-long-continued and extensive disease of the bowels,. accompanied with frequent and vitiated discharges-spasmodic closure of the glottis-convulsions, often of a violent character-and hyperæmia, inflammation, or dropsy of the brain, are among the most common results of difficult dentition. In the children of the poor especially, who are exposed to the overheated, stagnant, and impure atmosphere of the confined streets, courts, and alleys of our larger cities in the Middle and Southern States, dentition becomes, during the summer season, one of the most common exciting causes of the cholera of infants. Recently attention has been directed by Dr. Fliess, of Neusalt, to a paralytic condition of the limbs which sometimes occurs during dentition. (Journal für Kinderkrankheiten, July and August, 1849.) It is much less frequent during the first, than during the second dentition. Its attacks are almost always sudden. The child is cheerful, and playful as usual, has a good appetite, and goes to bed in the evening apparently quite well. At first, perhaps, it sleeps very quietly; but it soon becomes disturbed, tosses about in a restless manner, groans and screams out in its sleep, grinds its teeth, is thirsty, has some heat of the head, and towards morning is rather feverish. On the next day, when perfectly awake, it is discovered that the child is unable to use one of its arms, or, in rare cases, an arm and leg. If the arm alone be paralyzed, it hangs down, useless, by its side; it is warm, but in consequence of the gravitation of the blood in the limb, the joints of the hand and the fingers are of a bluish-red color and swollen. The sensibility of the arm is either entirely lost, or is very obtuse. The excito-motory power can be but little, if at all, excited by strong stimulation. If the child, at last, complains of pain, it is only from the dragging of the muscles of the shoulder. The paralysis sometimes extends to the leg of the same side the child is then unable to move it, and the sensation of the limb is lost, or at least impaired. More rarely, one arm and both legs, or both arms without the legs, are affected. The duration of the paralysis is very uncertain. In many cases, it lasts from a fortnight to three weeks, in others many months, and even, in some, many years, and then becomes incurable. Convulsions not unfrequently precede, or occasionally accompany the pa ralysis without any apparent exciting cause, or from a very slight If the child be in a passion, or annoyed about anything, the paralyzed limb sometimes becomes convulsed, and performs various movements which the child has not the power to restrain. one. The termination of the paralysis, under judicious treatment, is in most cases favorable. The limb regains gradually its lost power, with a pricking sensation, or a feeling of formication. Not unfre quently, however, the paralysis is obstinate, resisting the ordinary remedies, while other symptoms, indicative of an affection of the nervous centres make their appearance. The child is attacked with dyspnoea, palpitation, twitchings of the muscles of the eyes; it commences to squint, becomes dull, falls into a comatose state, and dies. The paralysis may become chronic; there are then no obvious indications of an affection of the nervous centres, but the affected limb remains paralyzed, and ultimately becomes atrophied. The indi vidual may be, in other respects, in the most flourishing health, even active and strong. According to Dr. Fliess, in cases of dental paralysis, it is generally the molar teeth that are at fault; much more seldom the incisors. In those cases at least which he has found recorded by various writers, where the situation of the teeth about protruding was given, the molars have almost always been mentioned as those in progress of escaping from the gums. Much may be done by a judicious course of treatment, towards preventing the mischief which the process of dentition has a tendency to develop. The child should, as far as possible, be removed from the influence of whatever morbific causes he may be surrounded with. He should be placed in a pure, fresh atmosphere. His diet should be mild, nourishing, and easy of digestion. If of a plethoric habit, every species of animal food should be withheld; if he be laboring under great exhaustion or debility, it may be necessary to allow him beef, mutton, or chicken broths, or even a portion of the meat of which these are prepared, plainly cooked, and in moderate quantities. The strictest cleanliness of person and clothing should be observed; the daily use of the warm bath, and frequent exposure to the open air, in suitable weather, with an amount of exercise adapted to his age and state of health, should be strictly enjoined. The condition of the gum should be daily and carefully examined. The moment it appears hard and swollen, and the teeth are evidently approaching the surface, a free incision should be made with a lancet, at the points where the teeth are about to protrude, so as completely to divide the tough membrane by which the tooth is enveloped, the pressure upon which of the advancing tooth being the cause of much of the pain and irritation consequent upon difficult dentition. The lancet should, in every instance, be carried down until it reaches the tooth, and if it be one of the molar teeth that is about to protrude, a crucial incision will be proper. This operation gives but little pain, and is rarely, when judiciously performed, attended with danger or inconvenience, while, in many cases, it is followed by immediate relief, and may be the means of preventing the occurrence of fever, convulsions, or fatal disease of the brain. Even subsequent to the occurrence of convulsions, of spasmodic closure of the glottis, or of deep stupor from hyperæmia of the brain, a free division of the gum over the advancing teeth has been known, in repeated We have said that the division of the gum over the protruding teeth, when performed at a proper time, and in a proper manner, is "rarely attended with danger or inconvenience." It should be performed only when the gum is evidently raised by the advancing tooth, and the surrounding parts are red and painful. We have never seen the aphthous or gangrenous ulceration which Billard apprehends may be produced by the incision. Were it to happen, in the majority of cases it would be a less troublesome and unmanageable occurrence than to prevent which the incision is made. In two instances, however, which fell under our notice, both occurring in children of a scrofulous habit, and who had suffered from long-continued chronic disease of the bowels, a constant oozing of blood took place from the incision, which could not be arrested by any means that were resorted to, including the actual cautery. instances, to be followed by an almost immediate cessation of every alarming symptom. A curious case is related by Robert, in his Treatise on the Principal Objects of Medicine, illustrative, as well of one of the effects of difficult dentition, as of the division of the gum. We give it upon the authority of Carault, not having seen the work of Robert. A child, after having suffered greatly from difficult dentition, apparently died, and was laid out for interment. Lemonnier, having some business at the house of the nurse, with whom the child resided, after fulfilling the object of his visit, was desirous of ascertaining the condition of the alveola. He accordingly made a free incision through the gums. On preparing to pursue further his examination, he perceived the child to open its eyes, and give other indications of life. He immediately called for assistance. The shroud was removed from the body, and by careful and persevering attention the child's life was saved. The teeth in due time made their appearance, and its health was fully restored. When considerable redness and tenderness of the gums occur about the period when the process of dentition is expected to commence, without, however, either of the teeth having advanced sufficiently near to the surface of the gum to render an incision of the latter necessary, emollient washes should be frequently applied to the gum, and a leech or two to the angles of the jaw. If the bowels are costive, a purgative of calomel, followed by castor oil, may be administered. Should a considerable degree of febrile excitement be present-particularly if it be attended by heat and tenderness of the abdomen a few leeches to the gums, and over the epigastrium, with the tepid bath, and small doses of calomel and ipecacuanha,' will be generally found advantageous. 'R.-Calomel, gr. ij. ad iij. Magnes. calc. gr. xxiv. Ipecacuanhæ, gr. ij. ad iij.-M. f. ch. No. xij. One to be given every three hours. When dentition is attended with frequent and copious discharges from the bowels, of a thin watery consistence, and accompanied with more or less griping-bland mucilaginous drinks, and the tepid bath, will, in general, afford relief; if, however, the diarrhoea continues unabated or increases, we have found the best means of arresting it to be a solution of acetate of lead given by the mouth." 2R.-Acetat. plumbi, gr. viij. Acid. acet. dilut. m viij. Sacch. alb. 3j. An ordinary-sized teaspoonful of which may be given as a dose, and repeated three or four times a day, until the frequency of the discharges is abated. When there exist increased heat and redness, with turgescence of the vessels about the head-particularly if, at the same time, the child is unusually drowsy, or starts frequently from its sleep, with a wild, affrighted aspect-a few leeches should be applied behind the ears, and the head sponged frequently with cold water alone, or cold water, with the addition of one-fourth of proof-spirits; the |