ever, showed any corresponding disorder in the dental structures. Curious though this circumstance may be, the experience of both physician and surgeon attests its reality. Our museums are filled with specimens of skeletons in every shape of disfigurement and destruction to which the osseous system is liable. But when the eye moves from the skeleton at large to its masticatory mechanism, the clear rows of firmly set teeth indicate how little these structures have shared with their neighbours in the almost universal malcondition.

Lastly, if there is any strumous disorder of active kind with which derangement of the teeth is an accompanying symptom, and with which such derangement seems to take part, it is that form of strumous disorder known as mesenteric disease. In these examples derangement of the digestive functions is a leading feature, and I have sometimes known struma as thus manifested, particularly in the young, accompanied with ulceration of the mouth, purulent deposit beneath the gum, and destruction of the tooth itself. But whether this disorder is primarily dependent on constitutional disposition, it is impossible to say, for the same state may obtain from other disorders involving the alimentary system.

There are also two other points of practice to be remembered in relation to the strumous diathesis, and the local maladies which are, or seem to be, engrafted on it. I mean, that strumous children are as liable as others to syphilitic taint; and, secondly, that strumous children, subject as they are in infancy to pulmonic affections of a low inflammatory type, are more liable to be subjected to the influence of mercurial treatment.

Further, the inheritor of the syphilitic taint or the acceptor of mercurial taint, feels the effects of these poisons the more the deeper he is tainted with the disease struma.

It would be necessary, consequently, in speaking of any variety of dental disorder as resting on the basis of a strumous diathesis, to eliminate, firstly, the possible influence of syphilis, and, secondly, the influence of mercury.

These eliminated, I opine from observation of the strumous manifestation, but without any attempt at dogmatism, that the strumous diathesis, per se, is not ordinarily a form of constitutional disorder from which dental diseases take their origin.

I would be inclined to urge the old rule, that of all the organic parts, the eliminative or glandular suffer most from struma, and to add, that of all the organic parts the organs of mastication suffer least.

At the same time, the fact is too obvious to be denied, that whenever certain abnormal states of the organs of mastication are developed by the agency of other causes, local or general, in so far as the strumous habit degrades nutrition, and suspends reparation of destroyed parts, in so far it favours the development of disease in the dental structures, favouring

specially such affections as are of purulent character: ulceration of gum, purulent exfoliation of the alveolus, and abscess of the antrum maxillare.

I shall have occasion again to dwell on the dyspeptic, the gouty, and the rheumatic diatheses, in their relation to toothache and diseased dental structure. Meantime, certain general considerations on these points deserve place.

Common dyspepsia, unaccompanied by any specific diathesis, in so far as it may produce headache, and other so called nervous affections of a temporary nature, may, and does, produce a nervous pain in the teeth. But it has never appeared a demonstration to my mind that simple functional dyspepsia does ever, acting as a constitutional disease, give origin, except in very early youth, either to caries or to true inflammation of the dental pulp. accords rather with my experience of simple dyspeptic toothache that when it occurs, it is confined to some tooth already advanced in caries, and to have been excited by a vitiated salival secretion-the upshot of the dyspeptic attack.

It

When therefore I see in practice dyspeptic symptoms, more or less permament, attended, as an apparent sequence, by pain in what seems to be a sound tooth; if the evidence inclines to symptoms of inflammation of the dental pulp; if destruction of tooth seems a sequence; or if purulent exudation beneath the gums seems a sequence, and these, any one, are traceable to the dyspepsia, independently of direct local cause, I am led to suspect that something more than dyspepsia is at work, that the dyspepsia itself is but a symptom of a more diffused malady. If the patient is young, I look for symptoms of syphilis or mesenteric disease, or inquire about mercury. If the patient is old, the syphilis and mercury may still be looked after, and something more-viz., gout.

It is the pleasure of gout to stand by the stomach. The stomach fathers it, and the stomach shows speedily by its own deficiencies the prodigal character of its offspring. The result is that we have set up in medicine for our observation a disease image with two heads, which we recognize as gouty dyspepsia.

А A very clear knowledge must be possessed of the pathology of gout before its full influence in modifying the nutrition of the tooth can be understood. But this I must impress, that gout is often manifested in the tooth in its acute form; that in young men inclined to the gouty diathesis it often manifests itself first in the tooth; that it is capable of setting up its specific inflammation in the dental pulp; that the results of such inflammation are often attributed to local causes when the general one is at work doing the mischief.

The rheumatic diathesis has often been adduced as connected with different forms of dental malady, and as playing the constitutional half of those maladies. Rheumatic toothache is a common, though an indefinite term, used sometimes by medical

men, occasionally by the people, but more rarely by members of the dental profession. The rheumatic diathesis in cases of rheumatic toothache is well marked in its characters, and is to be carefully isolated from the gouty diathesis, with which it has nothing in common save pain.

The rheumatic disease in its chronic or acute form has its affinity for fibrous structure. In its more insidious forms it creeps over nerve sheaths, diffuses through muscle, and works into the joints, thus realizing in its silent progressions neuralgia, muscular rheumatism, or flying rheumatism gnawing in the shoulder now and in the hip then.

In this way rheumatism moving about lights on tooth nerve, and gives the ache, of all others, most acute; a general ache with occasional stiffness in the muscles near; or sometimes rheumatism, still on his travels, takes the fibrous periosteum as his field ground, and supplies a pain-dull, heavy, diffuse-encircling the tooth, compressing it, and proving to the sufferer the existence of a tooth socket, without any reference either to the skeleton or anatomist's vade mecum.

But there is this peculiarity about these rheumatic affections, that although they may often recur, and constitute the severest aches, they leave but little behind in the way of organic change. Suppuration is not an effect, nor separation of tooth from its investment, nor injury to pulp, nor deposit of osseous matter, nor destruction of nutrition.

In its more severe forms the rheumatic disease, no longer creeping, lays sudden and violent grip on every limb, and thence, from the out-works to the citadel, carries the very heart by storm. Where there is fibrous structure there is rheumatism.

Yet there is an exception to this, which otherwise were a general rule. In the acute rheumatic arthritis the jaw and all its appendages are singularly and ordinarily saved. Call this a merciful provision in the midst of an unmerciful calamity if you will. I would prefer to say how remarkable in its pathological meaning is the fact, that generally, when the acute form of the rheumatic affection is most marked the patient seems as little susceptible to tooth affection as the healthiest member of the community.

The cancerous diathesis, or that condition in which the disposition to cancerous development is prominently marked, while it is in some measure removed from the study of simple dental diseases, is inseparably connected with the labours of those who practice dental surgery. In the tooth structure the cancer cell finds it may be no true point for development, but in all surrounding structures, in enclosing jaw, in soft parts and in neighbouring spongy bones, two varieties at least of the cancerous growth derived from the constitutional disposition, hereditary or acquired, manifest themselves; in their progress implicate the true dental organs, and in their growth, by interference with the

C

nutrition of adjoining structures and with nerve supply, lead to symptoms of dental disease which abound freely in diagnostic difficulties.

There are two other obscure affections, both, as I think, neuralgic in type, and which seem to have a common constitutional cause. These are, the toothache of pregnancy, and epidemic toothache.

The toothache of pregnancy is generally confined to the first months of utero-gestation, is connected with other pains, and is often seated in a carious tooth.

The epidemic toothache is generally connected with catarrh, and also, though not always, with a tooth that is carious.

To sum up

The following are the propositions which I would respectfully submit as expressing in a few words the relationships which exist between constitutional causes and dental diseases.

1. Dental diseases of whatever kind have two sources; a simple local source, and a constitutional source.

2. The diseases of the organs of mastication, arising purely from local causes, are limited in number; including caries, necrosis, inflammation or its upshot, and the ache, consequent upon exposure of nerve.

3. Every form of tooth disease may directly or indirectly originate in constitutional disorder, and some originate in no other ways.

4. In all such cases the true cause of the disease is external, and the system is merely the medium by which the cause passes, or through which it is carried to the locally diseased structure.

5. The causes acting on the teeth to produce diseases through the system, are of two kinds-chemical, as by introduction of poison into the body- and physiological, as by perversion of normal acts.

6. The inorganic poisons which through the system seem mostly to affect the teeth and adjacent parts, are mercury, the alkalies, and, perhaps, the malaria; the organic are the poisons of syphilis and small-pox.

7. Mercury produces caries, suppuration, and hæmorrhage from the gums; syphilis, atrophy, and tendency to caries; small-pox, suppuration, alveolar exfoliation and dental necrosis, and malarial poison intermittent tooth neuralgia. 8. Amongst the diatheses or dispositions of body affecting the teeth, the strumous, the dyspeptic, the gouty, the rheumatic, the cancerous, and the hæmorrhagic, are the most important.

9. The strumous diathesis, while it favours the development of all diseases of degenerative type, is not per se-i.e., like syphilis or small-pox-a constitutional cause of dental disease. Simple dyspepsia is not a true constitutional

cause. Gout is a true constitutional cause, leading both to acute ache and organic mischief; and rheumatism is a constitutional cause, giving rise to a specific rheumatic neuralgia of the tooth nerve and to a specific periostitis. That there may be other forms of constitutional disorder arising from external causes, by which dental diseases are originated and intensified, is possible and probable. But modern science, carefully read, yields at present no more than I have inadequately marked out, except one, which has been inten. tionally omitted.

The hæmorrhagic diathesis as a constitutional malady, comes strictly under our present head. But this condition being one of peculiar import, must, as the novelists have it, be considered in a chapter of its own.

LECTURE II.

ON THE HÆMORRHAGIC DIATHESIS, IN ITS, BEARINGS ON DENTAL PRACTICE.

[Delivered November 16th, 1858.]

MR PRESIDENT AND GENTLEMEN,

The subject before us for this evening's study, is entitled "The Hæmorrhagic Diathesis in its bearings on Dental Pratice."

I shall, in this lecture-for the purpose of being clearly understood by the younger members of the College, who may not have had the advantages of becoming practically conversant with anatomy and physiology-and specially with physiology-venture to move occasionally into the consideration of elementary principles and propositions.

It is the stamp of men of true knowledge that they learn and let learn, and learn again and again, never too often.

I know, therefore, I need not ask those who shall be conversant with every word I utter, to bear with me through the elementary teachings. I do not come here for the sake of display, but for the sake of instruction.

By the term Hæmorrhagic Diathesis is meant

"A disposition to the effusion of blood."

It must be understood that the term is not applied to any individual disease; it is the expression rather of a symptom of disease, and it is a symptom which may belong to many diseases.

The Hæmorrhagic Diathesis may accompany the following common forms of disease :

Scurvy, Purpura, Anæmia and its analogue Chlorosis, Dysentery, and Typhus.