exude through broken gum, the wound made may heal when pressure is removed, and the old miseries may be revived.

The practitioner may here learn an excellent lesson in reference to the mode of operating for gum boil. The proper plan being, not to pass through the gum with the scalpel, but to separate gum and tooth with the gum lancet as in the simple act of scarification previous to extraction.

The symptoms I have here described are those of acute abscess in the alveolus. But there is another and chronic form of the disease, in which pus, formed at first with some pain round or near a diseased tooth, remains and extends involving other teeth without any very great manifestation of suffering, but producing much discomfort and a secondary affection of the gum important in its way.

It will be remembered that when I was treating of hæmorrhage and the hæmorrhagic diathesis, I explained that there was a variety of hæmorrhage arising simply from disease of the vessels of a part and not from any disordered condition of the blood itself. Now this condition of vessel, and this variety of hæmorrhage is common to the chronic purulent affection to which reference is at this time being made. The gum, imperfectly nourished, becomes spongy in texture, bleeds on the slightest provocation, and presents all the local appearances of the true scurvy gum. This kind of gum is, indeed, often most improperly called scurvy gum, and treatment is adopted for it which for rank empiricism of principle has nothing for its equal.

Mr Humby has recently done me the kindness to show me a patient in whom chronic purulent disease of the alveolus involving the gum, as I have just explained, existed for a long time and presented at last many points of great practical value.

The patient in this case was one Edward Chester, a youth of eighteen years of age, by business, a clerk in a warehouse. He came before Mr Humby at the Royal General Dispensary. He stated that in early life he suffered from small-pox, and at nine years of age he had rheumatic fever. His father, a dissolute man, died many years ago, and a brother and a sister have also died. The first symptoms of tooth affection commenced when he was ten years of age. His teeth became dark in colour, brittle, and carious. He did not suffer much from toothache, but occasionally this was a symptom. At this time, and since, his general health has been good, but the gradual disorganisation of the teeth progressed, and in time all the teeth in both jaws were involved excepting the upper bicuspid on the left side, the second upper molars on both sides, the second lower bicuspid on the left side, and the first lower bicuspid on the right side. After seven years, i. e., when the lad was entering in his eighteenth year, purulent matter began to form around the diseased teeth, and the gums became soft, spongy, and so vascular that they bled on the merest touch. This condition constituted what was con

sidered to be the scurvy gum, and the patient seeing in the window of a dog doctor the history of a famous lotion invented by the said doctor for the scurvy gum, went in to be cured by a lotion, and came out to have his bad teeth as effectually finished off by art, as any dog doctor, aided by strong sulphuric acid, could devise. The lotion applied to the gums by this ingenious charlatan contained, in fact, the acid I have named. In its application to the gums it gave great pain; it set the teeth on edge, it turned the gums of a blue colour, and it removed the enamel from all the teeth with which it came in contact, so effectually, that the mouth may be virtually considered as destroyed, since any endeavour to save the majority of the teeth is bereft of any chance of success. The cast of the mouth of this youth is now before the members.

In the case here recorded, we have an illustration of purulent disease giving rise to symptoms closely resembling those which characterise true scurvy gum.

There is yet another class of cases in which the true scorbutic disorder sets up purulent deposit. In the case of a patient recently under my care for purpura, bleeding spongy gum was one of the marked symptoms. When this symptom was most marked, the alveolus became affected, and purulent fluid soon separated several of the teeth from their alveolar connection. Under general treatment the purpuric symptoms subsided and the teeth were saved. This satisfactory result, which I have seen before, is attributable to the fact that the tooth continues to receive its central nutritive supply. I believe, however, that in after years, teeth which have been separated from their alveolar connection are much more ready to decay under external influences, and they sometimes loosen and fall out with comparative suddenness and without expectation.

We have several times had before us the question of the influence of the eruptive diseases on dental affections. I recal this point merely to note that in small-pox, exfoliation of the alveolus and consequent purulent formation is an occasional result.

In past days the same often happened from the injudicious use of mercury, and one shudders to read the quiet stories of Astruc, about men who were fumigated into purulent puddings, whose teeth dropped in a row at a time, and whose decomposing gums and jaws emitted an odour which rendered life more

intolerable than death.

We have passed the day of these living recitals of ignorance, and now, though salivation is practised in some forms of disease, it is never carried so far, by intention, as to lead to consequences so seriously absurd as those above-named. Once, in a case where mercurial powders, by a mistake between nurse and doctor, were given to a child suffering from a slight febrile disorder, I saw the whole of the deciduous teeth made to slough away in a deluge of purulent fluid, and, as a further evil, a permanent set of teeth

developed, all of which were of dark colour, brittle, pitted, andvery soon carious.

Thus we see that alveolar abscess has an extended range of causes. I might enlarge on this point, indeed, vastly. But the leading facts being supplied, the rest must for this time remain.

The last variety of purulent disorder in and about the teeth, is that form of ulceration and purulent exudation, known under the very absurd term "cancrum oris." The affection is one mainly confined to children, and some confusion has arisen regarding it, by the fact that the term is too indefinite to be of practical meaning. It were well, indeed, to throw overboard the term cancrum oris altogether, and to speak of the affection now in hand, as suppurative ulceration of the gums and mouth.

I have said this disease occurs in children, and, ordinarily, during the period of the first dentition. I have told also, in a previous lecture, that the disease occurs only in the children of the poor, and in children badly sustained by the essentials to existence, food and air. I do not think there is any necessity to divide the purulent ulceration of the gums and mouth into two classes, as Mr Tomes suggests, viz., into ulceration as affecting the gums, and ulceration as affecting the other parts of the oral cavity. In Dispensary practice, I have had great opportunities of observing this disease, and my belief is, that as regards the kind of ulceration, as regards the exudation, and as regards general symptoms, there is only one disease, and that the position of the ulceration whether on the gum structure or on the inner surface of the cheek, is the merest accident.

The

In its course the disease does not commonly present itself until some of the deciduous teeth are through; nor does it commonly present itself after the appearance of the temporary teeth. The affection is always preceded by general symptoms. child is fretful, has griping pain in the bowels, has diarrhoea, has a burning pungently hot skin, great redness of the lips, gums, and tongue, and intense thirst. The saliva secreted at this time is strongly acid, and the excreta from the bowels are also acid. The attendants of the child are, moreover, conscious of an unbearable sour odour as arising from the body of the child. After a little time the true local symptoms appear. The parts of the mouth covered with mucous membrane swell and easily bleed. The lips often swell to double their size. A child brought before me yesterday presented this symptom in a severe degree; the upper lip was everted by the tension and cracked in bleeding fissures. The swollen condition having lasted for a period varying from two days to five or six the surface disintegrates at some point and the ulceration commences. A common point of ulceration is in the lower part of the buccal cavity, especially in parts where salival secretion can accumulate, as, for instance, at the point of junction between the lip and gum. The ulceration is indeed excited, as I think, by the presence of

a diseased salival excretion. Once started, it extends readily, breaking out in several patches, and leading to the exudation of free and offensive thin purulent matter, which, together with the saliva intermixed with it, fills the mouth at times with fluid, and excites appearances not unlike those produced by mercury carried to salivation.

The termination of the disease may be fatal under the best treatment, for the little sufferer is subjected to a triplet of misfortunes. The ulceration and discharge feeds on itself. Excited primarily by a degraded state of the blood, it progresses the more rapidly, as the nutritive process is the further degraded. There is added, too, the wear and tear of pain, and there is added, also, the difficulty of feeding. Thus, surrounded by all these evils, the disease is most difficult to meet, and in recovery, there is a slowness which calls for an extraordinary exhibition of patience.

In extreme cases the gum is entirely removed, and alveolar exfoliation is the consequence. In most cases the deciduous teeth are rendered carious, and the temporary set are sometimes injured. Dr Harris, quoting from Delabarre, gives instances in which there was softening of the whole maxilla, and carbunculous destruction of the cheek, hectic, and rapid death. These cases must be extremely rare. The same authority remarks that the disease is most common amongst females, but there are really no reliable data to prove that sex alone has any predisposing tendency.

There is one other form of purulent deposit which, though not manifested in the teeth or gums, depends, nevertheless, on the teeth; and deserves, therefore, an incidental notice.

In strumous children it sometimes happens, that during dentition there is enlargement and suppuration of the cervical glands. In many instances which I have seen of this kind of affection I have been able to trace the irritation to the teeth as the starting point. I have seen cases of this character in which enlargement of gland has followed every attack of dental irritation, and I have seen the glandular enlargement subside as soon as the irritation from the dental organs was relieved.

There are other cases in adults in which something of the same kind may result from the presence of a tooth having diseased fangs. A gentleman once applied to me for a hard swelling immediately under the jaw, and which showed a decided inclination to suppuration. After trying many remedies, I began to suspect that a diseased tooth was the head and front of the offending. The tooth, a first-lower molar, was situated directly over part of swelling. It was a very irritable tooth, and was of little use in mastication.

After much persuasion, my patient consented to have the tooth extracted; there was enlargement of the fangs, and the removal not only gave immediate and obvious relief but pro

duced a quick and permanent subsidence of the external tumour. In speaking of the general effects produced by purulent deposits, I alluded to certain present and after symptoms of a systemic kind as attendant or subsequent phenomena. These were the acute fever, the exhaustion consequent on the exudation of purulent matter, the low typhoid condition produced by decomposing pus, and pyæmia or impregnation of blood with purulent fluid.

In purulent diseases of the gums and their adjacent parts, the preceding and coincident acute febrile state is never absent. In diseases of the antrum, when pus is freely thrown out the subsequent exhaustive fever is often present, and in the purulent ulceration of the mouth, this exhaustive condition is a marked sign. In some cases of extreme kind, poisoning by absorption of an alkaline gas disengaged by the foetid pus may likewise present itself, and under unfavouring states even pyæmia may be a result. The latter, however, is an uncommon sequence.

But this point must always be remembered in connection with purulent exudation in and around the teeth, as in fact specially marking these affections-that whenever there is foetid matter in the dental structures, every breath inhaled, every fluid or solid swallowed is charged with diseased products in their fluid or gaseous form. In the mildest varieties of purulent disease in the mouth this result has weight; the poisonous inhalation tells speedily upon the general health; the body becomes anæmic; the stomach becomes deranged; the spirits flag; and, as the drop of water by persistence of repetition wears away the stone, so the slightly diseased tooth, acting as the source of a steadily produced poison, slow and insidiously sets up in the system a train of disorders, which render health an impossibility and life a burden.

In cases of extensive purulent formation, as in the purulent ulceration of children, the evil here indicated is intensified twenty fold. I have often wondered in cases where the health was intole rable from the cause named, by what conservation of nature death direct from volatile putrid poison was averted.

In the treatment of the purulent affections now considered certain general principles, well impressed on the mind, serve the practitioner better than the most refined arguments in detail. If the principles are known, the details follow. Let me, then, shadow forth those general rules which modern knowledge, as to symptom and cause, supplies, both by inference and experience. In the acute stages of a disorder in which the formation of purulent matter is dreaded, the first principle then is to look for, and if possible remove, the local irritant. If a gum is under distention, let it be divided; if a diseased tooth is the irritant, let it be removed. If removal of the irritant is impossible, the next best means is to soothe the local suffering, by exclusion of air and the use of anodyne applications, as opiate stopping or opiate fomentation. You will find most writers recommending blood