The mistake made consisted in operating in such a case at all,-but of this in its proper place.

The diagnostic signs of this form of odontologia are not difficult to the experienced practitioner, but to the inexperienced they are perplexing; and they are more perplexing to the Dental practitioner than to the Medical man, because the former by the nature of his speciality is prevented from making those inquiries into collateral symptoms which the medical man would institute at once, and on a knowledge of which his opinion and treatment would in nine cases out of ten be based.

At the same time there are certain general signs of hysteric toothache which are on the surface, and are fairly diagnostic and reliable.

First, there will always be found, either in the present or previous history of the case, some symptoms expressive of the hysterical tendency, some history of hysterical convulsion, and some presence of nervous excitement and trepidation.

There will also be commonly evidenced signs of debilitated health- —an anæmic cheek, a lax fibre, a rapid feeble pulse, and a corresponding quick and excitable respiration.

If the inquiry into preceding symptoms be pushed, other proofs of hysterical pain will be gleaned. One or other of the symptoms which have been described under the names suggested by Briquet will have been present at some recent period; as a general fact, indeed, the patient will be full of Îamentations as to the existence or recent existence of similar pain in other parts of the body, of brow-ache, or stomach-ache, or shoulder-ache, or stitch in the side.

The character of the toothache itself will be sure to attract notice; it will be found perchance to disappear altogether, if the mind is powerfully diverted to any taking topic. If the tooth is examined, however, when momentary excitement is quieted, it will be detected that interference with the tooth itself, if a special diseased tooth is present, does not materially aggravate the evil, or it will be found again that the patient is unable to fix on any one tooth as the true seat of the pain.

But that which most clearly indicates the simple fact of mere hysterical odontologia, is the almost immediate relieving effect of a narcotic remedy. The remedy is none the worse, too, if on its side it leave a little pungency, and excite some degree of sensation.

For all purposes, on these occasions chloroform locally applied is the best measure. The diffusibility of the liquid, the sensation it conveys, the smell and the rapid narcotisation of the parts, all lend to it an influence which is magical in its results.

To stop a hollow tooth, in pain from hysterical ache, is one of the immediate triumphs of tact in dentistry; and the more severe the representation of the pain, the more readily is it quenched by this ready method of relief.

G

There is yet one more diagnostic sign of hysterical toothache, and that consists in the circumstance, that the intensity of the pain is no measure of its duration, and that when the pain ha departed it leaves no lingering throb or ache behind. The pain is electrical. Ordinarily, after odontologia from exposure of nerve to air or other irritant, the suffering even when it is blunted, is for a time felt; so that the sufferer is in constant terror of eating and drinking, lest it should return. The tooth is tender, and reminds its owner, on the slightest approach of a foreign body, of the noli me tangere maxim. The same obtains also after neuralgia; there are signs of tenderness, stiffness, and a physical impression long remaining of that which

has been.

So, with regard to the commencement of either of these aches, there is some premonitory signal that pain is on the advance. There is sensation of gentle dart, or, curiously enough, there is sensation of numbness as the foregoing prophet. In the hysterical variety, all these symptomatic items are wanting, post et ante. Thought itself is not more swift than the onset; action not more rapid than the retreat.

As the pain may, as we have seen, be relieved by mental diversion, so may it almost at any time during the hysteric period be induced by similar emotion. The patient can summon it almost by her own will; it acts by her as the soldiers by the Roman centurion, who always came when he called them, but sometimes came when he did not want them.

The evidence from all these facts is very satisfactory in so far as it explains the seat of the malady; it proves that whatever may be the primary or predisposing cause, the excitement to the symptoms is in the mind's organ-the sentient brain.

In this description I have given the history of pure hysterical toothache. It is not absolute, however, nor must it be conceived as absolute that this toothache is the necessary accompaniment of hysteria. There may be true toothache together with general hysterical tendency, or true neuralgia with general hysterical tendency. And it is by no means rare for hysterical people to suffer from both these affections, as the result of the same causes, as severely as from those causes which lead to the same affections in the robust; viz., exposure of nerve from caries, cold, or by an agency influencing the pained part by general or reflex action.

One particular point in this respect bears notice. Hysterical people are often confirmed dyspeptics, and indeed it is doubtful whether hysteria is ever present, or is ever possible with an unimpaired digestion. In so far, therefore, as indigestion is capable of exciting a neuralgic face-ache by reflex action, and in so far as indigestion, by its induction of depraved salival secretion, is capable of causing irritation of an exposed nerve by the agency of an irritating secretion, so is the indigestion of

hysteria capable of producing either true neuralgic pain or true odontalgia.

The diagnosis of toothache or neuralgia thus induced will rest on the broad facts relating to the character of the pain, its mode of occurrence, its duration, and its response to external measures, diagnostic or remedial.

Hitherto, I have dwelt on the influence of hysteria in producing painful affections situated, apparently or really, in the teeth or the parts adjacent. But there is another relationship between tooth affection and hysteria, which is not of less moment than that which has gone before.

Hysteria may develope toothache; the reverse may obtain, toothache and irritation in tooth may, under favouring conditions, develope hysteria, and hysteria of the most determined kind.

It is sometimes the fact, that in children of nervous temperament and excitable disposition, hysterical convulsion, simulating epilepsy, accompanies, or rather results, from the irritation of the second dentition.

This result is most probable in instances where the dentition is prolonged, and where it occurs later than is ordinary. In such instances the hysteria may simulate numerous spasmodic affections, such as chorea or St Vitus dance, many forms of muscular pain, epilepsy, or trismus.

In instances such as these, the effect, through the nervous system, belongs again to the order of reflex phenomena. But in these examples the irritation at the one point sets up, not a reflex pain, but a reflex motion. The sensation, borne from the pained part along the nerve to the brain, is reflected back by motor filaments to the muscles which either directly or indirectly communicate with the nerve centre. As in common response to sensation, the hand feels, the brain receives, and the muscle answers-so here the tooth feels, the brain receives, and the muscles contract; but with this difference, that the exciting sensation is unqualified; the central impression is extreme, and the response is involuntary and diffusive.

The effect of the second dentition in producing this reflex convulsion in children of feeble and anæmic build, and of hysterical tendency, is much more frequent than is imagined. I believe I once saw a death from prolonged convulsions from this cause; and I have certainly seen sufficient evidence to excite suspicions, which examination has confirmed, that in cases of convulsive disease occurring during the second dentition, the irritation often supposed to be due to worms in the intestinal canal, or to irritable temper, or to dyspepsia, is really seated in the mouth, and is as distinctly traceable to dental irritation, as the convulsions of infancy are due to a similar and better acknowledged cause.

In these cases the irritation excited is not in the teeth which are being replaced, nor in those which are replacing the deciduous set, but in those of the second casting, which meet with opposition at their first appearance, and have to make their way through the opposing structure by the absorption process.

Touching on this subject some very valuable information was collected some twenty-five years ago by Dr Ashburner. Whatever may be the feeling of the Profession now in regard to the later works of Dr Ashburner, it must be admitted, in reference to his papers on Dentition, that in them he brought forward many all-important truths, and much that was novel in his time.

I have recollection of a case so analogous to the following one recorded by this Author, that the two cases may be considered as in symptom identical.

"A boy twelve years of age was cutting the second or posterior permanent molares of the upper jaw before those of the lower, and the process was accompanied by twitchings of various parts of the body. At last he became affected with chorea. Being a very nervous lad, if any notice were taken of him he would quite involuntarily make the most extraordinary grimaces, and contort his body into attitudes that appeared to be most difficult and painful. His chorea continued for three months, during which time a variety of medicines were swallowed. At last he fell into an epileptic fit, struggling much, foaming at the mouth, and grinding the teeth. I thrust my forefinger along the inside of his cheek, and found a hard cartilaginous space on each side, behind his first molar teeth. I succeeded in gashing these parts; he uttered a scream and fell out of his fit, becoming quite sensible; nor had he a recurrence of his chorea."

There is, again, another condition in which hysteria, or one of its allied disorders, may be excited by mischief in the teeth. I refer to the hysteria which often attends the cutting of the dentes-sapientiæ in young persons, especially in young women who are predisposed to hysterical paroxysms.

A young girl came under my care in 1855, and remained as a patient for many weeks. Her symptoms were those of hysteria, but from the description of the fits which according to the mother's statement she suffered from, I judged that she must be subjected to epilepsy, or at least to severe epileptiform hysteria. I treated her first with tonics, but no good having resulted, and feeling that some local mischief must be at work, I gave purgatives on the speculation of the presence of tapeworm or lumbricus. It was clear that tonics did not relieve, and that depressants increased the malady. Ultimately, there were general twitchings in the muscles, not exactly amounting to chorea, but such as are seen sometimes after the administration of strychnia. I was unavoidably kept from dispensary work for a few weeks, and returning to it was surprised to find a great improvement in this patient. She had been in great pain and

had cut a wisdom-tooth, since which she had lost all symptom of convulsive start. How I blamed myself for carelessness in not having examined for this simple cause of irritation, I need not say. How quickly I should have examined for it had my patient been in her first, instead of her last dentition, I need not explain. Suffice it, that I never meet with hysteria now, of extreme kind, if the excitant seems to be local, without asking in the most solicitous manner after the wisdom teeth.

Dr Ashburner has several cases equally in point, in which epileptiform hysteria, and tetanic hysteria, were one or other present.

I select a single illustration from this record.

"A young woman, nineteen years of age, with light hair and fair complexion, with fine tall figure, rather fat, was in the year 1818 an apprentice in a straw bonnet shop in Hayes court. The occupation was sedentary, and she had not been in the habit of paying attention to the state of her bowels: they were suffered to be very costive. For several months she had perspired very profusely at night, and her breath had been observed to be very offensive; she started in her sleep, and repeatedly awakened her bedfellow by kicking her on these occasions. She moaned and talked in her sleep. Dr Nutall, who was my colleague at the Westminster General Dispensary, was suddenly called to her on account of her having fallen into a fit. He caused her to be profusely bled, and she recovered so far as to be able to see her physician at the Dispensary. Three weeks afterwards, the doctor being from home, I was obliged to see this patient in a fit similar to the first she had had. I learned that she had been very odd and nervous in her manner, and had often suddenly screamed out from cramps seizing her toes and the calves of her legs, which were succeeded by her thumb being drawn inwards towards the palm of her hand, and her fingers being clenched upon it. I found her in a state of tetanus. vulsion was over, I thrust my forefinger into her mouth, where I found the wise teeth of the upper jaw through. In the lower jaw the teeth could not get through, for there were hard cartilaginous substances in their way. Through these I scored freely, and the young woman was relieved instantly."

The con

In girls predisposed to hysteria by preceding bad health, even slighter causes than those I have named are sufficient to excite the hysteric paroxysm. "A young lady on whom I was once in frequent attendance for hysteria, and in whom the symptoms were easily excited, was taken suddenly ill with convulsion which had more than hysteric meaning, and which was persistent. In the intervals of calmness, which indeed were few, I endeavoured from the immediate history of the symptoms to gain an insight into their cause. At last she admitted to me that she was in pain in the mouth, and bit by bit, and on pressing the necessity of examining the mouth, I learned that the day