young woman had no symptoms of compression till about three or four days before she died, though at intervals, for some time before, she had suffered agonizing headache in paroxysms of several hours.

When the vault of the skull is attacked with necrosis, not unfrequently very large portions of bone die, as does also the scalp covering it, excepting at the circumference of the dead bone, which the skin still overlaps and seems as it were folded in. When both tables of the bone die, which, as far as I have had opportunity of observing is most common, though not to equal extent, as in general the external table is more largely destroyed than the internal, suppuration begins between the bone and the dura mater, and if near a suture, the pus makes way between its teeth and is seen welling up at every pulsation of the brain. By degrees the granulations formed on the surface of the dura mater eat away holes of various size through the dead bone, and funguses appear, which, however, rarely exceed externally the size of the aperture. But on removing the dead bone, very large funguses are found on the dura mater, and in the course of a few hours, when freed from the pressure, rise above the surface of the scalp, sometimes to the size of half a split egg. These funguses are generally very foul, sloughy, blackish, green-coloured and horribly offensive; and when of large size the patient generally sinks with symptoms of inflamed brain. Instances do, however, happen in which enormous portions of the vault of the skull do separate, and the patient recover; I have at this time under my care a woman, who in the course of the last eight or nine years has lost by exfoliation, the greater part of both parietal bones, and some portions of the temporal and occipital. All one side of her face supplied by the facial nerve, (portio dura,) has been paralysed for many years, though it cannot be ascertained how this is connected with the necrosis during the course of which it has arisen. Other portions of the skull have from time to time exfoliated, but after the principal exfoliations, the deficient parts of the skull have filled, as usual, with tough fibrous membrane, and she has been able for four or five years to follow her ordinary occupation as one of the hospital servants. If the external table only have been destroyed, the bony granulations beneath as frequently make holes through it as those from the dura mater do through both tables.

Caries occurs also in the bones of the face as well as of the skull, and more especially of the nose-bones, where it is very frequently consequent on lupoid ulceration of the soft parts. I have also at present under my care a boy in whom the upper jaw-bone has been destroying slowly for the last four years from this same cause, and who has lost the greater part of the front of the alveolar arch and of the bony plate, nor has any remedy arrested the diseased process but for a very short time, after which it has burst out again with greater activity.

The disease which results from mercury is necrosis, rather than caries, whether happening either on the skull or face; and even in syphilis except when the bone is affected secondly by the extension of the ulcerative process from a sore in the soft parts, necrosis is more frequent than caries. SYME (a) relates the case of a woman who at the age of twenty years had a sore on her nose, for which she took large quantities of mercury. The sore rapidly extended, the bones became affected, and a rapid exfoliation commenced, which soon deprived her of all the face except the lower jaw and part of the ossa malarum. Five years after her eyes were divested of their coverings, the pharynx completely exposed to view, the tongue lay exposed from root to apex surrounded by the foul and vacillating teeth of the lower jaw, and the whole surface had a most unhealthy ulcerated appearance. In the course of the following four years the whole ulcerated surface had healed, and the eyes were covered with a thick skin. She was very weak and for a long period had existed on little else than laudanum, of which she took half an ounce daily. She died shortly after, and on examination it was ascertained that the remaining bone was everywhere perfectly sound. (p. 238.)-J. F. S.] 879. What relates to the causes of caries of the skull-bones has been already said on the general subject; it is, however, most frequently consequent on syphilis. The prognosis is determined according to the variety of the causes as well as the extent of the caries. If it occur on the inner table of the skull, or if the skull be eaten through from without to within, pressure on the brain or ulceration of its membranes, which often extends to the brain itself, is to be feared.

880. The treatment of this caries is guided by the general rules. Only when both plates of the skull are destroyed, especially if the caries have

(a) Edinburgh Medical and Surgical Journal, vol. xxxii, 1829.

been developed on the internal, trepanning is often necessary in order to relieve the collection of pus beneath the skull, or even to remove the whole diseased part of the bone. In caries of the mastoid process especial care must be taken for the proper escape of the pus, so that it should not collect in the drum. If the dura mater itself be ulcerated or covered with unhealthy granulations, it must be bound up with slightly stimulating remedies, with decoction of bark and lime water, with digestive ointments and the like, and the vital activity assisted by aromatic appli

cations.

B.-OF CARIES OF THE TEETH.

FAUCHARD, P., Chirurgien Dentiste. Paris, 1786.

vols.

BERDMORE, T., A Treatise on the Disorders and Deformities of the Teeth and Gums. London, 1768. 8vo.

PLENK, J. J., Lehre von den Krankheiten der Zähne. Wien, 1779. 8vo. HUNTER, JOHN, The Natural History of the Human Teeth, explaining their structure, use, formation, growth and diseases. London,

4to.

BUCKING, J. J., Vollständige Anweisung, zum Zahnausziehen. Stendal, 1782. 8vo. With copper plates.

JOURDAIN, Traité des Dépôts dans le Sinus Maxillaire, des Fractures, et des Caries de l'une et de l'autre Machoire. Paris, 1761.

12mo.

LA FORGUE, L., Sémeiologie Buccale et Buccamancie, ou Traités des Signes qu'on trouve à la Bouche. Paris, 1814. 8vo.

SERRE, J. J., Darstellung aller Operationen der Zahnarzneikunst. 8vo. With copper plates.

Berlin, 1804.

GALLETE, J. F., Blicke in das Gebiet der Zahnarzneikunde. Mainz, 1810. 8vo. Anatom. Physiolog. und Chirurgische Betrachtungen über die Zähne. Mainz, 1813. MAURY, C. J., Manuel du Dentiste pour l'application des dents incorruptibles, suivi de la description de quelques instrumens perfectionnés. Paris, 1814. With plates. Fox, Jos., The Natural History and Diseases of the Human Teeth. Second Edit. London, 1814. 4to.

KUGELMAN, K. J., der Organismus der Zähne, deren Krankheiten und Ersetzungen. Nürnberg, 1823. 8vo.

BELL, THOMAS, The Anatomy, Physiology, and Diseases of the Teeth. London,

1829. 8vo.

V. CARABELLI, Systematisches Handbuch der Zahnheilkunde. Wien, 1831. 8vo.! LINDERER, Handbuch der Zahnheilkunde. Berlin, 1837. 8vo. With lithographed plates.

NASMYTH, A., Researches on the development, structure and diseases of the Teeth. London, 1839. 8vo.

881. The teeth belong to the bony system, and therefore analogous diseased appearances are observed in them. Caries occurs in all the teeth, though more frequently in the molar than in the incisive teeth. Most commonly it begins in the crown, but not unfrequently also at the root of the tooth.

882. Caries is developed at the crown of the tooth, either from without inwards, or from within outwards. In the former, the enamel of the tooth is observed to lose its natural white colour and polish at one or more parts, either on the sides, or upon the top of the crown; clefts and hollows are seen which have a brown or blackish appearance, and gradually enlarge. The affected tooth gives out a nasty smell, and if the destruction penetrate to the inner substance so that the nerve be exposed to the contact of the

air and food, pain of varying severity and duration occurs, frequently also inflammation of the gums and the like. In the second case, no change is, in the beginning, observable on the crown of the tooth, but pain first occurs, is more or less severe and of indefinite continuance, though always soon returning, as often as it is suddenly excited by cold air, cold drinks, and the like. At last, on examining the tooth, a brownish or blackish spot, more or less deep, is observed in the enamel, which gradually enlarges, becomes darker, and destroys the enamel, when the internal substance of the tooth is found to be decayed, so that the enamel is often merely a thin shell which is easily broken.

When the crown is destroyed by caries, it spreads also to the root of the tooth, which is likewise destroyed, and then commonly the gums and alveolar process suffer. The gum surrounding the diseased root, puffs up and inflames, (Parulis,) and not unfrequently an abscess is formed. Oftentimes the membrane lining the tooth-socket also inflames, pus wells up between the gum and the tooth-fang, frequently very severe pain occurs which spreads over the entire half of the face, and is accompanied with swelling of the cheek.

[Occasionally it happens, that without any caries of the tooth, irritation is set up in its socket, and when the jaws are firmly closed the pressure of the tooth into the particular socket causes severe pain. In a very few hours the lining of the socket begins to swell and inflame, lifts the tooth much above its proper level, and consequently renders the closing of the jaws still more painful, and chewing the food almost agonizing. This continues for hours, and sometimes for two or three days, when suppuration commences, the pain and swelling subside, and the tooth again descends to its natural place. This unpleasant process is of very frequent recurrence, gradually separates the gum from the fang till the two are quite apart, and the tooth seems held merely by the vascular and nervous connexion of the ends of its fangs, when its looseness and the constant source of irritation it becomes, leads to the tooth being pulled out. Under these circumstances I have unfortunately had personal experience, that the fang is encrusted with a granular deposit seemingly bony. Leeching the neighbouring gum is all that can be done; but when the process has been once set up, it recurs again and again, till the connexions of the tooth and gum are entirely destroyed, although the tooth itself remains entirely free from caries.-J. F. S.]

883. Caries at the root of the tooth is often announced, for a long while, by very equivocal symptoms. Pain occurs in the tooth, but rarely of long continuance, inflammation and swelling of the gums about the diseased tooth, which frequently becomes very severe, abscesses in the gums, outside the mouth, upon the cheek, at the part corresponding to the root of the affected tooth (Tooth-fistula.) The crown is, under these circumstances, often still completely healthy, and the diagnosis can only be properly determined by particular observation of the symptoms mentioned and by the circumstance of the tooth smarting when touched with a metal probe.

884. Besides these symptoms caused by carious teeth, there occur not unfrequently, caries of the alveolar processes, diseased changes of the Highmorean cavern, if the tooth be in the upper jaw (1), as well as swellings and excrescences upon the gums, (Epulis,) which are of different kinds, sometimes soft and spongy, sometimes firm and hard, sometimes slightly or not at all, but at others severely painful; sometimes they have a broad, sometimes a pedicled base, and various size, but always red, and they are situated more commonly on the under than on the upper jaw (2).

[(1) Occasionally the inflammation extends from the sockets of the upper molar teeth into the Highmorean cavern, the lining of which becomes inflamed and suppurates.

This is accompanied with much deep-seated aching pain, and dusky redness, with tenderness of the cheek. When these symptoms are present, the condition of the cavern may be suspected; and the mouth must be examined, to ascertain whether there be any stumps of teeth in the neighbourhood exciting the irritation. If there be any such, they should be removed, and a probe, or iron wire, or a small trocar must be thrust up the tooth-socket, to open a way into the cavern, by which the pus may escape. This aperture will require for its establishment, the insertion of a little wooden plug, which should be removed three or four times a day, so that the pus may flow out. It is also a good plan to syringe the cavern with warm water through this hole, especially if the discharge be offensive; and if there be reason to suppose any ulceration of its lining membrane exist, injections of weak solutions of nitric acid may be used with advantage. (2) "The tumour of the gum, epulis, is often," observes LISTON (a), “ a simple growth of the consistence of the structure from which it proceeds, and not likely to be reproduced, if the exciting cause is removed, and the entire disease extirpated; the cause is decay of some part of one or more teeth, of the crown, neck or fang, or it may arise from their being crowded and displaced. The lower jaw is the most common situation of epulis; it appears in the front of the mouth, occasionally at the root of the molares, and the upper jaw is by no means exempt from it. Some of the large tumours in my collection, removed along with this bone, appear originally to have commenced in the alveolar ridge. The size and extent of epulis is various; it may be confined to the gum betwixt two teeth, or it may have been neglected long, have taken in several, and may be attended with alteration in structure of the alveolar processes and their covering. The disease is generally connected with affections of the permanent teeth, but it is met with as a disease of infancy. **** The tumour is of slow growth; it remains generally of the same firm consistence, and its attachments are broad and firm; its surface, even when large, is covered by membrane, is unbroken, it becomes lobulated, unless it projects from the mouth, and is exposed to injury; the teeth are loosened, and present in various parts of the tumour; around their base some excitement may be kept up, and even some ulceration and discharge. The tumour is not of a malignant nature in general, and even in its advanced stages is not inclined to contaminate the parts in its neighbourhood; if thoroughly removed, it does not return. A soft tumour of the gum, rapid in its progress, broken on its surface, and furnishing fetid and bloody discharge, is sometimes, it is said, met with; there is no danger of mistaking the one kind for the other, the remediable for the malignant; fortunately the latter is rare." (pp. 255, 56.)

I have occasionally, though not often, seen epulis of both kinds mentioned by LISTON; that which seems merely a luxuriant growth of one particular part of the gum, is most frequent, but that directly connected with the teeth is more rare. Of the latter kind I operated some time since, on a boy of twelve years old; the tumour was about the size of a bean, on the outside of the left branch of the lower jaw, when first observed, but in the course of two years it spread slowly, as far back as the last molar, and forward to the outer incisive tooth; it had risen to the edge of the gum, but had not descended quite so low as the base of the jaw; in front, its lower edge had either absorbed and imbedded itself in the jaw, or bony matter had sprung up around it, as it had there a distinct though irregular edge, but behind the ridge was less marked; its size was that of half a walnut; it was elastic, fluctuating, and seemed enclosed in a tough cyst, thinnest above; the membrane of the mouth moved freely over it. At the operation, the cyst was found to have a cartilaginous feel, and the shell of the jaw-bone evidently involved in it. When opened by a crucial cut, about a drachm of glary fluid was discharged, and at the bottom of the cavity, against the side of the jaw, was the second permanent bicuspid tooth, like the so-called lady (the grinding teeth) in the lobster's stomach. The tooth was drawn, the whole sac removed with scissors close to the surface of the jaw, and the remaining capsule sliced off. The case did well at the time, but eighteen months after he came again with a return of the swelling in the same place, but of a firmer texture. Having lost sight of him since, I do not know what has ensued.-J. F. S.]

885. The causes of caries of the teeth are either external or internal. To the former belong the improper use of acrid acid substances, negligent cleansing of the mouth, alternate use of cold and hot food, tobacco chewing, and mechanical injury of the teeth, by which the enamel is destroyed, and its internal substance is exposed to the air. In most cases, however,

(a) Practical Surgery.

caries of the teeth depends on an internal cause, namely, on that kind of caries which is developed in the interior of the tooth. This opinion is especially grounded on the circumstance, that rottenness of the teeth frequently appears in every member of the same family, that the corresponding teeth on both sides are attacked together, and the caries is accompanied with general disease, as rickets, scurvy, mercurial cachexy, bad constitution, weak chest, and the like. The spreading of the caries to the neighbouring teeth seems rather grounded on the collection of part of the food, which putrefies, or on the general causes, as in a peculiar participation, from the first, of the affected teeth.

COFFINIÈRE imagines that in persons with weak chests, the cure of the tooth-ache should not be effected by drawing the tooth, as by retaining the diseased tooth a good derivation may be kept up (a).

886. As to the treatment of carious teeth nothing can be done to prevent the further spread of the caries than removing the causes and improving the constitution, which in many instances is indeed impossible, as often no actual cause can be discovered.

887. For the purpose of restricting the further destruction of carious teeth many remedies have been proposed, which either destroy the carious part, or protect it from the contact of the air or food. To these belong spirituous aromatic tinctures, ætherial oils, kreosote, and even the actual cautery. In superficial caries, the carious part may be removed, by filing or scraping, for the purpose of preventing its effect upon the neighbouring teeth. As to the former remedies, they diminish the sensibility by their irrita tion of the nerve of the tooth, therefore the pain is lessened, and even the offensive smell of the tooth improved, but the progress of the caries is not in the least arrested. Filing the carious tooth, only for the time, suspends the evil; usually it soon reappears, and makes quicker progress than before, especially in old persons. Filling up the carious tooth with thin lead, tinfoil, or with tooth-cement, and the like, (stopping,) after the sensibility has been put an end to by acrid remedies, keeps the air and the food from the carious part, but the caries is not thereby removed. The cavity of the tooth always increases, and the metal at last falls out.

In order to avoid drawing the teeth, and whilst keeping them in, to get rid of the pain, the destruction of the nerve with hot platina thread or with hot iron, as well as, if the crown be tolerably healthy, the trepanning of the tooth in the direction of its root, by which the nerve is destroyed and then the tooth stopped, as also the introduction of a drop of concentrated sulphuric acid has been employed (RYAN.)

[CHELIUS's observations as to the falling out of the stopping are very correct, and it is frequently on this account necessary to repeat this operation, however skilfully performed. Before stopping, however, it must be ascertained whether the carious cavity be tender on touching with a probe, for if it be, the pressure of the stopping, whatever it may be, cannot be borne, and often excites such violent pain, that the tooth at once requires removal. I much prefer filling the hollow, once or twice a day, with a bit of cotton steeped in camphorated spirit, as it gradually diminishes the sensibility of the nerve, and sometimes entirely destroys it, so that it either renders the stopping bearable or sometimes even unneeded. All severe escharotics should be avoided, for they often increase the mischief, and compel the removal of the tooth.-J. F. S.]

888. It is most proper to recommend especial care of their teeth to persons affected with carious teeth, consisting in frequently rinsing the mouth, with water not cold, especially after every meal, and in removing with a quill toothpick everything between and in the teeth. For cleaning the teeth, which should be done every morning, a fine powder of linden wood

(a) ONDE, Dictionnaire de Médecine, vol. x. p. 174.