Mr. Fox follows the same opinion, and observes, that,

"Inflammation in the antrum is often occasioned by diseases of the teeth, but it also occurs when the teeth are quite sound. Sometimes in examining the prepared bones of the head, one or more fangs of the large molares may be found passing into the cavity. In such a case, inflammation excited by a diseased tooth is speedily communicated to the membrane lining the cavity and causes suppuration."

These views Mr. K. avers to be completely erroneous.

"The fangs of the large grinders, or, indeed, of any other tooth, never enter into the cavity of the jaw in the living subject, so long as they are possessed of vitality. Such appearances observable in anatomical preparations result from the bony structure surrounding the points of these fangs having been destroyed by the boiling or maceration in acids, or other processes, to which the maxillæ had been subjected in order to clean them from their soft parts.

"Whenever the fangs have passed into the cavity of the antrum, previously to death, they will always, together with their respective bodies, be found to have lost their vitality, the connection between them and the dental artery and nerve, the means of supporting that vitality, having been previously lost; in this state the irritation of the dead fangs produces an absorption of the osseous structure of the jaw immediately surrounding them; and occasionally inflammation and suppuration take place in what may be regarded as comparatively an early period of the disease.

Mr. K. declares it as his firm belief, the result of long experience, that diseases of both the upper and lower jaw are almost always brought on by some previous disease-disorder of the teeth, or of the parts immediately related to them.

Diseases of the maxillary bones, though not perhaps so common in this country as on the Continent, and in America, are yet by no means rare. Mr. K. has met with many instances during his residence in this metropolis, and refers to two cases successfully treated by him, that were recommended to his care by Mr. Lawrence. After enumerating the symptoms of diseases of the jaws, Mr. K. offers the following etiology:

"The proximate causes of these diseases are, as far as my experience has enabled me to judge, inflammation, suppuration, and mortification, commencing in the alveoli and the periosteum, and thence extended and communicated to the osseous structure, and the lining membrane of the cavity of the jaw.

"The exciting causes are, not only those already stated as the proximate causes of the disease, but also all diseases of the teeth, alveoli, periosteum and gums; as also dead and loose teeth, and decayed roots, or stumps of teeth, and tartar; all of which will be generally, more or less, observed to accompany the diseases of the maxillæ."

These local causes are, of course, aggravated by all constitutional derangements, whether of an acute or chronic nature-and also by all irregularities of diet and other debilitating causes. The unskilful and severe operations too often performed on the teeth, are not to be overlooked in the chain of causation.

After commenting on various modes which have been employed for destroying the vitality of the teeth, Mr. K. makes the following remark on an operation now in vogue:

"But the operation of breaking or cutting off the crown of painful teeth, which the inventor calls excision, is nothing less than an amputation by violent means, and cannot be adopted from any other cause than a culpable timidity on the part of the patient or the dentist, who are thus led to substitute it for the necessary extraction of the teeth, without even preserving the only useful and essential part, viz. its crown. It unquestionably effects, although not either without pain, or so instantaneously as it is asserted,

a destruction of the vitality of the remaining roots or stumps which then become extraneous bodies; the permanent irritation of which, however, must tend to excite disease and induce mortification not only in adjoining parts, but also in the remaining teeth and gums, not to mention the very great and dangerous irritation produced at the same time upon the whole nervous system.

"Should this be doubted, I beg to refer every medical and surgical reader to a careful examination of the parts which will evidence the fact; for it will be found, that, in a hundred jaws containing roots or stumps without one single exception, the parts contiguous to the roots exhibit some marks of disease or mortification; unless, indeed, the teeth have been broken after the death of the subjects from which the bones are taken."

Our author observes, that when the expulsion of the roots of teeth is left to the slow efforts of Nature, "a total destruction of the alveoli is the inevitable consequence, and not unfrequently very considerable portions of the bony structure of the jaw will perish through the diseased action." If the tooth be timely removed, not more than the extreme process of the alveoli is generally absorbed.

We must pass over the sections on inflammation and suppuration of the maxilla, fistulous perforations, malignant cancerous affections, &c. and shall merely give a summary of one of the cases detailed in the work.

Case. Capt. M. of the East India Company, had laboured under a distressing and complicated disease of the mouth, from an excessive use, or abuse, of mercury, at Calcutta, eleven months previously. On his arrival in England, he went to Mr. Lawrence, who directed him to our author, 26th June, 1826.

"The patient was a tall, well-formed handsome young man, about twenty-one years of age. According to his own statement his health was originally excellent, and his constitution strong, and only one year previously he was in the possession of a complete set of teeth, they, as well as all their contiguous parts being perfectly sound, regular, and beautiful; this was still evident, from the appearance of the remaining parts, which in the morbid and dead state evinced the most striking evidence of their previous perfection.

"All the teeth, although entirely free from caries, or any disease of their bony structure, were now perfectly dead, and only mechanically held in their sockets. The periosteum was also totally destroyed, either by absorption or corrosion. The alveoli were not only dead, but in a state of putrefaction, their upper edges all round the semicircle of the month being from an eighth to a quarter of an inch exposed, and exhibiting from their cadaverous appearance a very frightful aspect. The gums were partially destroyed, and the remaining portion of them either gangrenous and sloughing, or in a state of inflammation and suppuration. The disease had already extended to the maxillary bones, and their osseous structure as well as the periosteum of their cavaties was more or less under the influence of inflammation, suppuration, and mortification; but more especially the left side of the upper jaw, which was already much increased in size, accompanied with a correspondent swelling of the cheeks. The face was flushed, and the skin had a bloated, erysipelatous appearance, and the patient suffered excessive pain of the whole mouth, the jaw-bones and other parts of the head, as well as of other remote parts of the system.

"There was a constant flow of viscid ropy discharge from the mouth, like that of great salivation, mixed with greenish matter, and accompanied by a fœtid cadaverous odour, emanating from this fluid and the dead and morbid parts, and so exceedingly offensive as to be almost insupportable to the bystander."

The malady was greatly aggravated by numerous adhesions of the mus cles of the jaws to each other, by which almost all power of moving the under jaw was lost. In consequence of this, the teeth were mechanically pressed into their dead sockets, and the absorption and exfoliation of these last much retarded. In addition to these evils, the almost complete

closure of the mouth had prevented the patient from taking any solid food for a long time. He was, therefore, excessively debilitated and nervous. The indications were, to relieve the inflammation of the surviving osseous and soft structures, by promoting exfoliation of the carious sockets and other bones, and more especially by the removal of all the dead teeth. This was a difficult matter as may be readily imagined. All the dead teeth and sockets, however, were removed by Mr. K. and Mr. Lawrence, and by the middle of August, he was able to set off to visit his friends in the country.

As teeth are equally ornamental and useful in this world, and as we believe that bad teeth produce a number of derangements which are little sus pected as to their origin, we recommend the present, and the former work of our author, to the candid consideration of the public.

XVII.

On Nervous Affections of the Heart and Vessels. By the late M. LAENNEC. [Forbes' New Translation.]

As it is our intention shortly to dedicate an article to organic diseases of the heart, and as that article must necessarily be a very extensive one, we take this opportunity of touching on what the illustrious pathologist abovementioned has denominated "NERVOUS AFFECTIONS" of the Central Organs of the Circulation and its great Qutlets. M. Laennec justly observes, that the study of pathological anatomy has not been unattended with the disadvantage of blinding a considerable proportion of students and practitioners to every thing but organic lesions-to all affections of the nervesto all changes in the fluids. Nevertheless, (says he,) we are bound to admit, that every disease in which we can discover no constant lesion of the solids, nor evident alteration in the fluids, must consist in some disorder of the nervous influence." Of this class are several cardiac and arterial affections, which we are now to notice.

I. NEURALGIA OF THE HEART.

It is by no means uncommon to hear people complain of pains in the region of the heart, resembling rheumatic or neuralgic affections, and which are too frequently set down by inattentive practitioners as organic diseases.

"Sometimes these pains are confined to this spot, but frequently they extend at the same time, or vicariously, over a greater or less portion of the lungs and stomach. Sometimes they exist simultaneously in the superficial cervical plexus, and extend along the tract of the branches supplied by this to the anterior parts of the thorax still more frequently, at the very time they are felt most severely in the heart, they shoot with corresponding violence along the nerves of the axillary plexus, and more particularly along the brachial nerve to the elbow, and sometimes as far as the fingers. When this is the case, the affection is confounded with a nervous disease which, during the last twenty years, has been the object of much discussion, and seems to me only a variety in the neuralgia in question. This disease is the angina pectoris, which is very

remarkable, and very distressing, when it exists in a high degree, but which is far from possessing the degree of severity attributed to it by many authors."

Laennec first describes what has been called angina pectoris, before he discusses the English pathology of the disease-namely, change of structure in the heart. The following concise description of this dreadful disease is deserving of record :

"The attack commences with a sense of pain, pressure or constriction in the cardiac region or at the end of the sternum. There is at the same time a numbness, occasionally attended with pain in the left arm; rarely in both arms or in one half the body; more rarely still in the right arm only; and sometimes in all the limbs. The painful sensation is particularly felt on the inner side of the arm, as low as the elbow; and sometimes, as already mentioned, it shoots still further down. It is not unusual for the patient to suffer, at the same time, from pains over the fore part of the left chest; and in the female, these sometimes so affect the mamma that the slightest pressure becomes painful. Sometimes, particularly when the paroxysm is severe but short, the patient feels as if the same parts were pierced by iron nails or the claws of an animal. There are also pains in different points of the chest, dyspnoea (in extreme cases suffocative orthopnoea,) violent palpitations, congestion of blood in the head, and sometimes syncope or convulsions. When the attack is over, the patient merely retains a slight feeling of these various symptoms, particularly the numbness of the limbs, the left more especially."

It is well known, that Heberden and Parry attributed this peculiar disease to ossification of the coronary arteries-and this opinion has been embraced by several others. Nothing, however, can be more erroneous than this doctrine. Not one case in ten will be found to present this alteration--and, what is more, the symptoms of angina pectoris are seldom present in those cases where the ossification is found. The general belief in England, Italy, and Germany, is, that the said train of symptoms is dependent on some organic lesion of the heart-that the disease is almost always fatal. Laennec is of a different opinion.

"Angina pectoris, in a slight or middling degree, is extremely common, and exists very frequently in persons who have no organic affection of the heart or large vessels. I have known many individuals who had suffered a few very severe but short attacks of it, and had had no further return of it. I am even of opinion that the prevalent type of disease influences its developement, as I have some years met with it frequently, and hardly at all in others. On the other hand, it is certainly true that this affection frequently coincides with organic diseases of the heart; but nothing proves even then that it depends upon such diseases, inasmuch as they are of various kinds, and as the angina exists without any of them. I have examined several subjects who had laboured under this disease, and in whom there coexisted either hypertrophy or dilatation of the heart; and in none of these did I find the coronary arteries ossified. One of these died suddenly during an attack of angina; and such a result need not surprise us, when so severe a nervous affection coexists (as in this case) with extensive hypertrophy. Dr. Desportes, in a dissertation published some years since, has stated opinions very analagous to mine, respecting the nature and seat of this affection: he considers its site to be in the pneumo-gastric nerve. I conceive that the site of the disorder may vary, according to circumstances. For instance, when there exists, at the same time, pain in the heart and lungs, we may presume that the affection is principally seated in the pneumo-gastric; on the other hand, when there is simply a sense of stricture of the heart, without pulmonary pain or much difficulty of breathing, we may consider its site to be in the nervous filaments which the heart receives from the grand sympathetic. Other nerves are also simultaneously affected, either by sympathy or from direct anastomosis; for example, the branches of the brachial plexus, particularly the cubital, are almost always so; the anterior thoracic originating in the superficial cervical plexus, are also frequently affected; and this is also sometimes the case with

the branches derived from the lumbar and sacral plexuses, as we find the thigh and leg now and then participating in the pain and numbness. I have even seen the affection confined to the right side of the thorax. In this case the pain and numbness extended to the arm, thigh, and spermatic cord of the same side, and the testicle became swollen during the paroxysms. There was scarcely any pain in the region of the heart; but the attacks were attended by severe palpitation, without any sign of organic lesion of the heart."

The character of the symptoms, M. Laennec thinks, confirms this opinWe know that neuralgia of the most unequivocal kind, as sciatica and tic doloureux, give rise to the same variety and species of effects as angina does-namely, acute pain, painful torpor, simple numbness along the tract of nerve, and sometimes spasm of the parts to which the nerves are distributed.

It would be useless to discuss the various opinions on this disease, which have been broached by different writers, since the time of Parry and Fothergill. Dr. Forbes is inclined to agree with Hosack, that the disease "most frequently arises from a plethoric state of the blood-vessels-more especially from a disproportionate accumulation of blood in the heart and large vessels." Dr. F. observes also that, "in persons subject to this complaint, in whom no severe organic disease of the heart existed, he has generally found, by auscultation, that the organ was possessed of thin parietes and feeble powers." It would require a very long life, and a very extensive experience, to speak generally, and with much confidence, on the pathology of angina pectoris. Not more than three or four opportunities have occurred in our own practice, of examining, post mortem, those who have fallen victims to the disease. In only two, was there ossification of the coronary arteries, and, in these, there were other organic lesions. In all the cases, there was a flabby soft state of the muscular structure of the organ, whether or not accompanied by much fat. But we have seen several cases, unaccompanied by dissection, where there were strong reasons to believe that the disease could not be fairly attributable to ossification of the coronary arteries--and we have found this state of vessels in several subjects, where there was no symptom of angina pectoris before death. The impression on our own minds is, that the nerves of the heart are implicated in the pathology of the disease. The wasting and flabby structure of the organ are, in themselves, rather favourable to this doctrine. We see the muscles of a limb waste and become flaccid, where neuralgia, for example, sciatica, has long obtained. In short, wherever PAIN is a prominent symptom in any complaint, we have a fair right to conclude, that the nervous system of the organ is implicated in the pathology. That the symptoms included under the term angina pectoris may proceed from other causes than affection of the nerves, we will not deny-or at least that various organic derangements may be found after death; but, as the paroxysms come on like those of apoplexy, at various intervals, the organic change necessarily remaining the same, it is reasonable to infer, that the ostensible change of structure detected by the scalpel is rather the predisposing, than the direct occasional cause of the paroxysm. A determination of blood to the head, where there is disease of structure in the brain, will bring on the attack of apoplexy-and so a neuralgia may induce a paroxysm of angina pectoris, where there is already some defective structure in the part. The following therapeutical extract is rather curious:

"The means which I (Laennec) have found most successful in relieving neuralgia of the heart, whether existing in so violent a degree as to be named angina pectoris,